DESCRIPTION OF SERVICES
ADA CodeProcedure DescriptionMember Pays*
HYGIENE BUNDLES
1st Hygiene Child Bundle: Exam, X-Rays, Fluoride, & Child Cleaning $71.00
Additional Member Pays: Exam, X-Rays, Fluoride, & Child Cleaning $150.00
1st Hygiene Adult Bundle: Exam, X-Rays, Fluoride, & Adult Cleaning $121.00
Additional Member Pays: Exam, X-Rays, Fluoride, & Child Cleaning $200
2nd Hygiene Child Bundle of the year: Exam, X-Rays, Fluoride, & Child Cleaning $150.00
2nd Hygiene Adult Bundle of the year: Exam, X-Rays, Fluoride, & Adult Cleaning $200.00
PREVENTATIVE & DIAGNOSTIC
D0140 Limited Exam (Problem focused w/ necessary x-rays) Up to 85% off
D1351 Sealant - Per Tooth Up to 85% off
D1354 Interim Caries Arresting Medicament Application Up to 85% off
RESTORATIVE
D1510 Space Maintainer - Fixed, Unilateral, per quad 30-60% off
D1575 Distal Shoe Space Maintainer - per quad 30-60% off
D2330 Composite Filling - One Surface, Anterior 30-60% off
D2390 Composite Crown, Anterior 30-60% off
D2929 Porcelain/Ceramic Crown 30-60% off
D9230 Nitrous Oxide 30-60% off
Cell 1 Cell 2 Cell 3
20-50% OFF MOST OTHER SERVICES

*Services listed on Summary of Discounts, with the exception of Orthodontic services, are performed by your selected general dentist. Certain procedures may not be within the scope of practice or the ability of the general dentist.