Savings to Smile About
Below is a list of common dental services and what you’ll pay with DecisionOne Dental Plan.
| Savings Summary | ||
|---|---|---|
| ADA Code | Procedure Description | Member Pays* |
| Diagnostic & Preventative | ||
| D0120 | Periodic Oral Evaluation | $39.00 |
| D0140 | Limited Exam - Problem Focused | NO CHARGE |
| D0150 | Comprehensive Exam | $61.00 |
| D0210 | Full Mouth X-Rays | NO CHARGE |
| D0431 | Adjunctive Oral Cancer Exam | NO CHARGE |
| D1110 | Adult Teeth Cleaning | $99.00 |
| D1120 | Child Teeth Cleaning | $79.00 |
| D1206 | Fluoride - Including Varnish | $27.00 |
| Restorative | ||
| D2330 | Filling - 1 Surface, Anterior | $205.00 |
| D2391 | Filling - 1 Surface, Posterior | $223.00 |
| D2740 | Crown - Porcelain/Ceramic | $1,325.00 |
| Endodontics & Periodontics | ||
| D3310 | Root Canal - Anterior | 15% OFF |
| D3320 | Root Canal - Bicuspid | 15% OFF |
| D3330 | Root Canal - Molar | 15% OFF |
| D4341 | Perio Scaling/Root Planing - 4+ Teeth | $308.00 |
| D4910 | Periodontal Maintenance | $170.00 |
| Prosthodontics & Oral Surgery | ||
| D7140 | Simple Extraction | $241.00 |
*Member savings may vary by location. Free oral cancer screening limited to 1x per member/per annual membership term.