Savings to Smile About
Below is a list of common dental services and what you’ll pay with Total Health Savings Plan.
| Savings Summary | ||
|---|---|---|
| ADA Code | Procedure Description | Member Pays* |
| D0120 | Periodic Exam | NO CHARGE |
| D0140 | Limited Exam - Problem Focused | NO CHARGE |
| D0150 | Comprehensive Exam | NO CHARGE |
| D0210 | Full Mouth X-Rays | NO CHARGE |
| D0330 | Panoramic X-Rays | NO CHARGE |
| D1110 | Adult Cleaning | 20% OFF |
| D1120 | Child Cleaning | 20% OFF |
| D1208 | Fluoride - Excluding Varnish | 20% OFF |
| D1351 | Sealant - Per Tooth | 20% OFF |
| D2330 | Filling - 1 Surface, Anterior | 20% OFF |
| D2391 | Filling - 1 Surface, Posterior | 20% OFF |
| D2740 | Crown - Porcelain/Ceramic | 20% OFF |
| D3330 | Root Canal - Molar | 20% OFF |
| D4341 | Perio Scaling/Root Planing - 4+ Teeth | 20% OFF |
| D4910 | Periodontal Maintenance | 20% OFF |
| D7140 | Simple Extraction | 20% OFF |
| D7420 | Surgical Extraction | 20% OFF |
*Member savings may vary by location. Free exams and x-rays limited to 2x per member/per annual membership term.