| Restorative (D2000-D2999) |
Members’ Cost |
| Resin-based composite restorations direct |
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| D2330 resin-based composite one surface, anterior |
$179.00 |
| D2331 resin-based composite two surfaces, anterior |
$228.00 |
| D2332 resin-based composite three surfaces, anterior |
$278.00 |
| D2335 resin-based composite four or more surfaces or involving incisal angle, anterior |
$332.00 |
| D2390 resin-based composite crown, anterior |
$458.00 |
| D2391 resin-based composite one surface, posterior |
$198.00 |
| D2392 resin-based composite two surfaces, posterior |
$257.00 |
| D2393 resin-based composite three surfaces, posterior |
$312.00 |
| D2394 resin-based composite four or more surfaces, posterior |
$366.00 |
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| Crowns single restorations only |
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| D2740 crown porcelain/ceramic substrate |
$1,285.00 |
| D2750 crown porcelain fused to high noble metal |
$1,195.00 |
| D2751 crown porcelain fused to predominantly base metal |
$1,115.00 |
| D2752 crown porcelain fused to noble metal |
$1,185.00 |
| D2780 crown cast high noble metal |
$1,073.00 |
| D2781 crown cast predominantly base metal |
$1,028.00 |
| D2782 crown cast noble metal |
$1,050.00 |
| D2783 crown porcelain/ceramic |
$1,101.00 |
| D2790 crown full cast high noble metal |
$1,102.00 |
| D2791 crown full cast predominantly base metal |
$1,006.00 |
| D2792 crown full cast noble metal |
$1,052.00 |
| D2794 crown titanium |
$1,030.00 |
| D2950 core build up |
$310.00 |
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| Other restorative services |
Members’ Cost |
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| Extractions |
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| D7140 simple extractions |
$225.00 |
| D7210 surgical extractions |
$385.00 |
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| Implant Services |
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| D6010 surgical placement of implant |
$2,248.00 |
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| Dentures |
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| D5120 lower full denture |
$2,200.00 |
| D5130 immediate denture maxillaries |
$2,225.00 |
| D5213 upper partial |
$2,248.00 |
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| Orthodontics |
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| Under the age of 19 |
$6,094.00 |
| Over the age of 19 |
$6,463.00 |
| Orthodontic treatment not listed |
15% savings |
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