Savings to Smile About
Below is a list of common dental services and what you’ll pay with DecisionOne Dental Plan.
| Your Dental Savings at a Glance | ||
|---|---|---|
| ADA Code | Procedure Description | Member Pays* |
| Member Price For Exam, x-Ray and cleaning | $119 | |
| Preventative & Diagnostic | ||
| D0120 | Periodic Oral Evaluation | $20 |
| D0140 | Limited Oral Evaluation - Problem Focused | $20 |
| D0150 | Comprehensive Oral Exam | $20 |
| D0210 | X-Ray - Intraoral - Complete Series | No Charge |
| D0274 | X-Ray - Bitewing - Four Images | No Charge |
| D0330 | X-Ray - Panoramic Image (if available) | 30% Off |
| D0220 | X-Ray - Intraoral - Periapical - First Image | No Charge |
| D1110 | Prophylaxis - Adult (basic cleaning & polishing) | $99 |
| D0431 | Adjunctive Oral Cancer Exam | 30% Off |
| D1208 | Topical Application of Fluoride | 30% Off |
| Hygiene Services | ||
| D4910 | Periodontal Maintenance | 20% Off |
| D4341 | Periodontal Scaling and Root Planning (4+ Teeth per quad) | 20% Off |
| Major Services | ||
| D2740 | Crown - Full Porcelain/Ceramic Substrate | 20% Off |
| D2750 | Crown - Porcelain Fused to High Noble Metal | 20% Off |
| D2950 | Core Buildup (Including Pins) | 20% Off |
| Basic Services | ||
| D2140 | Amalgam - Posterior - One Surface | 20% Off |
| D2150 | Amalgam - Posterior - Two Surface | 20% Off |
| D7140 | Extraction - Erupted Tooth or Exposed Root | 20% Off |
| D7240 | Extraction Impacted Tooth - Full Bony | 20% Off |
| ADDITIONAL DISCOUNTS MAY BE AVAILABLE, SEE YOUR DENTAL OFFICE FOR COMPLETE LIST OF SAVINGS |
*Percentage discounts are based on a participating office’s usual and customary fees normally charged to uninsured, self-pay patients.