Summary of Savings & Discounted Fees
| ADA Code | Description | You Pay |
|
|---|---|---|---|
| Diagnostic & Preventative | |||
| D0120 | Periodic Oral Evaluation | $ 25 | |
| D0140 | Limited Oral Evaluation - problem focused | No Charge | |
| D0150 | Comprehensive Exam | $ 40 | |
| D0210 | X-Rays - Complete Set | No Charge | |
| D0220 | X-Ray - Intraoral - First Image (as needed) | No Charge | |
| D0270 | X-Ray - Bitewing - Single (as needed) | No Charge | |
| D0272 | X-ray - 2 Bitewings (as needed) | No Charge | |
| D0274 | X-Ray - 4 Bitewings (as needed) | No Charge | |
| D0431 | Adjunctive Oral Cancer Exam | No Charge | |
| D1110 | Adult Teeth Cleaning | $ 55 | |
| D1120 | Child Teeth Cleaning | $ 40 | |
| D1206 | Topical application of fluoride Varnish | $ 15 | |
| D1208 | Topical application of fluoride | $ 15 | |
| D1330 | Oral Hygiene Instructions | No Charge | |
| Restorative | |||
| D2330 | Resin-Based Composite - Anterior - One surface | $ 129 | |
| D2391 | Resin-Based Composite - Posterior - One Surface | $ 129 | |
| D2392 | Resin-Based Composite - Posterior - Two Surfaces | $ 172 | |
| D2750 | Crown Porcelain Fused to High Noble Metal | $ 950 | |
| Periodontics | |||
| D4341 | Perio scaling & root planing - (4+ teeth per quad) | $ 185 | |
| D4342 | Perio scaling & root planing - (1-3 teeth per quad) | $ 135 | |
| D4355 | Full mouth debridement | $ 140 | |
| D4381 | Localized delivery of antimicrobial agents | $ 48 | |
| D4910 | Periodontal maintenance - single visit | $ 99 | |
| Oral Surgery | |||
| D7140 | Simple Extraction | $ 150 | |
| D7210 | Surgical Extraction | $ 180 | |
Certain Limitations Apply. See decisiononedentalplan.com/support/ to view your state's Description of Service and Disclosure form.
Click here to view your state's General Dentist Fee Schedule.
With easy enrollment and immediate savings, DecisionOne Dental Plan gives you access to a wide selection of dental services and NO CHARGE on full mouth and individual X-rays, and oral cancer screenings. Simply present your Member ID card at your appointment and your discount will be applied instantly.
It's that easy!