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Summary of Discounts

Your membership in the DecisionOne Dental Plan provides you access to instant savings and up-front pricing so you will know what to expect when it comes to your dental care needs. After enrolling in the plan, just show your member ID at a participating dental office to take advantage of plan savings.

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!