Savings to Smile About
Below is a list of common dental services and what you’ll pay with TX Dental Plan.
| Savings Summary | ||
|---|---|---|
| ADA Code | Procedure Description | Member Pays* |
| Preventive & Diagnostic | ||
| 2 Limited Exams & X-Rays per year | NO CHARGE | |
| Adult Comprehensive Exam (D0150) & X-Rays Bundle | $149 | |
| Child Comprehensive Exam (D0150) & X-Rays Bundle | $59 | |
| D0120 | Periodic Exam | $52.73 |
| D0210 | Full Mouth X-Rays | $123.20 |
| D0220 | Intraoral - First Film | $27.53 |
| D0230 | Intraoral - Additional Films | $22.17 |
| D0272 | Bitewings - Two Films | $42.00 |
| D0274 | Bitewings - 4 Films | $60.43 |
| D0330 | Panoramic X-Rays | $107.10 |
| D1110 | Adult Cleaning | $89 |
| D1120 | Child Cleaning | $49 |
| D1208 | Fluoride - Excluding Varnish | $37.21 |
| Restorative | ||
| D2330 | Filling - 1 Surface, Anterior | $153.07 |
| D2331 | Filling - 2 Surfaces, Anterior | $186.09 |
| D2332 | Filling - 3 Surfaces, Anterior | $229.03 |
| D2391 | Filling - 1 Surface, Posterior | $166.05 |
| D2740 | Crown - Porcelain/Ceramic | $1,062.12 |
| D2750 | Crown - Porcelain/High Noble Metal | $1,046.27 |
| Endodontics & Periodontics | ||
| D3310 | Root Canal - Anterior | $787.29 |
| D3320 | Root Canal - Bicuspid | $930.43 |
| D3330 | Root Canal - Molar | $965.30 |
| D4341 | Perio Scaling & Root Planing - 4+ Teeth (Per Quad) | $226.33 |
| D4342 | Perio Scaling & Root Planing - 1-3 Teeth (Per Quad) | $165.90 |
| D4910 | Periodontal Maintenance - Single Visit | $146.30 |
| Prosthodontics & Oral Surgery | ||
| D5110 | Complete Denture (Upper) | $1,574.57 |
| D7140 | Simple Extraction | $200.40 |
| D7210 | Surgical Extraction | $279.13 |
*Member savings may vary by location. Free limited exams and necessary x-rays limited to 2x per member/per annual membership term.