Summary Of Discounts

ADA
Code
Diagnostic & Preventive Member Pays
D0150 Comprehensive oral evaluation - 2 per year NO CHARGE
D0120 Periodic oral evaluation - 2 per year NO CHARGE
D0140 Limited oral evaluation - problem focused Unlimited NO CHARGE
D0210 Intraoral - complete series of radiographic images NO CHARGE
D0220 Intraoral - periapical first radiographic image NO CHARGE
D0230 Intraoral - periapical each additional radiographic image NO CHARGE
D0270 bitewing - single radiographic image NO CHARGE
D0272 Bitewings - two radiographic images NO CHARGE
D0274 Bitewings - four radiographic images NO CHARGE
D0330 Panoramic radiographic image NO CHARGE
D1110 Prophylaxis (Cleaning) Adult $89.00
D1120 Prophylaxis (Cleaning) Child $60.00
D1206 Topical application of fluoride varnish $20.00
D1351 Sealant - per tooth $25.00
D9972 External tooth whitening per arch, in-office $245.00
D9975 Teeth whitening full mouth with custom take home trays $89.00
(Includes Above)

Restorative

Resin-based composite-anterior
D2330 One surface $101.00
D2331 Two surfaces $121.00
D2332 Three surfaces $144.00
D2335 Four or more surfaces $204.00
Resin-based composite-posterior
D2391 One surface $115.00
D2392 Two surfaces $145.00
D2393 Three surfaces $183.00
D2394 Four or more surfaces $218.00

Crowns

D2740 Crown – porcelain/ceramic substrate $767.00
D2750 Crown - porcelain fused to high noble metal $767.00
D2940 SedFill $69.00
D2950 Core buildup $150.00
D2954 Prefabricated post and core in addition to crown $197.00
D2962 Labial veneer (porcelain laminate) - laboratory $767.00

Endodontics

D3110 Pulp cap - direct (excluding final restoration) $51.00
D3220 Therapeutic pulpotomy $198.00
D3310 Root canal (anterior) $580.00
D3320 Root canal (bicuspid) $760.00
D3330 Root canal (molar) $880.00

Periodontics

D0180 Comprehensive perio evaluation NO CHARGE
D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth per quadrant $438.00
D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth per space $216.00
D4263 Bone replacement graft - first site in quadrant $300.00
D4264 Bone replacement graft - each additional site $166.00
D4266 Guided tissue regeneration - resorbable barrier, per site $300.00
D4341 Periodontal scaling and root planing (four or more teeth per quadrant) $150.00
D4342 Periodontal scaling and root planing - one to three teeth per quadrant $115.00
D4381 Localized delivery of antimicrobial agents via a controlled release $35.00
D4910 Periodontal maintenance $104.00

Prosthodontics

Removable
D5110 Complete denture - maxillary (upper) $888.00
D5120 Complete denture - mandibular (lower) $888.00
D5130 Immediate denture - maxillary (upper) $888.00
D5140 Immediate denture - mandibular (lower) $888.00
D5213 Maxillary partial denture (upper) - cast metal framework with resin denture bases $1,058.00
D5214 Mandibular partial denture (lower) - cast metal framework with resin denture bases $1,058.00
D5730-D5731 Reline denture upper or lower (chairside) $190.00
D5750-D5751 Reline denture upper or lower (laboratory) $251.00
D5820 Interim partial denture $347.00
Implants
D6010 Surgical placement of implant body endosteal implant $1,637.00
D6059 Abutment supported porcelain fused to metal crown (high noble metal) $778.00
Bridge
D6740 Crown – porcelain/ceramic substrate $767.00
D6750 Crown - porcelain fused to high noble metal $767.00

Oral Surgery

D7111 Extraction, erupted tooth deciduous tooth $49.00
D7140 Extraction, erupted tooth $125.00
D7210 Surgical removal of erupted tooth $214.00
D7220 Removal of impacted tooth- Soft tissue $230.00
D7230 Removal of impacted tooth- Partially Bony $320.00
D7240 Removal of impacted tooth- Completely Bony $385.00

Orthodontics

D8010-D8999 Orthodontic Treatment *20% Off UCR
D8010 Invisalign *20% Off UCR
*Participating Dental Providers have agreed to discount their usual and customary fees for services not listed on the Bright Choice Plus Summary of Discounted Fees, provided those ADA codes/ services are offered in office. “Usual” refers to the normal rate charged for the service by the Provider rendering the treatment, and “Customary”is defined as the usual rates of the Provider’s competitors in that local area. The UCR fee can vary by location.

For a complete summary of your discounts click here

Bright Choice Plus Dental Plan 20% Savings*On services not listed on Summary

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