| CDT | Procedure | Normal Fee | Member Fee | Savings |
|---|
| D2391 | Resin-based composite - one surface, posterior | $237 | $189 | $48 |
| D2392 | Resin-based composite - two surfaces, posterior | $299 | $239 | $60 |
| D2740 | Crown - porcelain/ceramic substrate | $1535 | $1228 | $307 |
| D2750 | Crown - porcelain fused to high noble metal | $1524 | $1219 | $305 |
| D3320 | Endodontic therapy, bicuspid tooth (excluding final restoration) | $1152 | $921 | $231 |
| D3330 | Endodontic therapy, molar (excluding final restoration) | $1399 | $1119 | $280 |
| D4210 | Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant | $861 | $688 | $173 |
| D4240 | Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant | $1106 | $884 | $222 |
| D4341 | Periodontal scaling and root planing - four or more teeth per quadrant | $327 | $261 | $66 |
| D5110 | Complete denture - maxillary | $2137 | $1709 | $428 |
| D5211 | Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) | $2267 | $1813 | $454 |
| D6010 | Surgical placement of implant body: endosteal implant | $2564 | $2307 | $257 |
| D6063 | Abutment supported cast metal crown (predominantly base metal) | $1587 | $1428 | $159 |
| D6067 | Implant supported metal crown (titanium, titanium alloy, high noble metal) | $1969 | $1772 | $197 |
| D6210 | Pontic - cast high noble metal | $1462 | $1169 | $293 |
| D7140 | Extraction, erupted tooth or exposed root (elevation and/or forceps removal) | $244 | $195 | $49 |
| D7220 | Removal of impacted tooth - soft tissue | $443 | $354 | $89 |
| D9215 | Local anesthesia in conjunction with operative or surgical procedures | $70 | $56 | $14 |
