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Gentle Dental Smile Plan

Fee Schedule Summary

  • Fees listed are valid only if performed by a General Dentist.
  • Fees not listed will be discounted 20% from the providers usual fee (UCR*).
  • Specialty fees are discounted 25% from the specialty providers usual fee (UCR*)
*UCR: Usual and customary rates (may differ per provider).
Fee Schedule PDF

(1) Usual fee – Usual and Customary rates (UCR). UCR fees obtained through NDA Fair Health data.
(2) You pay – Member pays the fee directly to the provider.

Diagnostic & Preventative Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D0120 Periodic Exam $46.00 $15.00 67.00 %
D0140 Limited Exam – problem focused $72.00 $25.00 65.00 %
D0150 Comprehensive Exam $72.00 $0.00 100.00 %
D0210 X-rays - complete series $116.00 $25.00 78.00 %
D0220 Intraoral X-ray (first film) $25.00 $15.00 40.00 %
D0274 Bitewings – four films $55.00 $15.00 73.00 %
D0330 Panoramic film $98.00 $50.00 49.00 %
D1110 Adult Cleaning - age 14 and over $83.00 $49.00 41.00 %
D1120 Child Cleaning - under age 14 $64.00 $35.00 45.00 %
D1208 Fluoride $30.00 $15.00 50.00 %
D1351 Sealant – per tooth $47.00 $30.00 36.00 %
Restorative (Fillings) - Amalgam Fillings Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D2140 One Surface $127.00 $70.00 45.00 %
D2150 Two Surfaces $153.00 $90.00 41.00 %
D2160 Three Surfaces $198.00 $95.00 52.00 %
Restorative (Fillings) - Composite Fillings (resin based) Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D2330 One Surface, anterior $140.00 $80.00 43.00 %
D2331 Two Surfaces, anterior $174.00 $100.00 43.00 %
D2332 Three Surfaces, anterior $206.00 $125.00 39.00 %
D2335 4+ Surfaces, anterior $247.00 $150.00 39.00 %
D2391 One Surface, posterior $152.00 $105.00 31.00 %
D2392 Two Surfaces, posterior $197.00 $135.00 31.00 %
D2393 Three Surfaces, posterior $242.00 $150.00 38.00 %
Crown Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D2740 Crown - porcelain/ceramic $1,200.00 $950.00 21.00 %
D2750 Crown – porcelain/high noble metal $938.00 $700.00 25.00 %
D2751 Crown – porcelain/base metal $891.00 $600.00 33.00 %
D2752 Crown – porcelain/noble metal $881.00 $650.00 26.00 %
D2950 Core build-up, including any pins $227.00 $130.00 43.00 %
D2952 Post and core in addition to crown, indirectly fabricated $331.00 $190.00 43.00 %
Root Canal Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D3310 Anterior root canal (excluding final restoration) $670.00 $425.00 37.00 %
D3320 Bicuspid Root Canal (excluding final restoration) $769.00 $535.00 30.00 %
D3330 Molar Root Canal (exclusing final restoration) $900.00 $635.00 29.00 %
Periodontics Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D4341 Scaling/Root Planing - 4+ teeth per quad $215.00 $140.00 35.00 %
D4342 Scaling/Root Planing - 1-3 teeth per quad $158.00 $115.00 27.00 %
D4910 Periodontal Maintenance $126.00 $75.00 40.00 %
D4921 Gingival Irrigation (per quad) $75.00 $40.00 47.00 %
Dentures Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D5110 Complete Denture – upper $1,310.00 $800.00 39.00 %
D5120 Complete Denture – lower $1,203.00 $800.00 33.00 %
D5510 Repair broken denture base $167.00 $110.00 34.00 %
D5730 Reline upper denture (chairside) $325.00 $175.00 46.00 %
D5730 Reline lower denture (chairside) $355.00 $175.00 51.00 %
D5740 Reline upper partial denture (chairside) $270.00 $200.00 26.00 %
D5740 Reline lower partial denture (chairside) $287.00 $200.00 30.00 %
D5750 Reline upper denture (laboratory) $404.00 $250.00 38.00 %
D5750 Reline lower denture (laboratory) $413.00 $250.00 39.00 %
Bridges Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D6240 Pontic – porcelain fused to high noble metal $956.00 $685.00 28.00 %
D6241 Pontic – porcelain fused to predominantly base metal $903.00 $590.00 35.00 %
D6242 Pontic – porcelain fused to noble metal $886.00 $635.00 28.00 %
D6750 Crown – porcelain/high noble metal $959.00 $700.00 27.00 %
D6751 Crown – porcelain/base metal $932.00 $600.00 36.00 %
D6752 Crown – porcelain/noble metal $894.00 $650.00 27.00 %
D6790 Crown – full cast high noble metal $962.00 $600.00 38.00 %
D6791 Crown – full cast predominantly base metal $1,147.00 $550.00 52.00 %
D6792 Crown – full cast noble metal $905.00 $600.00 34.00 %
Extractions Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D7140 Simple Extraction $133.00 $80.00 40.00 %

(1) Usual fee – Usual and Customary rates (UCR). UCR fees obtained through NDA Fair Health data.
(2) You pay – Member pays the fee directly to the provider.