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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 $60.00 $25.00 58.00 %
D0140 Limited Exam problem focused $75.00 $56.00 25.00 %
D0150 Comprehensive Exam $78.00 $25.00 68.00 %
D0210 X-rays, Complete Series $126.00 $25.00 80.00 %
D0220 Intraoral X-ray $27.00 $19.00 30.00 %
D0274 Bitewings four films $63.00 $15.00 76.00 %
D0330 Panoramic film $108.00 $77.00 29.00 %
D1110 Adult Cleaning age 14 and over $109.00 $65.00 40.00 %
D1120 Child Cleaning under age 14 $70.00 $55.00 21.00 %
D1208 Fluoride $43.00 $27.00 37.00 %
D1351 Sealant per tooth $51.00 $37.00 27.00 %
Amalgam Fillings Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D2140 One Surface $140.00 $96.00 31.00 %
D2150 Two Surfaces $180.00 $116.00 36.00 %
D2160 Three Surfaces $222.00 $138.00 38.00 %
Composite Fillings Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D2330 One Surface anterior $146.00 $105.00 28.00 %
D2331 Two Surfaces anterior $196.00 $137.00 30.00 %
D2332 Three Surfaces anterior $250.00 $174.00 30.00 %
D2335 4+ Surfaces anterior $292.00 $203.00 30.00 %
D2391 One Surface posterior $170.00 $125.00 26.00 %
D2392 Two Surfaces posterior $233.00 $162.00 30.00 %
D2393 Three Surfaces posterior $268.00 $190.00 29.00 %
Crowns Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D2740 Crown – porcelain ceramic $1,100.00 $950.00 14.00 %
D2750 Crown – porcelain high noble metal $997.00 $815.00 18.00 %
D2751 Crown – porcelain base metal $994.00 $740.00 26.00 %
D2752 Crown – porcelain noble metal $989.00 $775.00 22.00 %
D2950 Core buildup including any pins $229.00 $160.00 30.00 %
D2952 Post and core in addition tocrown, indirectly fabricated $376.00 $246.00 35.00 %
Root Canal Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D3310 Anterior Root Canal, excluding fi nal restoration $733.00 $476.00 35.00 %
D3320 Bicuspid Root Canal, excluding fi nal restoration $810.00 $550.00 32.00 %
D3330 Molar Root Canal, excluding fi nal restoration $1,124.00 $787.00 30.00 %
Periodontics Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D4341 Scaling/Root Planing 4+ teeth per quad $225.00 $184.00 18.00 %
D4342 Scaling/Root Planing 1-3 teeth per quad $165.00 $132.00 20.00 %
D4910 Periodontal Maintenance $175.00 $120.00 31.00 %
D4910 Gingival Irrigation (full mouth) $100.00 $70.00 30.00 %
Dentures Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D5110 Complete Denture upper $1,202.00 $990.00 18.00 %
D5120 Complete Denture lower $1,166.00 $990.00 15.00 %
D5510 Repair broken denture base $151.00 $120.00 21.00 %
D5730 Reline upper denture chairside $278.00 $205.00 26.00 %
D5731 Reline lower denture chairside $278.00 $205.00 26.00 %
D5740 Reline upper partial denture chairside $270.00 $230.00 15.00 %
D5741 Reline lower partial denture chairside $270.00 $230.00 15.00 %
D5750 Reline upper denture laboratory $423.00 $286.00 32.00 %
D5751 Reline lower denture laboratory $323.00 $280.00 34.00 %
Bridges Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D6240 Pontic porcelain/high noble metal $974.00 $795.00 18.00 %
D6241 Pontic porcelain/base metal $927.00 $720.00 22.00 %
D6242 Pontic porcelain/noble metal $966.00 $760.00 21.00 %
D6750 Crown porcelain/high noble metal $977.00 $815.00 17.00 %
D6751 Crown porcelain/base metal $952.00 $740.00 22.00 %
D6752 Crown porcelain/noble metal $972.00 $775.00 20.00 %
D6790 Crown full cast high noble metal $909.00 $740.00 19.00 %
D6791 Crown full cast base metal $972.00 $690.00 29.00 %
D6792 Crown full cast noble metal $998.00 $740.00 26.00 %
Extractions Top
CODE PROCEDURE USUAL FEE(1) YOU PAY(2) SAVINGS%
D7140 Simple Extraction $161.00 $108.00 33.00 %

(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.