Savings to Smile About
Below is a list of common dental services and what you’ll pay with Gentle Dental Plan.
Savings Summary
| ADA Code | Procedure Description | Member Pays* |
|---|---|---|
| Preventive & Diagnostic | ||
| D0120 | Periodic Exam | $25.00 |
| D0140 | Limited Exam - Problem Focused | $25.00 |
| D0150 | Comprehensive Exam | NO CHARGE |
| D0210 | Full Mouth X-Rays | NO CHARGE |
| D0330 | Panoramic X-Rays | NO CHARGE |
| D1110 | Adult Cleaning | $79.00 |
| D1120 | Child Cleaning | $69.00 |
| D1206 | Fluoride - Including Varnish | $37.50 |
| D1351 | Sealant - Per Tooth | $42.50 |
| Restorative | ||
| D2330 | Filling - 1 Surface, Anterior | $149.00 |
| D2391 | Filling - 1 Surface, Posterior | $159.00 |
| 2740 | Crown - Porcelain/Ceramic | $1,090.00 |
| D2750 | Crown - Porcelain/High Noble Metal | $1,090.00 |
| D2950 | Core Buildup - Including Pins | $249.00 |
| Endodontics & Periodontics | ||
| D3310 | Root Canal - Anterior | $700.00 |
| D3320 | Root Canal - Bicuspid | $800.00 |
| D3330 | Root Canal - Molar | $995.00 |
| D4341 | Perio Scaling/Root Planing - 4+ Teeth | $190.00 |
| D4910 | Periodontal Maintenance | $129.00 |
| Prosthodontics & Oral Surgury | ||
| D5110 | Complete Denture (Upper or Lower) | $1,250.00 |
| D5213 | Partial Denture (Upper or Lower) | $1,290.00 |
| D7140 | Simple Extraction | $125.00 |
| D7210 | Surgical Extraction | $249.00 |
*Member savings may vary by location. Free exams and x-rays limited to 2x per member/per annual membership term.
View Fee Schedule(s)