Savings to smile about
Below is a list of common dental services and what you’ll pay with Smile Protection Dental Plan.
| Savings Summary | ||
|---|---|---|
| ADA Code | Procedure Description | Member Pays |
| D0120 | Periodic Exam | No Charge |
| D0140 | Limited Exam | No Charge |
| D0150 | Comprehensive Exam | No Charge |
| D0210 | Full Mouth X-Ray | No Charge |
| D0220 | Intraoral - First Film | No Charge |
| D0230 | Intraoral - Each Additional Films | No Charge |
| D0272 | Bitewings - Two Films | No Charge |
| D0274 | Bitewings - Four Films | No Charge |
| D0330 | Panoramic X-Ray | No Charge |
| D1110 | Adult Cleaning | $89.00 |
| D1120 | Child Cleaning | $67.00 |
| D1206 | Fluoride - With Varnish | $37.00 |
| D1208 | Fluoride - Without Varnish | $37.00 |
| Restorative - Fillings Resin-Based Composite | ||
| D2330 | One Surface - Anterior | $145.00 |
| D2331 | Two Surfaces - Anterior | $186.00 |
| D2332 | Three Surfaces - Anterior | $219.00 |
| D2391 | One Surface - Posterior | $154.00 |
| D2392 | Two Surfaces - Posterior | $175.00 |
| D2393 | Three Surfaces - Posterior | $209.00 |
| Restorative - Crowns | ||
| D2740 | Crown - Porcelain/Ceramic Substrate | $1151.00 |
| D2750 | Crown - Porcelain Fused to High Noble Metal | $1151.00 |
| D2954 | Prefab Post & Core in Addition to Crown | $285.00 |
| Endodontics | ||
| D3310 | Root Canal - Anterior | $799.00 |
| D3320 | Root Canal - Bicuspid | $899.00 |
| D3330 | Root Canal - Molar | $1,199.00 |
| Periodontics | ||
| D4341 | Perio Scaling & Root Planing - 4+ Teeth (Per Quad) | $199.00 |
| D4342 | Perio Scaling & Root Planing - 1-3 Teeth (Per Quad) | $173.00 |
| D4910 | Periodontal Maintenance - Single Visit | $133.00 |
| Prosthodontics - Removable | ||
| D5110 | Complete Denture - Maxillary (Upper) | $1,333.00 |
| D5120 | Complete Denture - Mandibular (Lower) | $1,333.00 |
| D5213 | Partial Denture - Maxillary (Upper) | $1,493.00 |
| D5214 | Partial Denture - Mandibular (Lower) | $1,493.00 |
| Implant Services | ||
| D6056 | Prefabricated Abutment | $962.00 |
| D6058 | Abutment Supported Porcelain/Ceramic Crown | $1,452.00 |
| D6080 | Implant Maintenance Procedures, Including Cleansing of Prostheses and Abutments | $365.00 |
| Oral Surgery - Extractions | ||
| D7140 | Extraction ‐ Erupted Tooth or Exposed Root | $155.00 |
| D7210 | Surgical Removal of Erupted Tooth | $255.00 |
| D7220 | Impacted Tooth - Soft Tissue | $303.00 |
| D7230 | Impacted Tooth - Partial Bony | $363.00 |
| D7953 | Bone Replacement Graft (Per Site) | $400.00 |
Member savings may vary by location. Free exams and x-rays provided on an as-needed basis at the discretion of the dental provider. Please speak with your Great Expressions Dental Center provider for more information.