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/Saves |
| 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 | 38%–48% savings |
| D1120 | Child Cleaning | 41%–52% savings |
| D1206 | Fluoride - With Varnish | 40%–53% savings |
| Restorative - Fillings Resin-Based Composite | ||
| D2391 | One Surface - Posterior | 36%–46% savings |
| D2392 | Two Surfaces - Posterior | 39%–48% savings |
| D2393 | Three Surfaces - Posterior | 41%–50% savings |
| Restorative - Crowns | ||
| D2740 | Crown - Porcelain/Ceramic Substrate | $1,209–$1,295 |
| D2750 | Crown - Porcelain Fused to High Noble Metal | $1,151–$1,289 |
| D2950 | Core Buildup | $264–$285 |
| Endodontics | ||
| D3320 | Root Canal - Bicuspid | $925–$998 |
| D3330 | Root Canal - Molar | $1,225–$1,343 |
| Periodontics | ||
| D4266 | Guided Tissue Regen | 46%–65% savings |
| D4341 | Perio Scaling & Root Planing - 4+ Teeth (Per Quad) | 38%–52% savings |
| D4342 | Perio Scaling & Root Planing - 1-3 Teeth (Per Quad) | 32%–45% savings |
| D4910 | Periodontal Maintenance - Single Visit | 28%–39% savings |
| Prosthodontics - Removable | ||
| D5110 | Complete Denture - Maxillary (Upper) | $1,413–$1,595 |
| Implant Services | ||
| D6057 | Custom Abutment | $1,010–$1,097 |
| D6058 | Abutment Supported Porcelain/Ceramic Crown | $1,452–$1,655 |
| D6245 | Pontic - Porcelain/Ceramic | $1,151–$1,289 |
| D6740 | Retainer Crown - Porcelain/Ceramic | $1,151–$1,289 |
| Oral Surgery - Extractions | ||
| D7140 | Extraction ‐ Erupted Tooth or Exposed Root | 41%–53% savings |
| D7210 | Surgical Removal of Erupted Tooth | 32%–46% savings |
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.