SmartSmile-CA

Dental Health Services

    Monthly Premium

    $6.95

    Select

    PLAN TYPE

    Dental HMO

    DEDUCTIBLE

    None

    COVERAGE MAX

    $0

    PROCEDURE COSTS

    You Pay

    • Cleaning: $15
    • Filling: $44
    • Crown: $340

    Diagnostic

    Clinical Oral Evaluation
    periodic oral evaluation - established patient
    you pay no charge
    limited oral evaluation - problem focused
    you pay no charge
    comprehensive oral evaluation - new or established patient
    you pay no charge
    detailed and extensive oral evaluation - problem focused, by report
    you pay no charge
    re-evaluation - limited, problem focused (established patient; not post-operative visit)
    you pay no charge
    comprehensive periodontal evaluation - new or established patient
    you pay no charge
    office visit fee - per visit
    you pay $4
    Failed/no-show appointment without 24-hour notice
    you pay $20
    Radiographs/Diagnostic Imaging (Including Interpretation)
    intraoral - complete series (including bitewings)
    you pay no charge
    intraoral - periapical first film
    you pay no charge
    intraoral - periapical each additional film
    you pay no charge
    intraoral - occlusal film
    you pay no charge
    extraoral - first film
    you pay no charge
    extraoral - each additional film
    you pay no charge
    bitewing - single film
    you pay no charge
    bitewings - two films
    you pay no charge
    bitewings - four films
    you pay no charge
    vertical bitewings - 7 to 8 films
    you pay no charge
    panoramic film
    you pay no charge
    Tests and Examinations
    pulp vitality tests
    you pay no charge

    Preventive

    Dental Prophylaxis
    prophylaxis - adult
    you pay $15
    prophylaxis - child
    you pay $15
    Topical Fluoride Treatment (Office Procedure)
    topical fluoride varnish; therapeutic application for moderate to high caries risk patients
    you pay $12
    Other Preventive Services
    nutritional counseling for control of dental disease
    you pay no charge
    oral hygiene instructions
    you pay no charge
    sealant - per tooth
    you pay $10
    preventive resin restoration in a moderate to high caries risk patient - permanent tooth
    you pay $20
    Space Maintenance (Passive Appliances)
    space maintainer - fixed - unilateral
    you pay $100
    space maintainer - fixed - bilateral
    you pay $150
    space maintainer - removable - unilateral
    you pay $100
    space maintainer - removable - bilateral
    you pay $150
    re-cementation of space maintainer
    you pay $20

    Restorative

    Amalgam Restorations (Including Polishing)
    amalgam - one surface, primary or permanent
    you pay $32
    amalgam - two surfaces, primary or permanent
    you pay $42
    amalgam - three surfaces, primary or permanent
    you pay $50
    amalgam - four or more surfaces, primary or permanent
    you pay $60
    Resin - Based Composite Restorations - Direct
    resin-based composite - one surface, anterior
    you pay $44
    resin-based composite - two surfaces, anterior
    you pay $60
    resin-based composite - three surfaces, anterior
    you pay $80
    resin-based composite - four or more surfaces or involving incisal angle (anterior)
    you pay $120
    resin-based composite crown, anterior
    you pay $120
    resin-based composite - one surface, posterior
    you pay $60
    resin-based composite - two surfaces, posterior
    you pay $80
    resin-based composite - three surfaces, posterior
    you pay $100
    resin-based composite - four or more surfaces, posterior
    you pay $130
    Inlay/Onlay Restorations
    inlay - metallic - one surface
    you pay $310
    inlay - metallic - two surfaces
    you pay $310
    inlay - metallic - three or more surfaces
    you pay $310
    onlay - metallic-two surfaces
    you pay $310
    onlay - metallic-three surfaces
    you pay $310
    onlay - metallic-four or more surfaces
    you pay $310
    Crowns - Single Restorations Only
    crown - resin-based composite (indirect)
    you pay $250
    crown - 3/4 resin-based composite (indirect)
    you pay $250
    crown - resin with high noble metal
    you pay $250*
    crown - resin with predominantly base metal
    you pay $250
    crown - resin with noble metal
    you pay $250*
    crown - porcelain/ceramic substrate
    you pay $340
    crown - porcelain fused to high noble metal
    you pay $340*
    crown - porcelain fused to predominantly base metal
    you pay $340
    crown - porcelain fused to noble metal
    you pay $340*
    crown - 3/4 cast high noble metal
    you pay $310*
    crown - 3/4 cast predominantly base metal
    you pay $310
    crown - 3/4 cast noble metal
    you pay $310*
    crown - 3/4 porcelain/ceramic
    you pay $340
    crown - full cast high noble metal
    you pay $310*
    crown - full cast predominantly base metal
    you pay $310
    crown - full cast noble metal
    you pay $310*
    crown - titanium
    you pay $310
    Other Restorative Services
    recement inlay, onlay, or partial coverage restoration
    you pay $25
    recement cast or prefabricated post and core
    you pay $25
    recement crown
    you pay $25
    prefabricated stainless steel crown - primary tooth
    you pay $75
    prefabricated stainless steel crown - permanent tooth
    you pay $75
    prefabricated resin crown
    you pay $80
    prefabricated stainless steel crown with resin window
    you pay $100
    prefabricated esthetic coated stainless steel crown - primary tooth
    you pay $100
    protective restoration
    you pay $20
    core buildup, including any pins
    you pay $75
    pin retention - per tooth, in addition to restoration
    you pay $25
    post and core in additon to crown, indirectly fabricated
    you pay $110
    each additonal indirectly fabricated post - same tooth
    you pay no charge
    prefabricated post and core in addition to crown
    you pay $80
    each additonal prefabricated post - same tooth
    you pay no charge
    labial veneer (resin laminate) - chairside
    you pay $200
    labial veneer (resin laminate) - laboratory
    you pay $310
    labial veneer (porcelain laminate) - laboratory
    you pay $340
    additional procedures to construct new crown under existing partial denture framework
    you pay $25
    coping
    you pay $310

    Endodontics

    Pulp Capping
    pulp cap - direct (excluding final restoration)
    you pay $15
    pulp cap - indirect (excluding final restoration)
    you pay $15
    Pulpotomy
    therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament
    you pay $45
    pulpal debridement, primary and permanent teeth
    you pay $45
    Endodontic Therapy on Primary Teeth
    pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)
    you pay $80
    pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)
    you pay $80
    Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care)
    endodontic therapy, anterior tooth (excluding final restoration)
    you pay $200
    endodontic therapy, bicuspid tooth (excluding final restoration)
    you pay $250
    endodontic therapy, molar (excluding final restoration)
    you pay $310
    treatment of root canal obstruction; non-surgical access
    you pay $60
    incomplete endodontic therapy; inoperable, unrestorable or fractured tooth
    you pay $100
    internal root repair of perforation defects
    you pay $60
    Endodontic Retreatment
    retreatment of previous root canal therapy - anterior
    you pay $350
    retreatment of previous root canal therapy - bicuspid
    you pay $400
    retreatment of previous root canal therapy - molar
    you pay $425
    Other Endodontic Procedures
    canal preparation and fitting of preformed dowel or post
    you pay $60

    Periodontics

    Surgical Services (Including Usual Postoperative Care)
    gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant
    you pay $60
    Non-Surgical Periodontal Service
    periodontal scaling and root planing - four or more teeth per quadrant
    you pay $60
    periodontal scaling and root planing - one to three teeth per quadrant
    you pay $40
    full mouth debridement to enable comprehensive evaluation and diagnosis
    you pay $60
    localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report
    you pay $50
    Other Periodontal Services
    periodontal maintenance
    you pay $60

    Prosthodontics (removable)

    Complete Dentures (Including Routine Post-Delivery Care)
    complete denture - maxillary
    you pay $440
    complete denture - mandibular
    you pay $440
    immediate denture - maxillary
    you pay $440
    immediate denture - mandibular
    you pay $440
    Partial Dentures (Including Routine Post-Delivery Care)
    maxillary partial denture - resin base (including any conventional clasps, rests and teeth)
    you pay $440
    mandibular partial denture - resin base (including any conventional clasps, rests and teeth)
    you pay $440
    maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)
    you pay $480
    mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)
    you pay $480
    maxillary partial denture - flexible base (including any clasps, rests and teeth)
    you pay $680
    mandibular partial denture - flexible base (including any clasps, rests and teeth)
    you pay $680
    removable unilateral partial denture - one piece cast metal (including clasps and teeth)
    you pay $200
    Adjustments to Dentures
    adjust complete dentures - maxillary
    you pay $20
    adjust complete dentures - mandibular
    you pay $20
    adjust partial denture - maxillary
    you pay $20
    adjust partial denture - mandibular
    you pay $20
    Repairs to Complete Dentures
    repair broken complete denture base
    you pay $50
    replace missing or broken teeth - complete denture (each tooth)
    you pay $40
    Repairs to Partial Dentures
    repair resin denture base
    you pay $60
    repair cast framework
    you pay $80
    repair or replace broken clasp
    you pay $60
    replace broken teeth - per tooth
    you pay $50
    add tooth to existing partial denture
    you pay $50
    add clasp to existing partial denture
    you pay $60
    replace all teeth and acrylic on cast metal framework (maxillary)
    you pay $330
    replace all teeth and acrylic on cast metal framework (mandibular)
    you pay $330
    Denture Rebase Procedures
    rebase complete maxillary denture
    you pay $300
    rebase complete mandibular denture
    you pay $300
    rebase maxillary partial denture
    you pay $300
    rebase mandibular partial denture
    you pay $300
    Denture Reline Procedures
    reline complete maxillary denture (chairside)
    you pay $80
    reline complete mandibular denture (chairside)
    you pay $80
    reline maxillary partial denture (chairside)
    you pay $80
    reline mandibular partial denture (chairside)
    you pay $80
    reline complete maxillary denture (laboratory)
    you pay $140
    reline complete mandibular denture (laboratory)
    you pay $140
    reline maxillary partial denture (laboratory)
    you pay $140
    reline mandibular partial denture (laboratory)
    you pay $140
    Interim Prosthesis
    interim complete denture (maxillary)
    you pay $180
    interim complete denture (mandibular)
    you pay $180
    interim partial denture (maxillary)
    you pay $180
    interim partial denture (mandibular)
    you pay $180
    Other Removable Prosthetic Services
    tissue conditioning, maxillary
    you pay $50
    tissue conditioning, mandibular
    you pay $50

    Implant Services

    Implant Services
    surgical placement of implant body: endosteal implant
    you pay $1500
    Implant Supported Prosthetics
    implant/abutment supported removable denture for completely edentulous arch
    you pay $2300
    implant/abutment supported removable denture for partially edentulous arch
    you pay $2300
    prefabricated abutment - includes placement
    you pay $450
    custom abutment - includes placement
    you pay $450
    abutment supported porcelain/ceramic crown
    you pay $1000
    abutment supported porcelain fused to metal crown (high noble metal)
    you pay $1000*
    abutment supported porcelain fused to metal crown (predominantly base metal)
    you pay $1000
    abutment supported porcelain fused to metal crown (noble metal)
    you pay $1000*
    abutment supported cast metal crown (high noble metal)
    you pay $1000*
    abutment supported cast metal crown (predominantly base metal)
    you pay $1000
    abutment supported cast metal crown (noble metal)
    you pay $1000*
    implant supported porcelain/ceramic crown
    you pay $1000
    implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)
    you pay $1000*
    implant supported metal crown (titanium, titanium alloy, high noble metal)
    you pay $1000*
    abutment supported retainer for porcelain/ceramic FPD
    you pay $1000
    abutment supported retainer for porcelain fused to metal FPD (high noble metal)
    you pay $1000*
    abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)
    you pay $1000
    abutment supported retainer for porcelain fused to metal FPD (noble metal)
    you pay $1000*
    abutment supported retainer for cast metal FPD (high noble metal)
    you pay $1000*
    abutment supported retainer for cast metal FPD (predominantly base metal)
    you pay $1000
    abutment supported retainer for cast metal FPD (noble metal)
    you pay $1000*
    implant supported retainer for ceramic FPD
    you pay $1000
    implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal)
    you pay $1000*
    implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal)
    you pay $1000*
    abutment supported crown - (titanium)
    you pay $500
    abutment supported retainer crown for FPD - (titanium)
    you pay $500
    Other Implant Services
    recement implant/abutment supported crown
    you pay $30
    recement implant/abutment supported fixed partial denture
    you pay $40

    Prosthodontics, fixed

    Fixed Partial Denture Pontics
    pontic - indirect resin based composite
    you pay $250
    pontic - cast high noble metal
    you pay $310*
    pontic - cast predominantly base metal
    you pay $310
    pontic - cast noble metal
    you pay $310*
    pontic - titanium
    you pay $310
    pontic - porcelain fused to high noble metal
    you pay $340*
    pontic - porcelain fused to predominantly base metal
    you pay $340
    pontic - porcelain fused to noble metal
    you pay $340*
    pontic - porcelain/ceramic
    you pay $340
    pontic - resin with high noble metal
    you pay $250*
    pontic - resin with predominantly base metal
    you pay $250
    pontic - resin with noble metal
    you pay $250*
    Fixed Partial Denture Retainers-Inlays/Onlays
    retainer - porcelain/ceramic for resin bonded fixed prosthesis
    you pay $340
    inlay - cast high noble metal, two surfaces
    you pay $310*
    inlay - cast high noble metal, three or more surfaces
    you pay $310*
    inlay - cast predominantly base metal, two surfaces
    you pay $310
    inlay - cast predominantly base metal, three or more surfaces
    you pay $310
    inlay - cast noble metal, two surfaces
    you pay $310*
    inlay - cast noble metal, three or more surfaces
    you pay $310*
    onlay - porcelain/ceramic, two surfaces
    you pay $340
    onlay - porcelain/ceramic, three or more surfaces
    you pay $340
    onlay - cast high noble metal, two surfaces
    you pay $310*
    onlay - cast high noble metal, three or more surfaces
    you pay $310*
    onlay - cast predominantly base metal, two surfaces
    you pay $310
    onlay - cast predominantly base metal, three or more surfaces
    you pay $310
    onlay - cast noble metal, two surfaces
    you pay $310*
    onlay - cast noble metal, three or more surfaces
    you pay $310*
    inlay - titanium
    you pay $310
    onlay - titanium
    you pay $310
    Fixed Partial Denture Retainers-Crowns
    crown - indirect resin based composite
    you pay $250
    crown - resin with high noble metal
    you pay $250*
    crown - resin with predominantly base metal
    you pay $250
    crown - resin with noble metal
    you pay $250*
    crown - porcelain/ceramic
    you pay $340
    crown - porcelain fused to high noble metal
    you pay $340*
    crown - porcelain fused to predominantly base metal
    you pay $340
    crown - porcelain fused to noble metal
    you pay $340*
    crown - 3/4 cast high noble metal
    you pay $310*
    crown - 3/4 cast predominantly base metal
    you pay $310
    crown - 3/4 cast noble metal
    you pay $310*
    crown - 3/4 porcelain/ceramic
    you pay $340
    crown - full cast high noble metal
    you pay $310*
    crown - full cast predominantly base metal
    you pay $310
    crown - full cast noble metal
    you pay $310*
    crown - titanium
    you pay $310
    Other Fixed Partial Denture Services
    recement fixed partial denture
    you pay $30
    coping - metal
    you pay $40*

    Oral and Maxillofacial Surgery

    Extractions (Includes Local Anesthesia, Suturing, if Needed, and Routine Postoperative Care)
    extraction, coronal remnants - deciduous tooth
    you pay $35
    extraction, erupted tooth or exposed root (elevation and/or forceps removal)
    you pay $40
    Surgical Extractions (Includes Local Anesthesia, Suturing, If Needed, and Routine Postoperative Care
    surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth.
    you pay $70
    removal of impacted tooth - soft tissue
    you pay $85
    surgical removal of residual tooth roots (cutting procedure)
    you pay $80
    Surgical Incision
    incision and drainage of abscess - intraoral soft tissue
    you pay $50
    incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces)
    you pay $100

    Adjunctive General Services

    Unclassified Treatment
    palliative (emergency) treatment of dental pain-minor procedure
    you pay $25
    Anesthesia
    local anesthesia
    you pay no charge
    Professional Consultation
    consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician
    you pay $20
    Professional Visits
    office visit-after regularly scheduled hours
    you pay $50
    case presentation, detailed and extensive treatment planning
    you pay no charge
    Miscellaneous Services
    external bleaching - per arch
    you pay $200
    external bleaching - per tooth
    you pay $100
    internal bleaching - per tooth
    you pay $100

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    (800) 498-4601

    (800) 498-4601