Benefits & Coverage

Insurance Type
Dental Insurance
Insurance Provider
Dental Health Services
Plan Type
Dental HMO
Deductible
None
Coverage Maximum
None
Enrollment Fee
$20

Cost & Coverage

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

Dentist Directory

List of dentist that accepts SmartSmile-CA Dental Plan in CA

/
SARRAF, KEIVAN
5703 S VERMONT AVE
LOS ANGELES, CA 90037
SOUCHITSKI, ANDREI
514 E WASHINGTON BLVD
LOS ANGELES, CA 90015
HUNTINGTON PARK FAMILY DENTAL
2711 E SLAUSON AVE
HUNTINGTON PARK, CA 90255
THOMAS, VARTAN
7100 SANTA FE AVE
HUNTINGTON PARK, CA 90255
RABIZADEH, DAVID
2901 E WHITTIER BLVD
LOS ANGELES, CA 90023
ADONIS REGALA FAMILY DENTISTRY
4065 WHITTIER BLVD.
LOS ANGELES, CA 90023
KIM, GITAE
3054 W 8TH ST
LOS ANGELES, CA 90005
BANASKY, CHARLES
1440 W MANCHESTER AVE
LOS ANGELES, CA 90047
ZHANG, CHU
1440 W MANCHESTER AVE
LOS ANGELES, CA 90047
GANDHI, DEVANG
2500 W FLORENCE AVE
LOS ANGELES, CA 90043
BOREL, JOHN
3932 WILSHIRE BLVD
LOS ANGELES, CA 90010
SIRON, JUNE
3932 WILSHIRE BLVD
LOS ANGELES, CA 90010
SCHWARTZ, MARC
3932 WILSHIRE BLVD STE 100
LOS ANGELES, CA 90010
SILVERIO, WILLY
3932 WILSHIRE BLVD STE 100
LOS ANGELES, CA 90010
LASKA, MARK
3460 WILSHIRE BLVD STE 210
LOS ANGELES, CA 90010
BELGARDE-DURU, CARLA
3756 SANTA ROSALIA DR STE 517
LOS ANGELES, CA 90008
EMANUEL, DONNY
2379 N OXNARD BLVD
OXNARD, CA 93036
DALWANI, POORAN
400 E REGENT ST
INGLEWOOD, CA 90301
MEHTA, MAHENDRAKUMAR
4576 WHITTIER BLVD
LOS ANGELES, CA 90022
TAY, GEORGE
4607 HUNTINGTON DR N
LOS ANGELES, CA 90032
KELLEYAN, ANTRANIG
616 N GARFIELD AVE
MONTEREY PARK, CA 91754
TORRES, MARILYN
139 S VERDUGO RD
GLENDALE, CA 91205
DOUGLAS, JAMES
13450 S HAWTHORNE BLVD
HAWTHORNE, CA 90250
KHOSROVANI, ALI
4905 YORK BLVD
LOS ANGELES, CA 90042
GHARIBIAN, DERICK
8530 W PICO BLVD
LOS ANGELES, CA 90035
Details
KEIVAN SARRAF, DDS
Phone Number
(310) 230-4190
Office Locations
5703 S VERMONT AVE
LOS ANGELES, CA 90037
5703 S VERMONT AVE LOS ANGELES CA, 90037

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