Benefits & Coverage

Insurance Type
Dental Insurance
Insurance Provider
Dental Health Services
Plan Type
Dental HMO
Deductible
None
Coverage Maximum
No Limit
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
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
re-cement 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
re-cement 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 (In-Network)
514 E WASHINGTON BLVD
LOS ANGELES, CA 90015
ADONIS REGALA DDS INC
1269 S UNION AVE
LOS ANGELES, CA 90015
THOMAS, VARTAN
7100 SANTA FE AVE
HUNTINGTON PARK, CA 90255
HUNTINGTON PARK FAMILY DENTAL
2711 E SLAUSON AVE
HUNTINGTON PARK, CA 90255
RABIZADEH, DAVID
2901 E 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 (In-Network)
2500 W FLORENCE AVE
LOS ANGELES, CA 90043
BOREL, JOHN (In-Network)
3932 WILSHIRE BLVD
LOS ANGELES, CA 90010
SCHWARTZ, MARC (In-Network)
3932 WILSHIRE BLVD STE 100
LOS ANGELES, CA 90010
SIRON, JUNE (In-Network)
3932 WILSHIRE BLVD
LOS ANGELES, CA 90010
SILVERIO, WILLY (In-Network)
3932 WILSHIRE BLVD STE 100
LOS ANGELES, CA 90010
LASKA, MARK (In-Network)
3460 WILSHIRE BLVD STE 210
LOS ANGELES, CA 90010
BELGARDE-DURU, CARLA
3756 SANTA ROSALIA DR STE 517
LOS ANGELES, CA 90008
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 (In-Network)
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
ELYASSI, IGAL (In-Network)
6200 WILSHIRE BLVD STE 1609
LOS ANGELES, CA 90048
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

Similar Plans

Similar Plans to SmartSmile-CA in CA

PremiumPlan NameDeductible
$12.78
Foundation Dental - Protector I
$0
$20.82
Foundation Dental - Defender
$50 per person/per calendar year
$23.99
Foundation Dental - Protector I and Foundation Vision
$0
$32.03
Foundation Dental - Defender and Foundation Vision
$50 per person/per calendar year
$37.39
Foundation Dental - Guardian
$50 per person/per calendar year
$48.60
Foundation Dental - Guardian and Foundation Vision
$50 per person/per calendar year

Related Articles

Related Searches

 

 

Speak with a licensed agent

(800) 984-8015

(800) 984-8015

LEARN MORE​ 
{"globalPhoneNumber":"8009848015","helpInfo":{"leadCopy":"Speak with a licensed agent","phone":"8009848015","analyticsInfo":{"pageType":"details","productLine":"dental","phone":"8009848015"}},"bannerData":{"href":"https://www.agilehealthinsurance.com/dental-insurance-quotes/?xsell=1&utm_source=healthpocket&utm_medium=half_page&utm_campaign=dental_details_page"}}