Savings You Can Count On

Our Dental Plan

Enjoy the security of knowing you have a discount dental plan with access to the quality care you deserve. Smile Solutions offers you and your family the dental care you need with the freedoms you desire.

OUT-OF-POCKET COST
FOR FIRST CHECKUP WITHOUT
Initial Exam $146
Panoral $170
X-rays (4 Bite Wings) $98
Cleaning $149
Total Cost $563
   
   
   

OUT-OF-POCKET COST
FOR FIRST CHECKUP WITH
Initial Exam *FREE
Panoral *FREE
X-rays (4 Bite Wings) *FREE
Cleaning $50†
Smile Solutions Membership $99
Total Cost $149
   

SAVINGS

$414.00
Plus, another free exam and x-rays and discounts on all other dental services, this year.

†Includes a maximum of 2 check ups (exams, cleanings, and fluorides) per plan year.

Diagnostic & Preventive Procedures (Exams & X-Rays)

Dental Procedure Member Fee Non-Member Fee Savings
Periodic Oral EvaluationD120 Free* $80 $80
Emergency Oral EvaluationD140 Free* $121 $121
Comprehensive Oral EvaluationD150 Free* $146 $146
All X-RaysD210-330 Free*
Prophylaxis-AdultD1110 $50 $149 $99
Prophylaxis-ChildD1120 $50 $102 $52
Fluoride-Child (to age 16)D1206 Free* $43 $43
Sealant-Per ToothD1351 $35 $83 $48

*Benefits subject to plan frequency limitations.

Restorative Procedures (Fillings)

Dental Procedure Member Fee Non-Member Fee Savings
Amalgam 1 SurfaceD2140 $115 $221 $106
Amalgam 2 SurfaceD2150 $147 $272 $125
Amalgam 3 SurfaceD2160 $180 $339 $159
Amalgam 4+ SurfaceD2161 $225 $412 $187
Composite 1 Surface AnteriorD2330 $144 $256 $112
Composite 2 Surface AnteriorD2331 $176 $303 $127
Composite 3 Surface AnteriorD2332 $218 $375 $157
Composite 4+ Surface AnteriorD2335 $281 $480 $199
Crown-Porcelain/CeramicD2740 $995 $1,793 $798
Crown-Porcelain/High Noble MetalD2750 $1,025 $1,793 $768
Crown-Porcelain/Noble MetalD2752 $925 $1,674 $749
Sedative FillingD2940 $97 $199 $102
Core Build Up With or Without PinsD2950 $228 $409 $181
Pin Retention-Per ToothD2951 $57 $124 $67
Prefabricated Post & CoreD2954 $287 $492 $205

Cosmetic Procedures

Dental Procedure Member Fee Non-Member Fee Savings
Composite 1 Surface PosteriorD2391 $190 $301 $111
Composite 2 Surface PosteriorD2392 $243 $372 $129
Composite 3 Surface PosteriorD2393 $288 $459 $171
Composite 4+ Surface PosteriorD2394 $343 $552 $209
Labial Veneer Resin-ChairsideD2960 $557 $1,039 $482
Labial Veneer Porcelain-LabD2962 $991 $1,790 $799

Endodontic Procedures (Root Canals)

Dental Procedure Member Fee Non-Member Fee Savings
Root Canal AnteriorD3310 $612 $1,104 $492
Root Canal BicuspidD3320 $745 $1,269 $524
Root Canal MolarD3330 $927 $1,568 $641
Retreat AnteriorD3346 $740 $1,291 $551
Retreat BicuspidD3347 $831 $1,461 $630
Retreat MolarD3348 $998 $1,736 $738

Periodontic Procedures (Gums)

Dental Procedure Member Fee Non-Member Fee Savings
Crown LengtheningD4249 $718 $1,199 $481
Osseous Surgery-4+ Teeth Per QuadD4260 $990 $1,816 $826
Osseous Surgery-1-3 Teeth Per QuadD4261 $815 $1,405 $590
Bone Replacement-First Site in QuadD4263 $682 $1,019 $337
Bone Replacement-Each Add. SiteD4264 $519 $878 $359
Guided Tissue RegenerationD4266 $450 $1,079 $629
Scaling & Root Planing-4+ Teeth Per QuadD4341 $171 $382 $211
Scaling & Root Planing-1-3 Teeth Per QuadD4342 $150 $292 $142
Local Delivery of Antimicrobial AgentD4381 $49 $55 $6
Periodontal MaintenanceD4910 $99 $208 $109

Removable Prosthodontic Procedures (Dentures)

Dental Procedure Member Fee Non-Member Fee Savings
Complete Upper DentureD5110 $1,395 $2,653 $1,258
Complete Lower DentureD5120 $1,395 $2,697 $1,302
Immediate Upper DentureD5130 $1,560 $2,924 $1,364
Immediate Lower DentureD5140 $1,560 $2,881 $1,321
Upper Partial-Metal BaseD5213 $1,395 $2,718 $1,323
Lower Partial-Metal BaseD5214 $1,395 $2,718 $1,323
Upper Partial-Flex/ValplastD5225 $1,999 $2,312 $313
Lower Partial-Flex/ValplastD5226 $1,999 $2,339 $340
Repair Upper Resin DentureD5611 $194 $339 $145
Repair Lower Resin DentureD5612 $194 $337 $143
Repair Upper Cast FrameworkD5621 $250 $425 $175
Repair Lower Cast FrameworkD5622 $250 $423 $173
Repair or Replace Broken ClaspD5630 $225 $397 $172
Add Tooth to Existing PartialD5650 $187 $345 $158
Reline Complete Upper Denture-LabD5750 $422 $700 $278
Reline Complete Lower Denture-LabD5751 $422 $700 $278
Interim Partial Upper (Flipper)D5820 $608 $1,051 $443
Interim Partial Lower (Flipper)D5821 $608 $1,045 $437

Implant Procedures

Dental Procedure Member Fee Non-Member Fee Savings
Surgical Placement of ImplantD6010 $1,850 $2,849 $999
Prefabricated AbutmentD6056 $476 $1,116 $640
Custom AbutmentD6057 $710 $1,332 $622
Implant Supported Crown-Porcelain/CeramicD6058 $1,205 $1,975 $770
Implant Supported Crown-Porcelain/High Noble MetalD6059 $1,229 $2,043 $814
Implant Supported Crown-Porcelain/Noble MetalD6061 $1,190 $1,984 $794

Fixed Prosthodontic Procedures (Bridgework)

Dental Procedure Member Fee Non-Member Fee Savings
Pontic-Porcelain/High Noble MetalD6240 $1,025 $1,793 $768
Pontic-Porcelain/Noble MetalD6242 $924 $1,549 $625
Pontic-Porcelain/CeramicD6245 $995 $1,793 $798
Crown-Porcelain/CeramicD6740 $995 $1,620 $625
Crown-Porcelain/High Noble MetalD6750 $1,025 $1,657 $632
Crown-Porcelain/Noble MetalD6752 $924 $1,567 $643

Oral Surgery Procedures (Extractions)

Dental Procedure Member Fee Non-Member Fee Savings
Extraction-Erupted ToothD7140 $153 $295 $142
Extraction-Surgical Erupted ToothD7210 $249 $458 $209
Extraction-Impacted Soft TissueD7220 $288 $487 $199
Extraction-Impacted Partial BonyD7230 $370 $599 $229
Extraction-Impacted Complete BonyD7240 $453 $720 $267
Surgical Removal of Residual RootD7250 $289 $476 $187
Surgical Exposure of Unerupted ToothD7280 $495 $785 $290
Incision & Drainage AbscessD7510 $209 $371 $162
Bone Replacement Graft Per SiteD7953 $700 $1,072 $372

General Services Adjunctive

Dental Procedure Member Fee Non-Member Fee Savings
Nitrous OxideD9230 $99 $131 $32
Emergency Treatment PalliativeD9110 $141 $201 $60

Orthodontic Procedures (Braces)

Dental Procedure Member Fee Non-Member Fee Savings
Comprehensive Treatment of the Adolescent Dentition:D8080
Metal $4,417 $5,890 $1,473
Ceramic $5,086 $6,540 $1,454
Upper Ceramic and Lower Metal $4,752 $6,215 $1,463
Invisalign/Clear Aligners $5,403 $6,065 $662
Comprehensive Treatment of the Adult Dentition:D8090
Metal $4,417 $5,890 $1,473
Ceramic $5,086 $6,540 $1,454
Upper Ceramic and Lower Metal $4,752 $6,215 $1,463
Invisalign/Clear Aligners $5,403 $6,065 $662

*All procedures are to be billed at the amount listed, and fees are subject to change. Procedures not listed in this fee schedule are discounted by 30%.

**Benefits subject to plan frequency limitations.

Procedure Categories

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