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 $180
Panoral $210
X-rays (4 Bite Wings) $121
Cleaning $184
Total Cost $695
   
   
   

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

$546.00
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* $99 $99
Emergency Oral EvaluationD140 Free* $150 $150
Comprehensive Oral EvaluationD150 Free* $180 $180
All X-RaysD210-330 Free*
Prophylaxis-AdultD1110 $50 $184 $134
Prophylaxis-ChildD1120 $50 $126 $76
Fluoride-Child (to age 16)D1206 Free* $53 $53
Sealant-Per ToothD1351 $37 $103 $66

*Benefits subject to plan frequency limitations.

Restorative Procedures (Fillings)

Dental Procedure Member Fee Non-Member Fee Savings
Amalgam 1 SurfaceD2140 $121 $273 $152
Amalgam 2 SurfaceD2150 $154 $336 $182
Amalgam 3 SurfaceD2160 $189 $419 $230
Amalgam 4+ SurfaceD2161 $236 $509 $273
Composite 1 Surface AnteriorD2330 $151 $316 $165
Composite 2 Surface AnteriorD2331 $185 $374 $189
Composite 3 Surface AnteriorD2332 $229 $463 $234
Composite 4+ Surface AnteriorD2335 $295 $593 $298
Crown-Porcelain/CeramicD2740 $1,045 $2,216 $1,171
Crown-Porcelain/High Noble MetalD2750 $1,076 $2,216 $1,140
Crown-Porcelain/Noble MetalD2752 $971 $2,069 $1,098
Sedative FillingD2940 $102 $246 $144
Core Build Up With or Without PinsD2950 $239 $505 $266
Pin Retention-Per ToothD2951 $60 $153 $93
Prefabricated Post & CoreD2954 $301 $608 $307

Cosmetic Procedures

Dental Procedure Member Fee Non-Member Fee Savings
Composite 1 Surface PosteriorD2391 $182 $365 $183
Composite 2 Surface PosteriorD2392 $226 $452 $226
Composite 3 Surface PosteriorD2393 $279 $558 $279
Composite 4+ Surface PosteriorD2394 $336 $671 $335
Labial Veneer Resin-ChairsideD2960 $585 $1,284 $699
Labial Veneer Porcelain-LabD2962 $1,041 $2,212 $1,171

Endodontic Procedures (Root Canals)

Dental Procedure Member Fee Non-Member Fee Savings
Root Canal AnteriorD3310 $643 $1,364 $721
Root Canal BicuspidD3320 $782 $1,568 $786
Root Canal MolarD3330 $969 $1,938 $969
Retreat AnteriorD3346 $777 $1,595 $818
Retreat BicuspidD3347 $873 $1,806 $933
Retreat MolarD3348 $1,048 $2,145 $1,097

Periodontic Procedures (Gums)

Dental Procedure Member Fee Non-Member Fee Savings
Crown LengtheningD4249 $741 $1,482 $741
Osseous Surgery-4+ Teeth Per QuadD4260 $1,040 $2,244 $1,204
Osseous Surgery-1-3 Teeth Per QuadD4261 $856 $1,736 $880
Bone Replacement-First Site in QuadD4263 $630 $1,259 $629
Bone Replacement-Each Add. SiteD4264 $543 $1,085 $542
Guided Tissue RegenerationD4266 $473 $1,333 $860
Scaling & Root Planing-4+ Teeth Per QuadD4341 $180 $472 $292
Scaling & Root Planing-1-3 Teeth Per QuadD4342 $158 $361 $203
Local Delivery of Antimicrobial AgentD4381 $59 $175 $116
Periodontal MaintenanceD4910 $104 $257 $153

Removable Prosthodontic Procedures (Dentures)

Dental Procedure Member Fee Non-Member Fee Savings
Complete Upper DentureD5110 $1,465 $3,279 $1,814
Complete Lower DentureD5120 $1,465 $3,333 $1,868
Immediate Upper DentureD5130 $1,638 $3,614 $1,976
Immediate Lower DentureD5140 $1,638 $3,560 $1,922
Upper Partial-Metal BaseD5213 $1,465 $3,359 $1,894
Lower Partial-Metal BaseD5214 $1,465 $3,359 $1,894
Upper Partial-Flex/ValplastD5225 $1,429 $2,857 $1,428
Lower Partial-Flex/ValplastD5226 $1,445 $2,891 $1,446
Repair Upper Resin DentureD5611 $204 $419 $215
Repair Lower Resin DentureD5612 $204 $416 $212
Repair Upper Cast FrameworkD5621 $263 $525 $262
Repair Lower Cast FrameworkD5622 $261 $523 $262
Repair or Replace Broken ClaspD5630 $236 $491 $255
Add Tooth to Existing PartialD5650 $196 $426 $230
Reline Complete Upper Denture-LabD5750 $433 $865 $432
Reline Complete Lower Denture-LabD5751 $433 $865 $432
Interim Partial Upper (Flipper)D5820 $638 $1,299 $661
Interim Partial Lower (Flipper)D5821 $638 $1,291 $653

Implant Procedures

Dental Procedure Member Fee Non-Member Fee Savings
Surgical Placement of ImplantD6010 $1,760 $3,521 $1,761
Prefabricated AbutmentD6056 $500 $1,379 $879
Custom AbutmentD6057 $746 $1,646 $900
Implant Supported Crown-Porcelain/CeramicD6058 $1,220 $2,441 $1,221
Implant Supported Crown-Porcelain/High Noble MetalD6059 $1,262 $2,525 $1,263
Implant Supported Crown-Porcelain/Noble MetalD6061 $1,226 $2,452 $1,226

Fixed Prosthodontic Procedures (Bridgework)

Dental Procedure Member Fee Non-Member Fee Savings
Pontic-Porcelain/High Noble MetalD6240 $1,076 $2,216 $1,140
Pontic-Porcelain/Noble MetalD6242 $957 $1,914 $957
Pontic-Porcelain/CeramicD6245 $1,045 $2,216 $1,171
Crown-Porcelain/CeramicD6740 $1,001 $2,002 $1,001
Crown-Porcelain/High Noble MetalD6750 $1,024 $2,048 $1,024
Crown-Porcelain/Noble MetalD6752 $968 $1,937 $969

Oral Surgery Procedures (Extractions)

Dental Procedure Member Fee Non-Member Fee Savings
Extraction-Erupted ToothD7140 $161 $365 $204
Extraction-Surgical Erupted ToothD7210 $261 $566 $305
Extraction-Impacted Soft TissueD7220 $301 $602 $301
Extraction-Impacted Partial BonyD7230 $370 $740 $370
Extraction-Impacted Complete BonyD7240 $445 $890 $445
Surgical Removal of Residual RootD7250 $294 $588 $294
Surgical Exposure of Unerupted ToothD7280 $485 $970 $485
Incision & Drainage AbscessD7510 $219 $459 $240
Bone Replacement Graft Per SiteD7953 $662 $1,325 $663

General Services Adjunctive

Dental Procedure Member Fee Non-Member Fee Savings
Nitrous OxideD9230 $81 $162 $81
Emergency Treatment PalliativeD9110 $124 $248 $124

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 50%.

**Benefits subject to plan frequency limitations.

Procedure Categories

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