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Benefits Schedule

Preventive Member Fee Without Smile Bright
Dental Plan
Office Visits (Unlimited) No Charge 30
Oral Examinations & Diagnosis (Unlimited) No Charge 25
Home Care Prevention No Charge 20
X-Ray (Bitewings) – Adult & Child No Charge 55
Fluoride Treatment – Child (One per year) No Charge 35
Twice Yearly Maintenance
Routine Cleaning – Adult 38 120
Routine Cleaning – Child 34 110
Difficult Prophylaxis (Heavy calculus) 59 210
Additional Fluoride Treatment 15 35
Panoramic X-Ray 52 127
Full Mouth X-Ray 32 98
Single Film X-Ray 4 18
Sealants (Necidenus/Permanent) 18 38
Sterilization Fee (Per visit) 12 24
Emergency Treatment (Office hours) 25 48
Missed Appointments without 24 hr. notice 20 25

 

Extractions Member Fee Without Smile Bright
Dental Plan
Simple, Local Anesthetic 58 102
Surgical Extraction 146 255

 

Restorative (Fillings) Member Fee Without Smile Bright
Dental Plan
Amalgam Restorations in Primary & Permanent Teeth
1 Tooth Surface 58 88
2 Tooth Surfaces 69 129
3 Tooth Surfaces 84 158
4 Tooth Surfaces 96 182
Resin Restorations in Anterior Permanent Teeth
1 Tooth Surface 68 112
2 Tooth Surfaces 83 142
3 Tooth Surfaces 109 205
Resin Restorations in Psterior Permanent Teeth
1 Tooth Surface 84 149
2 Tooth Surfaces 109 205
3 Tooth Surfaces 129 224
Acid Etch 10 20
Sedative Base (Dycal) 10 20

 

Cosmetic Bonding Member Fee Without Smile Bright
Dental Plan
Facial Direct Bonding 119 149
Porcelain Laminate Veneer 712 1311
Bleaching (Per arch) 175 205

 

Pontics Member Fee Without Smile Bright
Dental Plan
Cast 398 952
Porcelain with Semi-Precious 521 1141
Porcelain with Meta 422 1009
Recementation 45 75

 

Crowns and Bridge Work Member Fee Without Smile Bright
Dental Plan
Stainless Steel Crown 92 172
Porcelain Crown with Metal 509 964
3/4 Crown 413 925
Full Crown with Semi-Precious 540 1086
Porcelain Crown with Semi-Precious 552 1122
Porcelain Crown Jacket 723 1400
Inlays
1 Surface 403 791
2 Surfaces 456 802
3 Surfaces 487 910
Pin Retention 29 44
Core BU 127 203
Performed Post/Core 131 212

 

Periodontics
Gum Treatment by a General Practitioner
Member Fee Without Smile Bright
Dental Plan
Full Mouth Debridement 119 219
Periodontal Prophylaxis (Post Maintenance) 63 95
Root Planing Per Quad 135 206
Subgingival Curettage Per Quad 132 209
Gingivectomy, Per Quad 231 427
Gingivectomy, Per Tooth 78 152
Osseus Surgery 378 612

 

Endodontics
Root Canal by a General Practitioner
Member Fee Without Smile Bright
Dental Plan
Vitality Test 19 46
Pulp Treatment 75 93
Pulp Cap 37 78
Pulpotomy 68 123
Recalcification/Tooth 26 65
Root Canal 1 382 724
Root Canal 2 475 935
Root Canal 3 598 1110
Apicoectomy 238 383
Anterior/Bicuspid/Molar Retro Fill 131 182

 

Prosthodontics
Or Denture & Partials
Member Fee Without Smile Bright
Dental Plan
Complete Maxillary Denture 752 1489
Complete Mandibular Denture 752 1489
Partial U or L Acrylic with Chrome 798 1590
Reline (Chair Side) 124 210
Reline (Lab) 188 297
Stayplate 225 310
Denture Repair, No Teeth 53 98
Replace Tooth (Plus Lab Fee) 31 78

 

Orthodontics
Or Braces
Member Fee
Discount 25%

 

Oral Surgery Member Fee
Discount 25%


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