Savings to Smile About
Below is a list of common dental services and what you’ll pay with Smart Choice Dental Plan.
| Savings Summary | ||
|---|---|---|
| ADA Code | Procedure Description | Member Pays* |
| Preventive & Diagnostic | ||
| D0120 | Periodic Exam | NO CHARGE |
| D0140 | Limited Exam - Problem Focused | NO CHARGE |
| D0150 | Comprehensive Exam | NO CHARGE |
| D0210 | Full Mouth X-Rays | $110.00 |
| D0330 | Panoramic X-Rays | $75.00 |
| D1110 | Adult Cleaning | $100.00 |
| D1120 | Child Cleaning | $75.00 |
| D1206 | Fluoride - Including Varnish | $35.00 |
| Restorative | ||
| D2330 | Filling - 1 Surface, Anterior | $145.00 |
| D2391 | Filling - 1 Surface, Posterior | $180.00 |
| D2740 | Crown - Porcelain/Ceramic | $1,150.00 |
| Endodontics & Periodontics | ||
| D4341 | Perio Scaling/Root Planing - 4+ Teeth | $250.00 |
| D4342 | Perio Scaling/Root Planing - 1-3 Teeth | $170.00 |
| D4910 | Periodontal Maintenance | $150.00 |
| Prosthodontics & Oral Surgery | ||
| D5110 | Complete Denture (Upper or Lower) | $1,750.00 |
| D5213 | Partial Denture (Upper or Lower) | $1,750.00 |
| D7140 | Simple Extraction | $150.00 |
| D9947 | Mandibular Advancement Device | $1,575.00 |
| Orthodontics | ||
| Orthodontic Treatment | 15% OFF | |
| Invisalign | 15% OFF |