Summary Of Discounts

Diagnostic & Preventive Member Pays
D0150 Comprehensive Oral Evaluation NO CHARGE
D0120 Periodic Oral Evaluation - 2 per year NO CHARGE
D0140 Limted Oral Evaluation - problem focused NO CHARGE
D0431 Oral Cancer Screening NO CHARGE
D0210 Intraoral - complete series of radiographic images NO CHARGE
D0220 Intraoral - periapical first radiographic image NO CHARGE
D0230 Intraoral - periapical each additional radiographic image NO CHARGE
D0272 Bitewings- two radiographic images NO CHARGE
D0274 Bitewings- four radiographic images NO CHARGE
D0330 Panoramic radiographic image NO CHARGE
D1110 Prophylaxis (Cleaning) Adult $29.98
D1120 Prophylaxis (Cleaning) Child $19.98
D1351 Sealant - per tooth $25.00
D1206 Topical application of fluoride varnish $20.00
D1208 Topical application of fluoride $20.00
Premium Plan Includes all Services
above in the STANDARD Plan

Restorative - Fillings

Member Pays

Rasin-based composite-anterior
D2330 One surface $89.00
D2331 Two surfaces $105.00
D2332 Three surfaces $130.00
Rasin-based composite-posterior
D2391 One surface $99.00
D2392 Two surfaces $122.00
D2393 Three surfaces $150.00

Restorative - Crowns

D2740 Crown – porcelain/ceramic substrate $800.00
D2750 Crown - porcelain fused to high noble metal $700.00
D2751 Crown - porcelain fused to base metal $548.00
D2952 Post and Core $190.00
D2920 Recementation - crown $113.00
D2950 Core buildup $125.00
D2962 Veneer $895.00


D3220 Therapeutic pulpotomy $145.00
D3310 Root canal (anterior) $557.00
D3320 Root canal (bicuspid) $681.00
D3330 Root canal (molar) $793.00


D4263 Bone replacement graft - first site in quadrant $350.00
D4264 Bone replacement graft - each additonal site $250.00
D4341 Periodontal scaling and root planing (four or more teeth per quadrant) $99.00
D4342 Periodontal scaling and root planing - one to three teeth per quadrant $89.00
D4355 Full mouth debridement $95.00
D4266 Guided tissue regeneration $250.00
D4381 Localized delivery of antimicrobial agents $48.00
D4910 Periodontal maintenance $80.00


Dentures /Partials - Removable
D5110 Complete denture - maxillary (upper) $698.00
D5120 Complete denture - mandibular (lower) $698.00
D5213 Maxillary partial denture (upper) - cast metal framework with resin denture bases $1,039.00
D5214 Mandibular partial denture (lower) - cast metal framework with resin denture bases $1,039.00
D5510 Repair broken complete denture base $89.00
D5520 Replace missing or broken teeth (each tooth) $69.00
D5730-D5731 Reline complete denture (chairside) $168.00
D5750-D5751 Reline complete denture (laboratory) $298.00
Implant - Fixed
D6010 Surgical placement of implant body: endosteal implant $990.00
D6056 Prefabricated abutment $121.00
D6057 Custom fabricated abutment $370.00
D6065 Implant supported porcelain crown $1,321.00
D6066 Implant supported porcelain fused to metal crown $1,160.00
Bridge - Fixed
D6240 Pontic-porcelain fused to high noble metal $800.00
D6241 Pontic-porcelain fused to base metal $650.00
D6750 Retainer crown-porcelain fused to high nobel metal $800.00
D6751 Retainer crown-porcelain fused-base metal $650.00

Oral Surgery

D7111 Extraction, coronal remnants - deciduous tooth $89.00
D7140 Extraction, erupted tooth or exposed root $98.00
D7210 Surgical removal of erupted tooth $208.00
D7220 Removal of impacted tooth- Soft tissue $252.00
D7230 Removal of impacted tooth- Partially Bony $260.00
D7240 Removal of impacted tooth- Completely Bony $305.00


D8090 Invisalign Full Case $4,195.00
D8040 Invisalign Express $2,495.00
D8680 Retainer $225.00

Other Services

D9230 Inhalation of nitrous oxide/anxiolysis, analgesia $55.00
D9940 Occlusal guard, by report $277.00
D9972 Teeth Whitening (in office) $89.00
D9975 Teeth Whitening (take home) $125.00


*Participating Dental Providers have agreed to discount their usual and customary fees for services not listed on the Smile Connection PREMIUM Summary of Discounted Fees, provided those ADA codes/ services are offered in office. “Usual” refers to the normal rate charged for the service by the Provider rendering the treatment, and “Customary”is defined as the usual rates of the Provider’s competitors in that local area. The UCR fee can vary by location.

To download complete fee schedule Click here.

35% Smile Connection PREMIUM Dental Plan Discounts on services not listed on Summary of Savings for the Premium Dental Plan.

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