 | |
DIAGNOSTIC & PREVENTIVE | |
| Full-mouth digital x-rays | No Charge |
| Single film | No Charge |
| Each additional film | No Charge |
| Oral examination & diagnosis | No Charge |
| Office visit | $ 5.00 |
| Prophylaxis (cleaning & polishing) | $ 75.00 |
| Oral hygiene instruction | No Charge |
| Sealants | $ 41.00 |
| Flouride Varnish | $ 30.00 |
| Full-mouth digital x-rays | No Charge |
RESTORATIVE DENTISTRY (Fillings) | |
| Amalgam (primary or permantent teeth) | |
| One tooth surface | $ 85.00 |
| Two tooth surfaces | $95.00 |
| Three tooth surfaces | $ 105.00 |
| Composite Restorations(anterior teeth) | |
| One tooth surface | $ 105.00 |
| Two tooth surfaces | $ 130.00 |
| Three tooth surfaces | $ 150.00 |
| Composite restorations (posterior teeth) | |
| One tooth surface | $ 135.00 |
| Two tooth surfaces | $ 175.00 |
| Three tooth surfaces | $ 195.00 |
| Lumineers | $ 1,095.00 |
ENDODONTICS | |
| Single-rooted canal therapy | $ 448.00 |
| Two-rooted canal therapy | $ 506.00 |
| Three-rooted canal therapy | $ 624.00 |
| Pulp capping | $ 65.00 |
| Pulpotomy | $ 188.00 |
PROSTHODONTICS - REMOVABLE | |
| Complete maxillary denture (acrylic) | $ 875.00 |
| Complete mandibular denture (acrylic) | $ 875.00 |
| Immediate maxillary denture | $ 875.00 |
| Immediate mandibular denture | $ 875.00 |
| Premium denture | $ 1,895.00 |
| Partial lower or upper, chrome cobalt alloy lingual or palatal bar & acrylic saddles base | $ 1,015.00 |
| Premium partial | $ 1,795.00 |
| Stayplate | $ 390.00 |
| teeth & clasps, extra per unit | $ 38.00 |
| Office reline - cold cure - acrylic | $ 210.00 |
| Denture reline - laboratory processed | $ 281.00 |
| Broken denture repair (no teeth involved) | $ 80.00 |
| replace teeth (each) | $ 75.00 |
| |
CROWNS & BRIDGES | |
| Porcelain fused to metal crown | $ 495.00 |
| Porcelain fused to gold crown | $ 775.00 |
| 3rd generation crowns | $ 820.00 |
| Full gold crown | $ 795.00 |
| Recementation | $ 113.00 |
| Endo cast post | $ 225.00 |
| Plastic core amalgam buildup | $ 140.00 |
| LAVA™ crown | $ 1150.00 |
| Cerec CAD/CAM Crown | $ 855.00 |
| Cerec CAD/CAM Inlay | $ 595.00 |
| Cerec CAD/CAM Onlay | $ 795.00 |
| Three tooth surfaces | $ 195.00 |
| Blue Block Cerec CAD/CAM Crown | $ 1050.00 |
ORAL SURGERY | |
| EXTRACTIONS | |
| Simple, local anesthesia | $ 95.00 |
| Extraction | $ 221.00 |
| Impaction, soft tissue | $ 236.00 |
| Impaction, partially bony | $ 281.00 |
| Impaction, full bony | $ 340.00 |
ORTHODONTICS | |
| CHILD (24 month case) | |
| Full upper & lower banded cases | $ 2,700.00 |
| Upper or lower banded cases | $ 1,900.00 |
| Retention upper & lower | $ 650.00 |
| Retention upper or lower | $ 450.00 |
| ADULT (24 month case) | |
| Full upper & lower banded cases | $ 2,900.00 |
| Upper or lower banded cases | $ 2,050.00 |
| Retention upper & lower | $ 650.00 |
| Retention upper or lower | $ 450.00 |
| Records | $ 200.00 |
OTHER SERVICES | |
| After hours emergency | $ 145.00 |
| Nightguard | $ 431.00 |
| Teeth-whitening (full mouth) w/ custom take-home trays | $ 245.00 |
| Nitrous | $ 105.00 |
Exclusions
- Treatment of fractures or dislocations, congenital malformations, malignancies, cysts or neoplasms, or Temporomandibular Joint Syndrome (TMJ).
- Prescription drugs and over the counter drugs.
Limitations
- Prophylaxis (Cleaning) is limited to once every six months.
- ll mouth x-rays are limited to once every 24 months.
- Replacement of partial dentures is limited to once every five years.
- Full upper and/or lower dentures are not to exceed one each in any five-year period.
- Denture relines are limited to one per arch in any 12 month period.
- Services performed by a non-participating provider are not covered.
Downloadable Forms and Documents
Description of Services and Disclosure Form - April 2009- My Smile Dental Plan Fee Schedule - April 2009
- Grievance Form - June 2009
Downloadable Forms and Documents (Texas Residents Only)
- Application Form (Texas residents only) - October 2009
- Description of Services and Disclosure Form (Texas residents only) - August 2009
- Grievance Form (Texas residents only) - August 2009
Coastal Dental is required to provide prospective Members a copy of the Individual and Family Combined Membership agreement and Description of Services and Disclosure Form prior to enrollment.
For Texas residents only-Providers available for the My Smile Dental Plan are located in Allen, Denton, Frisco, and McKinney.