| Covered Services |
Smile PPO |
Value Smile PPO |
| Calendar year deductible |
$50 |
$25 |
| Calendar year maximum |
$1,000
($500 max may be used for non-network dentists) |
$500 |
| Diagnostic & preventive services |
| Service |
With network dentist - you pay: |
With non-network dentists - they pay: |
With network dentist - you pay: |
With non-network dentists - they pay: |
| Comprehensive oral exams |
$0 |
$40 |
$0 |
$40 |
| Periodic oral exams |
$0 |
$16 |
$0 |
$16 |
| Complete X-Rays |
$0 |
$56 |
$0 |
$56 |
| Prophylaxis (cleanings, one every 6 months) |
| Adult |
$0 |
$48 |
$0 |
$48 |
| Child |
$0 |
$34 |
$0 |
$34 |
| Sealant/per tooth (covered to age 16) |
$0 |
$22 |
$0 |
$22 |
| Enahnced dental benefit for pregnant women |
$0 |
100% of charge |
$0 |
$48 |
| Routine Services |
| One-surface composite (filling) |
$37 |
$30 |
$37 |
$30 |
| Two-surface composite (filing) |
$56 |
$44 |
$56 |
$44 |
| Anterior root canal |
$156 |
$125 |
Not Covered |
Not Covered |
| Molar root canal |
$234 |
$187 |
Not Covered |
Not Covered |
| Periodontal root planing / per quadrant |
$65 |
$52 |
Not Covered |
Not Covered |
| Extraction (single tooth) |
$40 |
$32 |
Not Covered |
Not Covered |
| Major Services |
| Crown (porcelain fused to noble metal) |
$320 |
$256 |
Not Covered |
Not Covered |
| Osseous surgery / per quadrant |
$263 |
$210 |
Not Covered |
Not Covered |
| Bridge pontic/false tooth - high noble metal (per unit) |
$293 |
$234 |
Not Covered |
Not Covered |
| Bridge retainer - porcelain fused to high noble metal (per unit) |
$313 |
$250 |
Not Covered |
Not Covered |
| Complete denture (upper or lower) |
$388 |
$310 |
Not Covered |
Not Covered |
| Removal of impacted tooth (complete bony) |
$113 |
$90 |
Not Covered |
Not Covered |
| |
| Fully banded (two year) case - child |
$2,350 |
Not Covered |
Not Covered |
Not Covered |
| Fully banded (two Year) case - adult |
$2,650 |
Not Covered |
Not Covered |
Not Covered |
NOTE: Diagnostic and preventive services are not subject to plan deductibles |
Anthem California
Blue Shield of California now offers a range of affordable and comprehensive dental plans available to residents of California with or without a Blue Shield health plan. With Blue Shield's broad dental network including nearly 20,000 dental PPO providers and more than 8,600 HMO providers in California it is easy to access one of the largest networks in California.
