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Below explanation is for California plan only

Blue Shield Dental Insurance 
(877)566-5454 Toll Free
BLUE SHIELD DENTAL PLANS MONTHLY RATES (under age 65)
 
SMILE PPO
VALUE SMILE PPO
Adult or Child $39.70 $21.40
Adult & Spouse $83.90 $45.30
Adult & Child $60.10 $32.40
Adult & Children $89.50 $48.40
Family $139.50   $75.30

BLUE SHIELD INDIVIDUAL DENTAL SMILE PPO & VALUE SMILE PPO HIGHLIGHTS
 
SMILE PPO ¹ ² ³
VALUE SMILE PPO ¹
In network
you pay:
Non-network
we pay up to:
In network
you pay:
Non-network
we pay up to:
Diagnostic & preventive services
Calendar-year deductible
$50 per person
$25 per person
Calendar-year maximum
$1000*
$500
Comprehensive Oral Exams $0 $40 $0 $40
Periodic oral exams $0 $16 $0 $16
Complete X-Rays $0 $56 $0 $56
Prophylaxis (cleaning, 1 every 6 months)
     Adult $0 $48 $0 $48
     Child $0 $34 $0 $34
Sealant/per tooth (covered to age 16) $0 $22 $0 $22
Enhanced dental benefits
  for pregnant women		 $0 100%
of charge		 $0 $48
Routine services
1-surface composite (filling) $37 $30 $37 $30
2-surface composite (filling) $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
Orthodontics
Fully bonded (two year) case - child $2,350    Not Covered Not Covered Not Covered
Fully bonded (two year) case - adult $2,650    Not Covered Not Covered Not Covered
Note: Diagnostic & preventive services are not subject to plan deductibles.
* $500 maximum may be used for non-network dentists.
¹ You must be a California resident and under age 65 at the time of enrollment.
² Smile PPO members have certain waiting periods: 6 months for minor restorative (such as fillings), endodontics, periodontics, and oral surgery services; 12 months for major restorative (such as crowns), orthodontics, and prosthetics (removable and fixed) services.
³ Smile PPO plan covers orthodontic services with a fixed copayment, which does not apply to your $1,000 benefit maximum. You pay the copayment plus up to $250 for records.

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Or you can fill in this form to have your Blue Shield Dental Insurance brochure with pricing & application mailed to you. Further information on our plans is shown below. Or just call us Toll-free at 877-Look4Life (877-566-5454).
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