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Benefit Summary
| Affordable Smile Plan | MCDP | Standard Fee |
|---|---|---|
| Periodic Oral Exam | 100% | $63.00 |
| Limited Oral Exam | 100% | $94.00 |
| Comprehensive Oral Exam | 100% | $109.00 |
| Comprehensive Periodontal Exam | 100% | $120.00 |
| Full Mouth X-Rays | 100% | $156.00 |
| Panoramic X-Ray | 100% | $131.00 |
| Bitewing X-Rays – 4 films | 100% | $80.00 |
| Bitewing X-Rays – 2 films | 100% | $54.00 |
| Dental Cleaning – Adult | 100% | $109.00 |
| Dental Cleaning – Child | 100% | $81.00 |
| Fluoride Treatment | 72% | $53.00 |
| Tooth Colored Fillings | 51% | $351.00 |
| All Porcelain Crowns | 34% | $1373.00 |
| Core Buildup | 56% | $323.00 |
| Root Canal Therapy | 53% | $1,242.00 |
| Deep Scale Cleaning | 51% | $307.00 |
| Dentures | 50% | $2,264.00 |
| Partials | 50% | $2,187.00 |
| Surgical Extraction | 43% | $335.00 |
| Orthodontia – Child* | $3,400.00 | $6,033.00 |
| Orthodontia – Adult* | $3,400.00 | $6,177.00 |
| Individual Plan | $129.00** | |
| Family Plan (up to 4 family members) | $199.00** |
All services not listed are discounted 20% off of Standard fees
*Price valid for traditional braces only, does not include Invisalign
**No refunds on the purchase of the Affordable Smile Plan will be given once services have been provided at the discounted rate.
| Affordable Smile Plan | MCDP – E | Standard Fee |
|---|---|---|
| Periodic Oral Exam | 100% | $63.00 |
| Limited Oral Exam | 100% | $94.00 |
| Comprehensive Oral Exam | 100% | $109.00 |
| Comprehensive Periodontal Exam | 100% | $120.00 |
| Full Mouth X-Rays | 100% | $156.00 |
| Panoramic X-Ray | 100% | $131.00 |
| Bitewing X-Rays – 4 films | 100% | $80.00 |
| Bitewing X-Rays – 2 films | 100% | $54.00 |
| Dental Cleaning – Adult | 100% | $109.00 |
| Dental Cleaning – Child | 100% | $81.00 |
| Fluoride Treatment | 100% | $53.00 |
| Tooth Colored Fillings | 71% | $351.00 |
| All Porcelain Crowns | 49% | $1,373.00 |
| Core Buildup | 73% | $323.00 |
| Root Canal Therapy | 62% | $1,242.00 |
| Deep Scale Cleaning | 67% | $307.00 |
| Dentures | 60% | $2,264.00 |
| Partials | 63% | $2,187.00 |
| Surgical Extraction | 64% | $335.00 |
| Orthodontia – Child* | $3,400.00 | $6,033.00 |
| Orthodontia – Adult* | $3,400.00 | $6,177.00 |
| Individual Plan | $349.00** | |
| Family Plan (up to 4 family members) | $399.00** |
All services not listed are discounted 30% off of Standard fees
*Price valid for traditional braces only, does not include Invisalign
**No refunds on the purchase of the MetroCare Dental Discount Plan will be given once services have been provided at the discounted rate.
Plan Exclusions:
- Treatment of fractures or dislocations, congenital malformations, malignancies, cysts or neoplasms, or TMJ
- Prescription drugs and over-the-counter drugs
Plan Limitations
- Full mouth x-rays are limited to once every 24 months
- Replacement of partial denture is limited to once every five years
- Full upper and/or lower dentures are not to exceed once 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.