TERMS & CONDITIONS

In-network Locations__________________________

Canton45650 Ford RoadCanton, MI 48087

734.207.3740

Dearborn5050 Schaefer RoadDearborn, MI 48126

313.582.0150

Farmington32750 Grand River Avenue

Farmington, MI 48336248.476.6200

East Lansing2035 Asher Ct

East Lansing, MI 48823517.394.1495

Sterling Heights37734 Van Dyke Road

Sterling Heights, MI 48312586.978.2100

Warren7591 Nine Mile Road

Warren, MI 48091586.759.3030

Woodhaven22500 Allen Road

Woodhaven, MI 48183734.676.7878

$89 Annual Membership

See details inside

The Smile Savers Dental plan can be used at any of the

following locations.S

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• Dental Plan will become effective on the first of the month in which membership is paid.

• Membership is for a period of one year from the effective date.

• You must be treated by a participating dentist.

• Any procedure that cannot be performed by a participating provider is not covered.

• Any procedure not listed is covered at 30% discount off provider’s then current fees.

• Orthodontic treatment: must remain covered under the entire duration of treatment or risk additional costs.

• This program cannot be used with any other insurance or benefit coverage.

• This is not dental insurance.

AN

NU

AL M

EM

BE

RS

HIP

FEE

:

Mem

ber: $89.00 Fam

ily (2 or more): $170.00

ME

TH

OD

OF P

AY

ME

NT:

Payment enclosed (M

ake check or money order payable to M

idwestern Dental.

Visa Discover M

asterCard American Express

4. _____________________________________ DOB_________

5. _____________________________________ DOB_________

6. _____________________________________ DOB_________

DENTAL PLAN FEE SCHEDULEAll procedures are to be billed at the amount listed, and fees are subject to change. Procedure not listed in this fee schedule are discounted by 30%.

Code Full Length Description

Typical Fee

Plan Fee Savings Discount

D120 Periodical Oral Evaluation $56 $0 $56 100%

D140 Emergency Oral Evaluation $86 $0 $86 100%

D150 Comprehensive Oral Evaluation $99 $0 $99 100%

D210-330 All X-Rays - $0 - -

D1110 Prophylaxis - Adult $103 $0 $103 100%

D1120 Prophylaxis - Child $79 $0 $79 100%

D1208 Fluoride - Child (to age 19) $43 $21 $22 51%

D1351 Sealant Per Tooth $63 $36 $27 43%

D2140 Amalgam 1 Surface Pri/Perm $157 $81 $76 48%

D2150 Amalgam 2 Surface Pri/Perm $243 $103 $140 58%

D2160 Amalgam 3 Surface Pri/Perm $335 $121 $214 64%

D2161 Amalgam 4 Surface Pri/Perm $367 $153 $214 58%

D2330 Resin 1 Surface Anterior $230 $93 $137 60%

D2331 Resin 2 Surface Anterior $268 $121 $147 55%

D2332 Resin 3 Surface Anterior $345 $148 $197 57%

D2335 Resin 4 Surf/Incisal Angle $415 $187 $228 55%

D2740 Crown Porcelain - High Noble $1,335 $793 $542 41%

D2751 Crown Porcelain - Non Precious $1,235 $683 $552 45%

D2790 Crown Full Cast - High Noble $1,430 $887 $543 38%

D2940 Sedative Filling $153 $68 $85 56%

D2950 Core Build Up With or With Pins-Post $325 $187 $138 42%

D2954 Post & Core Prefab in Addition to Crown $425 $238 $187 44%

DIAG

NO

STIC

& P

REVE

NTA

TIVE

PR

OCE

DURE

S (E

XAM

S &

X-R

AYS)

REST

ORA

TIVE

PRO

CEDU

RES

(FIL

LIN

GS)

D6010 Surgical Placement of Implant Body $2,230 $1,730 $500 22%

D6056 Prefabricated Abutment $869 $415 $454 52%

D6057 Custom Abutment $1,033 $635 $398 39%

D6059 Implant Crown - Porcelain/Gold $1,585 $1,005 $580 37%

D6740 Pontic - Porcelain to Gold $1,217 $795 $422 35%

D6750 Crown-Porcelain to Gold $1,222 $795 $427 35%

D6241 Pontic - Porcelain to Non-Precious $1,125 $645 $480 43%

D6751 Crown - Porcelain to Non-Precious $1,107 $645 $462 42%

D7140 Extraction-Erupted Tooth $235 $93 $142 60%

D7210 Extraction-Surgical Erupted Tooth $329 $183 $146 44%

D7220 Extraction-Impacted Soft Tissue $363 $203 $160 44%

D7230 Extraction-Impacted Partial Bony $476 $253 $223 47%

D7240 Extraction-Impacted Complete Bony $587 $308 $279 48%

D7250 Surgical Removal of Residual Root $385 $178 $207 54%

D7310 Alveoplasty with Extractions $348 $183 $165 47%

D8080Comprehensive

Treatment - Adolescent

$5,883 $3,970 $1,913 33%

D8090 Comprehensive Treatment - 19+ $6,015 $4,310 $1,705 28%

ORT

HODO

NTI

C FI

XED

PRO

STHO

DON

TIC

PRO

CEDU

REIM

PLAN

T PR

OCE

DURE

SO

RAL

SURG

ERY

PRO

CEDU

RES

(EXT

RACT

ION

S)

D3310 Root Canal Anterior $803 $487 $316 39%

D3320 Root Canal Bicuspid $937 $567 $370 39%

D3330 Root Canal Molar $1,128 $687 $441 39%

D3346 Retreat Anterior $1,128 $787 $341 30%

D3347 Retreat Bicuspid $1,235 $835 $400 32%

D3348 Retreat Molar $1,338 $937 $401 30%

D4249 Crown Lengthening $1,015 $535 $480 47%

D4260 Osseous Surgery $1,323 $735 $588 44%

D4263 Bone Replacement-First Site in Quad $785 $257 $528 67%

D4341 Scaling & Root Planing-Per Quad $287 $157 $130 45%

D4910 Periodontal Maintenance $163 $121 $42 26%

D5110 Complete Upper Denture $1,880 $893 $987 53%

D5120 Complete Lower Denture $1,880 $893 $987 53%

D5130 Immediate Upper Denture $2,035 $957 $1,078 53%

D5140 Immediate Lower Denture $2,035 $957 $1,078 53%

D5213 Upper Partial-Metal Base $1,983 $968 $1015 51%

D5214 Lower Partial-Metal Base $1,983 $968 $1015 51%

D5225 Upper Partial-Flex/Valplast $1,983 $1,060 $923 47%

D5226 Lower Partial-Flex/Valplast $1,983 $1,060 $923 47%

D5820 Interim Partial Upper (Flipper) $387 $225 $162 42%

D5821 Interim Partial Lower (Flipper) $387 $225 $162 42%

D2391 Composite 1 Surface Posterior $243 $103 $140 58%

D2392 Composite 2 Surface Posterior $335 $151 $184 55%

D2393 Composite 3 Surface Posterior $393 $183 $210 53%

D2394 Composite 4 Surface Posterior $485 $236 $249 51%

D2960 Labial Veneer Resin - Chairside $806 $487 $319 40%

D2962 Labial Veneer Porcelain-Lab $1,516 $839 $677 45%

D9972 Bleaching - ZOOM $499 $399 $100 20%

ENDO

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PRO

CEDU

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(DEN

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COSM

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First Nam

e: ____________________________________ M.I. _____ Last N

ame: _______________________________________

Address: _______________________________________________ City: ______________________________ Zip: ____________

Telephone#: _____________________________________________ Social Security#: _______________________ DOB_________

Nam

es of Dependents*:

1. ____________________________________ DOB_________

2. ____________________________________ DOB_________

3. ____________________________________ DOB_________

*List spouse or civil union partner and unmarried dependent children under age 26 that you w

ish to enroll.

Card#: _____________________________________________ Security Code (3 or 4 digit # on back of card): _________________

Expiration date: __________________________________________ Billing zip code: _____________________________________

Nam

e on card: ______________________________________________________________________________________________

Signed: ________________________________________________________ Date Signed: ________________________________

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