Summary of Benefits

Summary of CDN Individual Dental Plan 1000z

Benefits and Copayments

The following dental procedures are covered at the listed copayment price, when administered by a general dentist at Dr. Zak Dental Care in Valencia.

I. PREVENTIVE SERVICES

 
Office visitNo Charge
Oral examinationNo Charge
Intraoral x-rays, complete seriesNo Charge
Bitewing x-rays, single filmNo Charge
Topical fluoride (child)No Charge
Oral hygiene instructionNo Charge
Prophylaxis (teeth cleaning)No Charge
Sealant per tooth$25.00

II. ROUTINE SERVICES

 
RESTORATIONSCOPAYMENT
Amalgam, 1 surface$85.00
Amalgam, 2 surfaces$95.00
Amalgam, 3 surfaces$105.00
Composite 1 surface anterior$95.00
Composite 2 surface anterior$120.00
Composite 3 surface anterior$145.00
Composite 1 surface posterior$125.00
Composite 2 surface posterior$165.00
Composite 3 surface posterior$190.00
ORAL SURGERY 
Extraction, single permanent tooth$120.00
Surgical removal of erupted tooth$190.00
Removal of impacted tooth, soft tissue$220.00
Removal of impacted tooth, partially bony$245.00
Removal of impacted tooth, full bony$275.00
ENDODONTICS 
Pulp cap$50.00
Pulpotomy vital or therapeutic$85.00
Root canal, anterior$435.00
Root canal, bicuspid$511.00
Root canal, molar$655.00
PERIODONTICS 
Scaling & root planning, per quadrant$95.00
Full Mouth Debridement$99.00
Periodontal Maintenance$89.00

III. MAJOR SERVICES

 
CROWNSCOPAYMENT
Porcelain fused to high noble metal$597.00
Bridge abutment or pontic unit$647.00
Cast post & core$195.00
Prefabricated post & core$189.00
*member is responsible for copayment plus actual lab cost of gold 
DENTURESCOPAYMENT
Complete upper or lower denture$975.00
Upper or lower partial denture, resin base$775.00
Upper or lower partial denture, cast metal base with resin saddles$1,075.00
Adjust complete or partial upper or lower denture$50.00
Replace missing or broken teeth, complete denture, each tooth$50.00
Reline complete or partial upper or lower denture, chairside$175.00
Reline complete or partial upper or lower denture, laboratory$245.00
Stayplate$325.00

IV. ORTHODONTICS

 
STANDARD 24-MONTH CARE COPAYMENT 
Full-banded, upper and lower, to age 19$2,850.00
Full-banded, upper and lower, adults$3,050.00
Upper or lower, to age 19$1,970.00
Upper or lower, adult$2,120.00
Ortho Retention upper and lower$650.00

V. COSMETIC SERVICES

 
In Office Bleaching, full mouth$249.00
Ceramic Crown, 3rd generation$697.00
Labial veneer (porcelain laminate), laboratory$697.00
Night guards, soft, includes lab fee$397.00
Broken Appointment w/out 24 hr notice$50.00
Emergency after-hours$145.00

The ratio of premium costs to health services paid, for plan contracts with individuals and groups of 25 or fewer members, during the preceding fiscal year was 50%.

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