Schedule of Benefits
for Individual Plan 460
Download Benefit
Schedule
The following dental services are covered
benefits for the Specified copayment, only when
provided by a participating California Dental
Network general Dentist.
Preventive Services
Office
visit..............................................
$5.00
Oral
examination......................................
No Charge
Intraoral x-rays, complete series...............
No Charge
Bitewing x-rays, single
film........................ No Charge
Panoramic
x-ray....................................... No
Charge
Prophylaxis
(cleaning)............................... No
Charge
Topical fluoride
(child).............................. No Charge
Oral hygiene
instruction............................. No
Charge
Routine Services
RESTORATIONS
Amalgam, one
surface.......................................$10.00
Amalgam, two
surfaces.....................................$15.00
Amalgam, three
surfaces....................................$20.00
Resin, up to three surfaces
................................$25.00
ORAL SURGERY
Extraction, single
tooth......................................
$25.00
Surgical removal of erupted
tooth........................$45.00
Removal of impacted tooth, soft
tissue................$60.00
Removal of impacted tooth, partially
bony...........$75.00
Incision & drainage of
abscess...........................$40.00
ENDODONTICS
Pulp cap,
direct.................................................$15.00
Pulp cap,
indirect...............................................$15.00
Therapeutic pulpotomy.......................................$25.00
Root canal,
anterior............................................$125.00
Root canal,
bicuspid...........................................$150.00
Root canal,
molar...............................................$185.00
Canal preparation & post
fitting...........................$70.00
PERIODONTICS
Gingivectomy or gingivoplasty, 4 or more
contiguous teeth, per
quadrant........................$150.00
Scaling & root planning, per
quadrant.............$40.00
Major Services
CROWNS
Resin with
metal*................................................$175
Porcelain fused to high noble metal*
(not for
molars)...............................................$275.00
Porcelain fused to high noble metal*
(for
molars)....................................................$350.00
Full cast high noble
metal*..................................$250.00
3/4 cast
metallic*................................................$250.00
Prefabricated stainless steel, primary
tooth..........$50.00
Temporary sedative
filling...................................$10.00
DENTURES & PROSTHODONTICS
Cast high noble metal* pontic..............................$200.00
Porcelain fused to high noble metal* pontic..........$200.00
Resin with high noble metal* pontic......................$175.00
Re-cement
bridge................................................$25.00
Complete upper or lower
denture........................$350.00
Upper or lower partial denture, resin
base............$300.00
Upper or lower partial denture, cast metal base
with resin
saddles............................................$350.00
Adjust complete
denture......................................$25.00
Repair broken complete denture
base...................$50.00
Replace missing or broken teeth,
complete denture, each
tooth...........................$25.00
Add tooth to existing partial
denture.....................$50.00
Add clasp to existing partial
denture.....................$50.00
Reline complete or partial upper or lower
denture, chairside............................................$65.00
Reline complete or partial upper or lower
denture,
laboratory...........................................$100
MEMBER IS RESPONSIBLE FOR COPAYMENT PLUS ACTUAL
LAB COST Of GOLD.
Orthodontics
STANDARD 24-MONTH CASE
Full-banded, upper and lower, to age
19................$1,775
Full-banded, upper and lower,
adults......................$1,975
Banded, upper or lower, children &
adults..............$1,000
Consultation...........................................................$25.00
Broken appointments without 24-hour
notice..........$25.00
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 0%.
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Who Is Eligible?
You may enroll yourself, your spouse and
eligible dependents. Eligible dependents include
unmarried children to age 19 and full-time
students to age 23. A full-time student is
defined as taking 12 or more units. Verification
is required.
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Out-of-Area Emergency Care is Covered Too!
If an emergency happens and you need care at a
location that is more than 50 miles from your
California Dental Network dental office,
California Dental Network will reimburse you up
to $50 per year for out-of-area emergency
treatment.
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Exclusions and Limitations
Prophylaxis (cleaning) is limited
to once every six months.
Bitewing x-rays are limited to one Series of
four films every 12 months.
Full mouth x-rays are limited to once every 24
months.
Periodontal treatments (subgingival curettage
and root planning) are limited to one treatment
per quadrant in any 12-month period.
Fixed bridgework will be covered only when a
partial cannot satisfactorily restore the case.
Replacement of partial dentures is limited to
once every five years.
Full upper and/or lower dentures are not to
exceed , one each in any five-year period.
Denture relines are limited to one per arch in
any ! 12-month period.
General anesthesia, analgesia (nitrous oxide),
intravenous sedation, or the services of an
anesthesiologist.
Treatment of fractures or dislocations;
congenital malformations; malignancies. cysts,
or neoplasms; or Temporomandibular Joint I
Syndrome (TMJ).
Extractions or x-rays for orthodontic purposes.
Prescription Drugs and. over the counter drugs.
Any services involving implants
or experimental procedures.
Any procedures performed for cosmetic, elective
or aesthetic purposes.
Any procedure to replace or stabilize tooth
structure lost by attrition, abrasion, erosion
or grinding.
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