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Schedule of Benefits for Individual Plan 460

 

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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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