Plan 595

Rates
Single $18.95
Two People $28.95
Family $39.95

Rates reflect payment by credit card or automatic deduction.
For monthly payment by check, please add $1.00 to the total.

One time enrollment fee
Single $20
Two People $20
Family $20

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Best Coverage

California Dental’s Plan 595 offers the most coverage of our individual plans, including reduced specialist copays. It is a great choice for those who have not been to the dentist for awhile and are looking to get started with a healthy smile. Plan 595 includes:

Preventive services, including cleanings, x-rays and check-ups at no charge
Fillings from $4.00 to $14.00
Extractions from $10.00 to $50.00
Root Canals from $140.00 to $180.00

Specialty Coverage

Not all general dentists are capable of performing each of the services listed herein and, based upon the member’s condition, certain procedures may not be within the scope of practice or ability of a general dentist. In such cases, the general dentist will refer the member to a dental specialist. The plan will cover 30% of the specialist’s fees during the first year of enrollment and 50% thereafter, for up to $1000 in services per year.

Summary Of Benefits and Copayments

Below is a summary of benefits that are available at participating California Dental Network providers. For a complete list of
benefits see the benefits schedule.

I. Preventive Services
  Your Copayment
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
II. Basic Services
Restorations  
Amalgam, one surface $4.00
Amalgam, two surfaces $5.00
Amalgam, three surfaces $6.00
Resin, up to 3 surfaces $14.00
Temporary sedative filling $5.00
Oral Surgery  
Extraction, Single Tooth $10.00
Surgical removal of erupted tooth $30.00
Removal of impacted tooth, soft tissue $40.00
Removal of impacted tooth, partially bony $50.00
Incision & drainage of abscess, intraoral soft tissue $14.00
Endontics  
Pulp cap, direct $5.00
Pulp cap, indirect $12.00
Therapeutic pulpotomy $12.00
Root canal, anterior $80.00
Root canal, bicuspid $100.00
Root canal, molar $140.00
Periodontics  
Gingivectomy or gingivoplasy, 4 or more contiguous teeth, per quadrant $100.00
Scaling & root planing, per quadrant $40.00
III. Major Services
Crowns Your Copayment
Resin with metal* $156.00
Porcelain fused to high noble metal* (not for molars) $156.00
Porcelain fused to high noble metal* (for molars) $236.00
Full cast high noble metal* $142.00
3/4 cast metallic* $142.00
Prefabricated stainless steel, primary tooth $17.00
Dentures & Prosthodontics  
Complete upper or lower denture $160.00
Upper or lower partial denture, resin base $150.00
Upper or lower partial dentrue, cast metal base with resin saddles $175.00
Adjust complete denture No charge
Repair broken complete denture base $15.00
Replace missing or broken teeth, complete denture, each tooth $17.00
Reline complete or partial upper or lower denture, chair side $20.00
Reline complete or partial upper or lower denture, laboratory $42.00
IV. Orthodontics
Standard 24-month case  
Full-banded, upper and lower, to age 19 $1695.00
Full-banded, upper and lower, adults $1695.00
Banded, upper or lower, children & adults $1000.00
Consultation $40.00
Broken appointments without 24 hour notice $40.00
V. Cosmetic Benefits
Tooth colored fillings, on surface, back tooth $60.00
Bleaching, per arch $125.00
Labial veneer (porcelain laminate), laboratory $400.00
Night Guards, soft, includes lab fee $175.00
Bridge abutment porcelain fused to high noble metal $345.00
Bridge pontic porcelain fused to high noble metal $350.00

* Member is responsible for copayment plus actual lab cost of gold

Limitations

Prophylaxis (cleaning) is limited to once every six months

Bitewing x-rays are limited to one series of four lms every 12 months

Full mouth x-rays are limited to once every 24 months

Periodontal treatments (subgingival curettage and root planing) 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 ve years

Full upper and/or lower dentures are not to exceed one each in any ve-year period

Denture relines are limited to one per arch in any 12-month period

Exclusions

General anesthesia, analgesia (nitrous oxide), intravenous sedation, or the services of an anesthesiologist

Treatment of fractures or dislocations; congential malformations; malignancies, cysts, or neoplasms; or Temporomandibular Joint Syndromw (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