California Dental Plan 411

Rates
Single $12.95
Two People $19.95
Family $29.95
One time enrollment fee
Single – Two People – Family $20

Lowest Monthly Fee

California Dental Plan 411 offers bigger savings at the dentist. It is a great choice for those who may need to see the dentist a little less often. Plan 411 includes:

Preventive services, including cleanings, x-rays and check-ups at no charge
Fillings from $15.00 to $25.00
Extractions from $19.00 to $65.00
Root Canals from $100.00 to $175.00

Specialty Coverage

With California Dental Plan 411 you will receive a 30% discount if you ever need to see a specialist. Why would you need to see a specialist? You might require treatment that is beyond the ability of a general dentist. Such treatment may require an expert that has been specially trained to treat your condition.

 

 

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 $10.00
Amalgam, two surfaces $15.00
Amalgam, three surfaces $20.00
Resin, up to 3 surfaces $25.00
Temporary sedative filling $10.00
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, intraoral soft tissue $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
Periodontics
Gingivectomy or gingivoplasty, 4 or more contiguous teeth, per quadrant $150.00
Scaling & root planing, per quadrant $40.00
III. Major Services
Crowns Your Copayment
Resin with metal* $175.00
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
Dentures & Prosthodontics
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, chair side $65.00
Reline complete or partial upper or lower denture, laboratory $100.00
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
IV. Orthodontics
Standard 24-month case  
Full-banded, upper and lower, to age 19 $1775.00
Full-banded, upper and lower, adults $1975.00
Banded, upper or lower, children & adults $1000.00
Consultation $25.00
Broken appointments without 24 hour notice $40.00

* 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 films 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 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

Exclusions

  • 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 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