| Rates |
| Single |
$18.95 |
| Two People |
$28.95 |
| Family |
$39.95 |
| One time enrollment fee |
| Single – Two People – Family |
$20 |
Best Coverage
California Dental 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 |
| Endodontics |
|
| 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 denture, 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 |
| Implants – Services Covered at the General Dentist only |
|
| Surgical placement of implant body, endosteal |
$1500.00 |
| Prefabricated abutment, includes placement |
$450.00 |
| Abutment supported porcelain/ceramic crown |
$1055.00 |
| Recement implant/abutment supported crown |
$45.00 |
|
| 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 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
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