Summary of Individual Dental Plan through California Dental Network
Benefits and Copayments
The listed dental care procedures are available to you at the following prices, when provided by a general dentist at Dr. Zak Sea Breeze Dental Care in Agoura Hills.
I. PREVENTIVE SERVICES | |
Office visit | No Charge |
Oral examination | No Charge |
Intraoral x-rays, complete series | No Charge |
Bitewing x-rays, single film | No Charge |
Topical fluoride (child) | No Charge |
Oral hygiene instruction | No Charge |
Prophylaxis (teeth cleaning) | No Charge |
Sealant per tooth | $25.00 |
II. ROUTINE SERVICES | |
RESTORATIONS | COPAYMENT |
Amalgam, 1 surface | $85.00 |
Amalgam, 2 surfaces | $95.00 |
Amalgam, 3 surfaces | $105.00 |
Composite 1 surface anterior | $95.00 |
Composite 2 surface anterior | $120.00 |
Composite 3 surface anterior | $145.00 |
Composite 1 surface posterior | $125.00 |
Composite 2 surface posterior | $165.00 |
Composite 3 surface posterior | $190.00 |
ORAL SURGERY | |
Extraction, single permanent tooth | $120.00 |
Surgical removal of erupted tooth | $190.00 |
Removal of impacted tooth, soft tissue | $220.00 |
Removal of impacted tooth, partially bony | $245.00 |
Removal of impacted tooth, full bony | $275.00 |
ENDODONTICS | |
Pulp cap | $50.00 |
Pulpotomy vital or therapeutic | $85.00 |
Root canal, anterior | $435.00 |
Root canal, bicuspid | $511.00 |
Root canal, molar | $655.00 |
PERIODONTICS | |
Scaling & root planning, per quadrant | $95.00 |
Full Mouth Debridement | $99.00 |
Periodontal Maintenance | $89.00 |
III. MAJOR SERVICES | |
CROWNS | COPAYMENT |
Porcelain fused to high noble metal | $597.00 |
Bridge abutment or pontic unit | $647.00 |
Cast post & core | $195.00 |
Prefabricated post & core | $189.00 |
*member is responsible for copayment plus actual lab cost of gold | |
DENTURES | COPAYMENT |
Complete upper or lower denture | $975.00 |
Upper or lower partial denture, resin base | $775.00 |
Upper or lower partial denture, cast metal base with resin saddles | $1,075.00 |
Adjust complete or partial upper or lower denture | $50.00 |
Replace missing or broken teeth, complete denture, each tooth | $50.00 |
Reline complete or partial upper or lower denture, chairside | $175.00 |
Reline complete or partial upper or lower denture, laboratory | $245.00 |
Stayplate | $325.00 |
IV. ORTHODONTICS | |
STANDARD 24-MONTH CARE COPAYMENT | |
Full-banded, upper and lower, to age 19 | $2,850.00 |
Full-banded, upper and lower, adults | $3,050.00 |
Upper or lower, to age 19 | $1,970.00 |
Upper or lower, adult | $2,120.00 |
Ortho Retention upper and lower | $650.00 |
V. COSMETIC SERVICES | |
In Office Bleaching, full mouth | $249.00 |
Ceramic Crown, 3rd generation | $747.00 |
Labial veneer (porcelain laminate), laboratory | $697.00 |
Night guards, soft, includes lab fee | $397.00 |
Broken Appointment w/out 24 hr notice | $50.00 |
Emergency after-hours | $145.00 |
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 50%.