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 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 | $697.00 |
| 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%.
