Summary of Benefits

Summary of CDN Individual Dental Plan

Benefits and Copayments

The following dental procedures are covered at the listed copayment price, when administered by a general dentist at Dr. Zak Dental Care.

 

I. PREVENTIVE SERVICES

 
Office visitNo Charge
Oral examinationNo Charge
Intraoral x-rays, complete seriesNo Charge
Bitewing x-rays, single filmNo Charge
Topical fluoride (child)No Charge
Oral hygiene instructionNo Charge
Prophylaxis (teeth cleaning)No Charge
Sealant per tooth$25.00

II. ROUTINE SERVICES

 
RESTORATIONSCOPAYMENT
Amalgam, 1 surface$85.00
Amalgam, 2 surfaces$95.00
Amalgam, 3 surfaces$105.00
Amalgam, 4 or more surfaces TBD
Composite 1 surface anterior$95.00
Composite 2 surfaces anterior$120.00
Composite 3 surfaces anterior$145.00
Composite 4 or more surfaces anterior                                             TBD
Composite 1 surface posterior$125.00
Composite 2 surfaces posterior$165.00
Composite 3 surfaces posterior$190.00
Composite 4 or more surfaces posterior TBD

 

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
Surgical removal of residual root tips TBD
Synthetic bone graft TBD

 

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
Periodontal Irrigation, per quadrant TBD
Periodontal Irrigation, generalized TBD
Arestin (per site) TBD

III. MAJOR SERVICES

 
CROWNS AND BRIDGESCOPAYMENT
Porcelain fused to base metal crown TBD
Porcelain fused to noble metal crown TBD
Porcelain fused to high noble metal$597.00
All porcelain crown TBD
Porcelain Inlay or Onlay (1-4 surfaces) TBD
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 
Reattach crown TBD
Reattach bridge TBD

 

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
Add clasp to existing denture TBD
Denture rebase TBD

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
InvisalignTBD

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%.

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