Zak Dental
DENTAL EMERGENCY? telephone call (833)-ZAK-TEAM
DENTAL EMERGENCY? telephone

COVERED BENEFITS & COPAYS

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I. PREVENTIVE SERVICESPREVENTIVE 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
restoration
copayment
  • Amalgam, 1 surface

    $85.00
  • Amalgam, 2 surfaces

    $95.00
  • Amalgam, 3 surfaces

    $105.00
  • Amalgam, 4 or more surfaces

    $120.00
  • Composite 1 surface anterior

    $125.00
  • Composite 2 surfaces anterior

    $145.00
  • Composite 3 surfaces anterior

    $175.00
  • Composite 4 or more surfaces anterior

    $215.00
  • Composite 1 surface posterior

    $140.00
  • Composite 2 surfaces anterior

    $165.00
  • Composite 3 surfaces anterior

    $190.00
  • Composite 4 or more surfaces anterior

    215.00
oral surgery
copayment
  • Amalgam, 1 surface

    $85.00
  • Amalgam, 2 surfaces

    $95.00
  • Amalgam, 3 surfaces

    $105.00
  • Amalgam, 4 or more surfaces

    $120.00
  • Composite 1 surface anterior

    $125.00
  • Composite 2 surfaces anterior

    $145.00
  • Composite 3 surfaces anterior

    $175.00
  • Composite 4 or more surfaces anterior

    $215.00
  • Composite 1 surface posterior

    $140.00
  • Composite 2 surfaces anterior

    $165.00
  • Composite 3 surfaces anterior

    $190.00
  • Composite 4 or more surfaces anterior

    215.00
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

    $325.00
  • Surgical removal of residual root tips

    $150.00
  • Synthetic bone graft

    TBD
endodontics
  • Pulp cap

    $50.00
  • Pulpotomy vital or therapeutic

    $85.00
  • Root canal, anterior

    $525.00
  • Root canal, bicuspid

    $615.00
  • Root canal, molar

    $754.00
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 BRIDGES
COPAYMENT
  • Porcelain fused to base metal crown

    $697.00
  • Porcelain fused to noble metal crown

    $747.00
  • Porcelain fused to high noble metal

    $747.00
  • All porcelain crown

    $747.00
  • Porcelain Inlay or Onlay (1-4 surfaces)

    $697.00
  • Bridge abutment or pontic unit

    $797.00
  • Cast post & core

    $195.00
  • Prefabricated post & core *

    $225.00
  • *member is responsible for copayment plus actual lab cost of gold

  • Reattach crown

    $80.00
  • Reattach bridge

    $135.00
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

    $70.00
  • Replace missing or broken teeth, complete denture, each tooth

    $145.00
  • Reline complete or partial upper or lower denture, chairside

    $225.00
  • Reline complete or partial upper or lower denture, laboratory

    $275.00
  • Stayplate

    $475.00
  • Add clasp to existing denture

    $200.00
  • Denture rebase

    $300.00
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
  • Invisalign

    TBD
V. COSMETIC SERVICES
  • In Office Bleaching, full mouth

    $249.00
  • Ceramic Crown, 3rd generation

    $747.00
  • Labial veneer (porcelain laminate), laboratory

    $847.00
  • Night guards, soft, includes lab fee

    $447.00
  • Broken Appointment w/out 24 hr notice

    $447.00
  • 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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