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 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
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 posterior $165.00
Composite 3 surfaces posterior $190.00
Composite 4 or more surfaces posterior $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 $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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