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$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 BRIDGESCOPAYMENT
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
InvisalignTBD

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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