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CapDent INDIVIDUAL PLAN
This is an in-network dental plan. There is no out-of-network benefit. Benefits are only available at the offices of the more than 3,000 dentists that participate in the CapDent Panel.
| PROCEDURE |
PATIENT COPAYMENT |
Diagnostic & Preventive Services |
|
| Oral Exam |
No Charge |
| Full Mouth X-rays |
No Charge |
| Single Films |
No Charge |
| Bitewing Series |
No Charge |
| Oral Hygiene Instruction |
No Charge |
| Cleaning of Teeth (polishing) |
No Charge |
| Fluoride Treatment |
No Charge |
| Emergency Treatment |
No Charge |
| |
|
| Restorative Dentistry Primary and Permanent |
| Silver amalgam, one surface |
$20.00 |
| Silver amalgam, two surfaces |
$35.00 |
| Silver amalgam, three surfaces or more |
$50.00 |
| Composite filling, one surface |
$25.00 |
| Composite filling, two surfaces |
$40.00 |
| Composite filling, three surfaces or more |
$55.00 |
| |
|
| Oral Surgery* |
| Routine Extractions - per tooth |
$45.00 |
| Surgical Extraction |
$75.00 |
| Soft Tissue Impaction |
$95.00 |
| Partial Bony Impaction |
$125.00 |
| Full Bony Impaction |
$160.00 |
| Alveolectomy, per quad |
$95.00 |
| |
|
| Root Canal Therapy* |
|
| Pulp Capping |
$10.00 |
| Pulpotomy |
$35.00 |
| Root Canal Therapy-Anterior |
$225.00 |
| Root Canal Therapy-Bicuspid |
$290.00 |
| Root Canal Therapy-Molar |
$395.00 |
| Apicoectomy |
$175.00 |
| |
|
| Periodontics* |
|
| Scaling of teeth, per quad |
$25.00 |
| Gingivectomy, per quad |
$125.00 |
| Osseous surgery, per quad |
$425.00 |
| |
|
| Prosthetics - Crowns |
|
| Acrylic with metal crown |
$295.00 |
| Porcelain crown |
$385.00 |
| Porcelain w/ metal crown |
$425.00 |
| Stainless steel crown |
$95.00 |
| Cast post |
$95.00 |
| Recementation, per crown |
$35.00 |
| |
|
| Prosthetics - Fixed Bridges |
|
| Acrylic w/ metal bridge crown or pontic |
$295.00 |
|
Porcelain w/ metal bridge crown or pontic |
$425.00 |
| Recementation, bridge |
$35.00 |
| |
|
| Prosthetics - Removable |
|
| Full upper denture, inc. adjustments |
$395.00 |
| Full lower denture, inc. adjustments |
$395.00 |
| Partial upper denture, cast base and acrylic |
$395.00 |
| Partial lower denture, cast base and acrylic |
$395.00 |
Denture Adjustments
for denture not made in office |
$35.00 |
| |
|
| Prosthetics - Repairs |
|
| Broken body of denture (no teeth involved) |
$95.00 |
| Replacing broken, missing teeth |
$35.00 |
| Office Reline |
$95.00 |
| Lab Reline |
$150.00 |
| |
|
| Orthodontics |
|
| Maximum Case Fee - 24 months |
75% UCR |
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|
* When a participating specialist renders these services, the copayment will be 25% less than specialist's usual fees. |
