No charge for exams, x-rays or cleaning once every 6 months  
No deductibles!  
No waiting period to see a dentist!  
No claim forms!  
No annual maximums!  
No limitations on most pre-existing conditions!  
Adult and Children braces Include on Plans  
  Individual Family Plans start at just $12 a month (I-430 Plan)  

Schedule of I-430 Discount Dental Plan  Membership Discount Fees
The following dental services are provided for the specified discounts only when provided by a participating Pacific Dental Network general dentist.
General dental services not listed are provided at a 30% discount of the participating general dentist’s usual fees. 

Other discounts do not apply or may not be used in connection with any other coverage or plan the Member may have.


CLICK HERE for PDF Version of Below Application For Printing and Mailing (Attached)


              Office Visit                                                   $5.00
120.. Periodic Oral Examination                          No Charge
140.. Limited Oral Exam/Problem Focused.        No Charge
150  Comprehensive Exam....                             No Charge
170.. Re-evaluation, Limited, Problem Focused  No Charge
180   Comprehensive Periodontal Evaluation           $15.00

210-240    Intraoral                                             No Charge
270-274   Bitewings                                           No Charge
330..        Panoramic Film......                             No Charge
350..       Oral/Facial Images, Non-Orthodontic   No Charge
Tests & Laboratory Examinations

460 ...    Pulp Vitality Tests                                 No Charge
470        Diagnostic Casts, Non-Orthodontic            $10.00

1110,20  Prophylaxis, Child or Adult                  No Charge
1201,03 Topical Application of Fluoride, Child    No Charge
1310... Nutritional Counseling for Disease
            Control                                                    No Charge
1320... Tobacco Counseling for Disease
            Control                                                    No Charge
1330... Oral Hygiene Instruction                         No Charge 1351     Sealant, Per Tooth, Under
            Age 14 Only                                                 $20.00
Amalgam Restorations, Including Polishing

2140... One Surface, Primary or Permanent.           $20.00
2150... Two Surfaces, Primary or Permanent.        $25.00
2160... Three Surfaces, Primary or Permanent.      $34.00
2161... Four or More Surfaces, Primary or
            Permanent.                                                   $43.00

Resin Restorations

2330-32..One, Two or Three Surfaces,
                Anterior                                                    $35.00
2335... Four+ Surfaces or w/ Incisal Angle
           Anterior                                                         $37.00
2390... Resin-Based Composite Crown,
            Anterior                                                        $45.00
2391... Resin-Based Composite, One Surface, Posterior,
Facial Surface of Bicuspid Only When Caries orFailing Restoration Exists                                                                                                                                                 $45.00

Crowns, Single Restoration Only #

2710..... Resin,Laboratory                                      $115.00
2720-22 Resin w/ Metal....                                     $140.00
2750-52 Porcelain Fused to Metal                          $200.00
              For Molars                                                $275.00
2780-82 3/4 Cast Metal....                                      $185.00
2790-92   Full Cast Metal                                        $185.00

Other Restorative Services #

2910..... Recement Inlay, Metallic Only                     $12.00
2920... Recement Crown...                                      $12.00
2930  Prefabricated Stainless Steel Crown,
          Primary                                                           $45.00
2931... Prefab. Stainless Steel Crown,
           Permanent                                                     $45.00
2940... Temporary Sedative Filling                             $7.00
2950... Crown Build-Up, w/ Any Pins......          No Charge
2951... Pin Retention, Per Tooth, w/
           Restoration......                                        No Charge
2952... Cast Post & Core In Addition to
            Crown....                                                      $75.00
2953    Each Additional Cast Post, Same Tooth No Charge

Other Restorative Services* (continued)

2954  Prefabricated Post & Core In
          Additon to Crown....                                       $70.00
2970  Temp Crown w/ Fractured Tooth             No Charge


3110, 20.. Direct or Indirect Pulp Capping
                 w/out Final Restoration                           $15.00
3220         Therapeutic Pulpotomy
                  w/out Final Restoration                          $25.00

Root Canal Therapy, w/ Treatment Plan, Clinical Procedures & Follow-Up Care

3310..... One Canal, w/out Final Restoration         $125.00
3320...    Two Canals, w/out Final Restoration     $150.00
3330       Three Canals, w/out Final
               Restoration                                             $185.00

Apicoectomy/Periradicular Surgery

3410,21,25..Anterior, Bicuspid
                   or Molar First Root...                              $90.00
3426... Each Additional Root                                    $90.00
3430... Retrograde Filling, Per Root                          $65.00

Other Endodontic Procedures

3950        Canal Prep & Fitting of Pre-Formed
                Dowel                                                       $70.00


Surgical Services, w/ Usual Post-Operative Services

4210  Gingivectomy or Gingivoplasty,
          Per Quadrant..                                              $150.00
4240... Gingival Flap Procedure w/ Root Planing,
           Per Quadrant..                                             $150.00
4263... Bone Replacement Graft, 1st Site in
            Quadrant                                                   $150.00
4264... Bone Replace. Graft, Ea. Add’l.
           Site in Quad                                                 $100.00

Other Periodontal Services

4341....... Root Planing, Per Quadrant                      $40.00
4910... Periodontic Recall, w/ Prophylaxis               $25.00
4920    Unscheduled Dressing Change             No Charge


Complete Dentures, w/ Routine
Post-Delivery Care

5110,20          Upper or Lower...                           $280.00
5130,40          Immediate Upper or Lower              $280.00

Partial Dentures, w/ Routine Post-Delivery Care

5211,12 Upper or Lower, Resin Base,
             ConventionalClasps & Rests.....                $250.00
5213,14 Upper or Lower, Cast Metal Base w/                         AcrylicSaddles                                         $280.00

Adjustments to Dentures

5410,11 Complete Upper or Lower.............             $20.00
5421,22   Partial Upper or Lower                             $20.00

Repairs to Complete Dentures

5510..... Broken Base......                                         $37.00
5520... Missing or Broken Teeth, Per Tooth...          $25.00

Repairs to Partial Dentures

5610..... Resin Denture Base                                   $37.00
5630... Repair or Replace Broken Clasp.....             $25.00
5640... Replace Broken Teeth, Per Tooth...             $25.00
5650,60   Add Tooth or Clasp                                  $40.00

Denture Reline Procedures

5730,31 Complete, Upper or Lower, Chairside....    $45.00
5740,41   Partial, Upper or Lower, Chairside           $45.00

Denture Reline Procedures (continued)

5750,51 Complete, Upper or Lower, Laboratory.    $87.00
5760,61 Partial, Upper or Lower, Laboratory.         $87.00

Bridge Pontics*

6210-12             Cast Metal                                   $177.00
6240-42            Porcelain Fused to Metal,
                         Not for Molars                               $187.00
6250-52            Resin w/ Metal....                          $155.00

Bridge Retainers – Crowns*

6720-22 Resin w/ Metal....                                    $185.00
6750-52 Porcelain Fused to Metal, Not for Molars $200.00
6780-82 ¾ Cast Metal....                                        $185.00
6790-92 Full Cast Metal....                                      $185.00

Other Fixed Prosthetic Services

6930..... Recement Bridge...                                     $25.00
6970...  Cast Post & Core In Addition to
             Bridge Retainer                                           $75.00
6971... Cast Post, As Part of Bridge Retainer          $75.00
6972... Prefab Post & Core In Add’n to Bridge
            Retainer                                                        $70.00
6973... Core Build-Up for Retainer, w/ Any Pins     $18.00

                6975    Coping Metal                                          No Charge
Extractions, Local Anesthesia, Routine Post-Op Care

7111..... Coronal Remnants, Deciduous Tooth        $19.00
7140      Extraction, Erupted Tooth or Exposed                          Root                                                           $19.00

Surgical Extractions, Local Anesthesia Routine Post-Op

7210..... Surgical Removal of Erupted Tooth, Requiring
Elevation of Mucoperiosteal Flap......                       $45.00
7220... Removal of Impacted Tooth, Soft Tissue.    $60.00
7230... Removal of Impacted Tooth, Partially Bony  $75.00
7510... Surgical Incision w/ Drainage of Abscess,
Intraoral Soft Tissue                                                $40.00


9110..... Emergency Treatment of Pain                    $20.00
9215... Local Anesthesia                                   No Charge
9430... Office Visit for Observation                           $8.00
9440... Office Visit, After Hours                              $25.00
9930... Post-Surgical Treatment of
           Complication                                            No Charge
9951   Occlusal Adjustment, Limited                  No Charge

*The Member is responsible for the discount fee plus the actual lab cost of gold.
Standard 24-Month Case

Full Banded, Upper & Lower,
Children to Age 19                                             $1,775.00
Full Banded, Upper & Lower, Adults                  $1,975.00
Banded, Upper or Lower, Children & Adults....  $1,000.0

Other Fees

Consultation                                                             $25.00
Broken Appointments, w/out 24-Hour Notice          $40.00

+As provided by a participating orthodontist.  Services not listed are provided at the orthodontist’s usual fees.

This is only a summary of covered charges, not a contract.  A complete and accurate list is provided with the contract upon enrollment.

Pacific Dental
Network, Inc.
Discount Plan

     Mail application and check for
membership fee and the one time
administration fee to:

         CDI Insurance Service
“The Dental People”
P.O. Box 1507
Victorville, Ca. 92393-1507


Monthly  Monthly       Annual 
checking    coupons          fee


Single$ 12.00 $ 13.00$ 144.00
Couple$17.00$ 18.00 $ 204.00
Family$ 22.00$ 23.00 $ 264.00
Please include  the  one time 

      $20.00 membership fee.
I-430 MEMBERSHIP APPLICATION (print or type clearly)                        Agent #002174

Last Name                      First name                  MI                                          Birthday                 Home  phone


Address                                                                 City                                       State                       Zip


Employer                                                                                                Address


Dependents to be covered                     

                                  Birthday                                                                                                    Birthday

               Last Name               First                       Birthday                                              Last name            First              Birthday

On behalf of the above individual(s), I hereby apply for membership in Pacific Dental network  for a period of no less than one year and certify that the above information is true and
correct. I understand that I have 30days from receipt of my ID card to cancel my membership and receive a full refund of my membership fees, if I have not used the discount plan.


   Applicant Signature                                                                                                                                                         Date



              Signature                                                                                                                                                                Date

Dentist office #

Groups must have at least 2 employees to be eligible for coverage.
Premiums must be paid with a company check and must include the one time non-refundable administration fee.
The monthly premium covers the employee and their eligible dependents.

Pacific Dental Network, Inc.


The No Problem Discount Plan!
Who Is Eligible?

I-430 Discount Dental Plan


¨ NoDeductibles!

¨ NoClaim Forms!

¨ NoAnnual Maximums!

¨ NoLimitations on Most Pre-Existing                  Conditions!

¨ NoWaiting Periods to See a Dentist

You may enroll your spouse and eligible

dependents. Eligible dependents include unmarried children to age 19 and full time students to age 23. A full time student is defined as taking 12 or more units. We will require verification


Savings Program

 For Individals,Couples,

Families,Self Employed
See Your Savings!
It’s Easy To Enroll!

Compare your costs  with  Pacific   Dental  Network’s    Discount Dental  Plan   to   average dental fees:

    Sample                   Avg.           With        Your

Treatment Plan         Fee*   Plan I-430            Savings

Exams                   $47.00    No Charge                $47.00

Cleanings              $65.00    No Charge                $65.00

Full Mouth X-Rays $86.00   No Charge                 $86.00

Filling, 1surface     $70.00        $20.00                 $50.00

Root Canal,
single                     $404.00       $125.00             $279.00

Crown, PFM          $662.00        $200.00            $462.00

                        $1,334.00        $345.00               $989.00

To  enroll  in   Pacific Dental Network’s  Discount Dental Plan, just follow these easy steps:

1.   Complete  the  attached  Enrollment  Application, indicating the number of the dental office you have selected in the box at the bottom left corner of the Application.

3.   Include a Company check, payable to Pacific Dental  Network, for your membership fee and   the  one-time enrollment fee.

4.  Mail the applications and check to:    

CDI Insurance Services
“The Dental People”
P.O. Box 1507
Victorville, CA  92393-1507

We must receive your application and     payment by the 20th of the month for your    discount dental plan to begin on the first day of the following month.

Pacific Dental Network  is  a membership     savings  program that offers members          discounts on certain services, including dental services,  through participating dental  providers.

Exclusively Distributed by:
CDI Insurance Services
“The Dental People”
P.O. Box 1507
Victorville, CA  92393-1507
Phone 877-234-3368

Fax 760-946-2518

Pacific Dental

Network, Inc.

1971 E. 4th Street, Suite 184, Santa Ana, CA  92705-3917
Phone: (714) 479-0777  Fax: (714) 479-0779 Toll-free: (877) 4-DENTAL

*2003 National Dental Advisory Service for 92805
Affordable Membership Fees!

Monthly                Monthly                                Annual

Checking                Coupon                                   Fees

Single        $12.00                $13.00                $144.00

Couple      $17.00                $18.00                $204.00

Family       $22.00                $23.00                $264.00

Plus one-time non-refundable

administration fee of $20.00


Specialty Coverage!

All  general  dentists  may not be capable of performing each of the services listed herein and,   based   upon  a  Member’s condition,  certain  procedures may not be within the scope of practice or ability of a general dentist.  In such a case,  the  general dentist will refer the  Member   to   a   Pacific   Dental   Network   participating dental specialist who will give the Member a 30% discount from their regular fees



  © Copyrights 2009 California Dental Insurance All Rights reserved