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Individual Family Plans start at just $12 a month (I-430 Plan) |
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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.
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CLICK HERE for PDF Version of Below Application For Printing and Mailing (Attached) |
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| ADA CODE |
PROCEDURE |
DISCOUNT FEE |
| DIAGNOSTIC |
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 |
| Radiographs |
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 |
| PREVENTIVE |
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 |
| RESTORATIVE |
| 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 |
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| ADA CODE |
PROCEDURE |
DISCOUNT FEE |
| Other Restorative Services* (continued) |
2954 Prefabricated Post & Core In
Additon to Crown.... $70.00
2970 Temp Crown w/ Fractured Tooth No Charge |
| ENDODONTICS |
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 |
PERIODONTICS |
| 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 |
| REMOVABLE PROSTHODONTICS |
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 |
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| ADA CODE |
PROCEDURE |
DISCOUNT FEE |
| Denture Reline Procedures (continued) |
5750,51 Complete, Upper or Lower, Laboratory. $87.00
5760,61 Partial, Upper or Lower, Laboratory. $87.00 |
| FIXED PROSTHODONTICS |
| 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 |
| ORAL SURGERY |
| 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 |
| MISCELLANEOUS SERVICES |
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 |
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| *The Member is responsible for the discount fee plus the actual lab cost of gold. |
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| ORTHODONTICS+ |
| 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 |
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| Other Fees |
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Consultation $25.00
Broken Appointments, w/out 24-Hour Notice $40.00 |
+As provided by a participating orthodontist. Services not listed are provided at the orthodontist’s usual fees. |
| This is only a summary of covered charges, not a contract. A complete and accurate list is provided with the contract upon enrollment. |
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Pacific Dental
Network, Inc.
I-430
Discount Plan
Mail application and check for
membership fee and the one time
administration fee to:
CDI Insurance Service
“The Dental People”
P.O. Box 1507
Victorville, Ca. 92393-1507
1-877-234-3368
Monthly Monthly Annual
checking coupons fee |
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Single$ 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. |
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| I-430 MEMBERSHIP APPLICATION (print or type clearly) Agent #002174 |
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Last Name First name MI Birthday Home phone
____________________________________________________________________________________________
Address City State Zip
_____________________________________________________________________________________________
Employer Address
_____________________________________________________________________________________________
Dependents to be covered
Spouse_____________________________________________Child_________________________________________
Birthday Birthday
Child_____________________________________________Child_____________________________________________
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
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. |
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Pacific Dental Network, Inc. |
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The No Problem Discount Plan! |
Who Is Eligible? |
I-430 Discount Dental Plan |
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¨ 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 |
Membership
Savings Program
For Individals,Couples,
Families,Self Employed |
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See Your Savings! |
It’s Easy To Enroll! |
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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.
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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 |
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| *2003 National Dental Advisory Service for 92805 |
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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 |
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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 |
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© Copyrights 2009 California Dental Insurance All Rights reserved |
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