CaliforniaDental HMO Dental Plan California HMO Plan Target CW is pleased to offer you participation in the California Dental Plan. Below is some important information to know about the plan. If you have any questions, please do not hesitate to contact your Benefits Administrator at: 619-704-7720 or [email protected]

Important Plan Information  The effective date for your coverage will be the first of the month after 30 days employment. Late applications can be accepted up to 7 days after the effective date, however, retroactive deductions may occur.  Employees working 20 or more hours per week are eligible.  If you do not submit your application by the above deadline, you may not enroll until the next Open Enrollment period or if you experience a Family Status Change (marriage, divorce, birth of a child, spouse’s job change, etc.). You have 30 days from the event to update your coverage. Documentation will be required.  Changes or cancellation of your coverage can only occur during the annual Open Enrollment period or if you experience a Family Status Change. Adjustments relating to a Family Status Change must be made within 30 days of the event. Documentation will be required.  Deductions for your coverage will be taken per paycheck on a pre-tax basis unless you notify us, in writing, otherwise.  Please review the plan documents carefully. If you have any questions on the coverage, contact the Payrolling.com Benefits Department.

Weekly Rates California Dental HMO (available for California employees only) Employee only $3.08 Employee + Spouse $5.85 Employee + Child(ren) $6.46 Family $8.61

Instructions for completing the HMO application:  Complete the application labeled HMO. To view a list of dentists, visit www.cadental.net. Select accepting plan 100.

Fax completed application to the Target CW Benefits dept at 619-704-7799 or by email to [email protected]

PERIODONTICS Gingivectomy or gingivoplasty, 4 or more contiguous teeth, per quadrant ............................... $50.00 Scaling & root planning, per quadrant ......................... $25.00

Tooth colored fillings, one surface, back tooth............ $65.00 Bleaching, per arch .................................................. $125.00 Labial veneer (porcelain laminate), laboratory .......... $300.00 Night guards, soft, includes lab fee .......................... $150.00

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 65%.

Dental Office #

Date Applicant’s Signature

X

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Birthday First

Child: Last Name (if different)

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First

Birthday

Child:

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Work Telephone

Zip

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State Initial

On behalf of the above named individuals, I hereby apply for enrollment in CDN and certify that the above information is true and correct. NOTICE: BY SIGNING THIS APPLICATION YOU ARE AGREEING TO HAVE ANY DISPUTE WITH THE PLAN, INCLUDING MEDICAL MALPRACTICE, DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR CONSITUTIONAL RIGHT TO A JURY OR COURT TRIAL. SEE THE COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM FOR DETAILS

Advantage 100

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/ Home Phone Birthday

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Child: Last Name (if different)

V. COSMETIC BENEFITS

www. caldental.net

Not all general dentists are capable of performing each of the services listed herein and, based upon the member’s condition, certain procedures may not be within the scope of practice or ability of a general dentist. In such cases, the general dentist will refer the member to a dental specialist. The plan will pay for up to $1000 per year in specialty care after the members copayments for the services received.

STANDARD 24-MONTH CASE Phase one interceptive treatment .......................... $1,150.00 Full-banded, upper and lower, to age 19................ $1,775.00 Full-banded, upper and lower, adults ..................... $1,975.00 Banded, upper or lower, children & adults ............. $1,000.00 Consultation ........................................................ No Charge

Spouse:

SPECIALTY COVERAGE!

ENDODONTICS Pulp cap, direct ....................................................No Charge Pulp cap, indirect ..................................................No Charge Therapeutic pulpotomy .........................................No Charge Root canal, anterior .................................................... $75.00 Root canal, bicuspid ................................................... $85.00 Root canal, molar ..................................................... $200.00

IV. ORTHODONTICS

Dependents to be covered:

California Dental Netw ork offers comprehensive dental benefits through hundreds of independently owned and operated dental offices conveniently located throughout California.

Advantage Plan 100 covers many of the name brand crowns and dentures. See evidence of coverage for details.

Phone (714) 479-0777 Toll-Free (877) 433-6825 Fax (714) 479-0779

CHOOSE FROM HUNDREDS OF DENTISTS!

ORAL SURGERY Extraction, single tooth .........................................No Charge Surgical removal of erupted tooth ............................... $20.00 Removal of impacted tooth, soft tissue ....................... $50.00 Removal of impacted tooth, partially bony ................ $100.00 Surgical incision with drainage of abscess, intraoral soft tissue ................................................. $40.00

Employer’s Name

*2003 National Dental Advisory Service for 92805

YOUR RESTORATIONS COPAYMENT Amalgam, one surface..........................................No Charge Amalgam, two surfaces ........................................No Charge Amalgam, three surfaces ......................................No Charge Resin, one surface anterior......................................... $10.00 Resin, two surface anterior ......................................... $12.00

1971 E. 4th Street Suite 184 Santa Ana, CA 92705

Exams .................... $55.00 .. No Charge ... $55.00 Cleanings ............... $62.00 .. No Charge ... $62.00 Full Mouth X-Rays .. $93.00 .. No Charge ... $93.00 Filling, 1 surface ... $104.00 .. No Charge . $104.00 Root Canal, single . $503.00 ..... $75.00 .... $428.00 Crown, PFM ......... $814.00 .... $100.00 ... $714.00 $1,631.00 ... $175.00 . $1,456.00

II. ROUTINE SERVICES

City

Your Savings

DENTURES & PROSTHODONTICS Complete upper or lower denture.............................. $125.00 Upper or lower partial denture, resin base ................ $150.00 Upper or lower partial denture, cast metal base with resin saddles ................................................. $150.00 Adjust complete denture ...................................... No Charge Repair broken complete denture base ........................$15.00 Replace missing or broken teeth, complete denture, each tooth .................................$15.00 Reline complete or partial upper or lower denture, chairside ...................................................$40.00 Reline complete or partial upper or lower denture, laboratory .................................................$40.00

Address

With ADV 100

Pl e as e p rint o r t yp e .

Avg. Fee*

YOUR CROWNS COPAYMENT Porcelain fused to base metal (not for molars) .......... $100.00 Porcelain fused to base metal (for molars) ................ $175.00 Full cast base metal.................................................. $100.00 3/4 cast metallic ........................................................ $100.00 Prefabricated stainless steel, permanent tooth ...........$35.00

First

Sample Treatment Plan

COPAYMENT Office visit ............................................................No Charge Oral examination ..................................................No Charge Intraoral x-rays, complete series ...........................No Charge Bitewing x-rays, single film ...................................No Charge Panoramic x-ray ...................................................No Charge Prophylaxis (teeth cleaning) .................................No Charge Topical fluoride (child) ..........................................No Charge Oral hygiene instruction ........................................No Charge

III. MAJOR SERVICES

Last Name

Compare your costs with California Dental Network’s ADVANTAGE PLAN 100 to average dental fees:

YOUR

Social Security No.

SEE YOUR SAVINGS!

I. PREVENTIVE SERVICES

ENROLLMENT APPLICATION

No Deductibles! No Claim Forms! No Annual Maximums! No Limitations on Most Pre-Existing Conditions! No Waiting Periods to See a Dentist!

The following dental services are covered benefits for the specified copayment, only when provided by a participating California Dental Network general dentist, which may be found online at www.caldental.net

Detach and Return

THE NO PROBLEM PLAN!

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Summary of Benefits and Copayments Advantage Plan 100

WHO IS ELIGIBLE? 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. Verification is required.

IT’S EASY TO ENROLL! To enroll in California Dental Network’s ADVANTAGE PLAN 100, just follow these easy steps: 1. 2. 3.

Select a dental office from our List of Participating Dentists. Complete the attached Enrollment Application, indicating the number of the dental office you have selected. Return the Application to your Group Benefits Coordinator.

An Enrollment Application is a request for coverage which, if approved by California Dental Network, becomes the enrollment form used to issue an identification card and Combined Evidence of Coverage and Disclosure Form. All benefits, limitations and exclusions are stated in full in the Combined Evidence of Coverage and Disclosure Form which is provided when coverage becomes effective. Members will have 30 days from receipt of the Combined Evidence of Coverage and Disclosure Form to cancel their enrollment and receive a full refund of their premiums if they have not utilized the Plan. You may obtain a copy of the Combined Evidence of Coverage and Disclosure Form from our Corporate Office before you enroll.

OUT-OF-AREA EMERGENCY CARE IS COVERED TOO!

LIMITATIONS SUMMARY Fluoride treatment is covered once every 12 months for Members up to age 14. Bitewing x-rays are limited to one series of four films every 12 months. Full mouth x-rays are limited to once every 24 months. Sealants are covered for Members up to the age of 14 and are limited to permanent first and second molars. Periodontal treatments (subgingival curettage and root planing) are limited to one treatment per quadrant in any 12-month period. Fixed bridgework will be covered only when a partial cannot satisfactorily restore the case. Replacement of partial dentures is limited to once every five years. Full upper and/or lower dentures are not to exceed one each in any five-year period. Denture relines are limited to one per arch in any 12-month period.

ADVANTAGE PLAN

EXCLUSIONS SUMMARY General anesthesia, analgesia (nitrous oxide), intravenous sedation, or the services of an anesthesiologist, except as listed in the schedule of benefits. Treatment of fractures or dislocations; congenital malformations; malignancies, cysts, or neoplasms; or Temporomandibular Joint Syndrome (TMJ). Extractions or x-rays for orthodontic purposes. Prescription drugs and over the counter drugs. Any services involving implants or experimental procedures. Any procedures performed for cosmetic, elective or aesthetic purposes. Any procedure to replace or stabilize tooth structure lost by attrition, abrasion, erosion or grinding.

100

Para recebir una copie de esta plan dental en espanol llame a California Dental Network gratis a numero (877) 433-6825.

SUMMARY OF PLAN BENEFITS

If an emergency happens and you need care at a location that is more than 50 miles from your California Dental Network dental office, California Dental Network will reimburse you up to $50 per year for out-of-area emergency treatment.

AND 1971 E. 4th Street, Suite 184, Santa Ana, CA 92705-3917 Phone: (714) 479-0777 Fax: (714) 479-0779 Toll-free: (877) 4-DENTAL www.caldental.net 5-08

COPAYMENTS

Advantage Plan 100

Schedule of Benefits The following procedures are covered benefits when preformed by a California Dental participating dentist and are subject to exclusion, limitations and administrative policies, which are detailed in the Plan's Combined Evidence of Coverage and Disclosure Form. If you have any questions about your eligibility, the Plan benefits or need assistance in selecting a dentists, please call California Dental's Customer Service Department, toll-free at: (877) 4DENTAL Please discuss all treatment options with your dentist before starting treatment. Failure to do so may limit the patient's options once treatment has started. Code

Description

Copayments

Diagnostic Services D0120 Periodic oral evaluation D0140 Limited oral evaluation - problem focused D0150 Comprehensive oral evaluation - new or established patient D0170 Re-evaluation - limited, problem focused D0180 Comprehensive periodontal evaluation - new or established patient D0210 Intraoral - complete series (including bitewings) D0220 Intraoral - periapical first film D0230 Intraoral - periapical each additional film D0240 Intraoral - occlusal film D0250 Extraoral - first film D0260 Extraoral - each additional film D0270 Bitewing - single film D0272 Bitewings - two films D0274 Bitewings - four films D0277 Vertical bitewings - 7 to 8 films D0330 Panoramic film D0350 Oral/facial photographic images D0460 Pulp vitality tests D0470 Diagnostic casts

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Preventive Services * - Procedures limited to once every 6 months D1110 Prophylaxis - adult * D1110 Prophylaxis - adult (each additional) D1120 Prophylaxis - child * D1120 Prophylaxis - child (each addittional) D1201 Topical application of fluoride (including prophylaxis) - child * D1203 Topical application of fluoride (prophylaxis not included) - child * D1204 Topical application of fluoride (prophylaxis not included) - adult * D1205 Topical application of fluoride (including prophylaxis) - adult * D1310 Nutritional counseling for control of dental disease D1320 Tobacco counseling for the control and prevention of oral disease D1330 Oral hygiene instructions D1351 Sealant - per tooth D1510 Space maintainer - fixed - unilateral D1515 Space maintainer - fixed - bilateral D1520 Space maintainer - removable - unilateral

$0 $45 $0 $35 $0 $0 $0 $0 $0 $0 $0 $0 $35 $45 $35

Code

Description

Copayments

D1525 Space maintainer - removable - bilateral D1550 Re-cementation of space maintainer

$55 $0

Restorative Services D2140 Amalgam - 1 surface, primary or permanent D2150 Amalgam - 2 surfaces, primary or permanent D2160 Amalgam - 3 surfaces, primary or permanent D2161 Amalgam - 4 or more surfaces, primary or permanent D2330 Resin-based composite - 1 surface, anterior D2331 Resin-based composite - 2 surfaces, anterior D2332 Resin-based composite - 3 surfaces, anterior D2335 Resin-based composite - 4 or more surfaces or involving incisal angle (anterior) D2390 Resin-based composite crown, anterior D2391 Resin-based composite - 1surface, posterior D2392 Resin-based composite - 2 surfaces, posterior D2393 Resin-based composite - 3 surfaces, posterior D2394 Resin-based composite - 4 or more surfaces, posterior

$0 $0 $0 $0 $10 $12 $14 $20 $75 $65 $85 $100 $120

Inlays/Onlays D2510 Inlay - metallic - 1 surface D2520 Inlay - metallic - 2 surfaces D2530 Inlay - metallic - 3 or more surfaces D2542 Onlay - metallic - 2 surfaces D2543 Onlay - metallic - 3 surfaces D2544 Onlay - metallic - 4 or more surfaces D2610 Inlay - porcelain/ceramic - 1 surface D2620 Inlay - porcelain/ceramic - 2 surfaces D2630 Inlay - porcelain/ceramic - 3 or more surfaces D2642 Onlay - porcelain/ceramic - 2 surfaces D2643 Onlay - porcelain/ceramic - 3 surfaces D2644 Onlay - porcelain/ceramic - 4 or more surfaces D2650 Inlay - resin-based composite - 1 surface D2651 Inlay - resin-based composite - 2 surfaces D2652 Inlay - resin-based composite - 3 or more surfaces D2662 Onlay - resin-based composite - 2 surfaces D2663 Onlay - resin-based composite - 3 surfaces D2664 Onlay - resin-based composite - 4 or more surfaces

$85 $90 $95 $90 $95 $100 $185 $200 $215 $200 $215 $225 $75 $80 $85 $80 $85 $90

Crowns Porcelian (tooth colored) crowns on molars cost $75 extra per crown D2740 Crown - porcelain/ceramic substrate D2750 Crown - porcelain fused to high noble metal D2751 Crown - porcelain fused to predominantly base metal D2752 Crown - porcelain fused to noble metal D2780 Crown - 3/4 cast high noble metal D2781 Crown - 3/4 cast predominantly base metal D2782 Crown - 3/4 cast noble metal D2783 Crown - 3/4 porcelain/ceramic D2790 Crown - full cast high noble metal D2791 Crown - full cast predominantly base metal D2792 Crown - full cast noble metal D2794 Crown - titanium D2910 Recement inlay, onlay, or partial coverage restoration D2915 Recement cast or prefabricated post and core

$250 $250 $100 $200 $250 $100 $200 $250 $250 $100 $200 $250 $0 $0

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Toll Free Customer Service (877) 4DENTAL

Code D2920 D2930 D2931 D2940 D2950 D2951 D2952 D2953 D2954 D2955 D2957

Description Recement crown Prefabricated stainless steel crown - primary tooth Prefabricated stainless steel crown - permanent tooth Sedative filling Core buildup, including any pins Pin retention - per tooth, in addition to restoration Cast post and core in addition to crown Each additional cast post - same tooth Prefabricated post and core in addition to crown Post removal (not in conjunction with endodontic therapy) Each additional prefabricated post - same tooth

Copayments

Code

$0 $25 $35 $0 $10 $5 $50 $0 $50 $15 $0

D3426 D3430 D3450 D3920

Alternative Crowns Most dental offices offer alternative to the porcelain/ceramic substrate and porcelain fused to metal crowns which are marketed under different brand names and maybe avaiable through your California Dental participating provider for the following copayments: Porcelain/ceramic substrate crown Lava Empress Procera In-Ceram

$700 $650 $700 $650

Porcelain fused to high noble crown Captek Bio - 2000 Ceramco II Occlusal Gold

$625 $625 $625 $625

Call California Dental for a updated list of brand names covered LABIAL Veneers (replaced once every 5 years) D2961 Labial veneer (resin laminate) - laboratory D2962 Labial veneer (porcelain laminate) - laboratory

$300 $300

Endodontics (excluding final restorations) D3110 Pulp cap - direct D3120 Pulp cap - indirect D3220 Therapeutic pulpotomy D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth D3310 Root canal - anterior per tooth D3320 Root canal - bicuspid per tooth D3330 Root canal - molar per tooth D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth D3346 Retreatment of previous root canal therapy - anterior D3347 Retreatment of previous root canal therapy - bicuspid D3348 Retreatment of previous root canal therapy - molar D3351 Apexification/recalcification - initial visit D3352 Apexification/recalcification - interim medication replacement D3353 Apexification/recalcification - final visit (includes completed root canal) D3410 Apicoectomy/periradicular surgery - anterior D3421 Apicoectomy/periradicular surgery - bicuspid (first root) D3425 Apicoectomy/periradicular surgery - molar (first root)

$0 $0 $0 $10 $15 $75 $85 $200 $75 $95 $120 $210 $75 $65 $75 $200 $200 $200

Description Apicoectomy/periradicular surgery (each additional root) Retrograde filling - per root Root amputation - per root Hemisection (including any root removal), not including root canal therapy

Copayments $100 $150 $100 $115

Periodontics * - Covered only when preformed by the member's primary general dentist D4210 Gingivectomy or gingivoplasty - 4 or more contiguous teeth per quadrant D4211 Gingivectomy or gingivoplasty - 1 to 3 contiguous teeth per quadrant D4240 Gingival flap procedure - 4 or more contiguous teeth per quadrant D4241 Gingival flap procedure - 1 to 3 contiguous teeth per quadrant D4249 Clinical crown lengthening - hard tissue* D4260 Osseous surgery - 4 or more contiguous teeth per quadrant D4261 Osseous surgery - 1 to 3 contiguous teeth per quadrant D4263 Bone replacement graft - first site in quadrant D4341 Periodontal scaling and root planing - four or more teeth per quadrant D4342 Periodontal scaling and root planing - one to three teeth per quadrant D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis D4381 Localized delivery of antimicrobial agents, per tooth D4910 Periodontal maintenance - once every 6 months D4910 Periodontal maintenance - each additiional

$50 $40 $300 $225 $125 $300 $225 $225 $25 $20 $25 $60 $25 $50

Removable Prosthodontics Replaced once every 5 years & relined once every 24 months D5110 Complete upper denture D5120 Complete lower denture D5130 Immediate upper denture D5140 Immediate lower denture D5211 Upper partial denture - resin base D5212 Lower partial denture - resin base D5213 Upper partial denture - cast metal framework with resin denture bases D5214 Lower partial denture - cast metal framework with resin denture bases D5225 Upper partial denture - flexible base D5226 Lower partial denture - flexible base D5410 Adjust complete denture - upper D5411 Adjust complete denture - lower D5421 Adjust partial denture - upper D5422 Adjust partial denture - lower D5510 Repair broken complete denture base D5520 Replace missing or broken teeth - complete denture (each tooth) D5610 Repair resin denture base D5620 Repair cast framework D5630 Repair or replace broken clasp D5640 Replace broken teeth - per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture D5670 Replace all teeth and acrylic on cast metal framework (Upper) D5671 Replace all teeth and acrylic on cast metal framework (Lower) D5710 Rebase complete upper denture D5711 Rebase complete lower denture D5720 Rebase upper partial denture D5721 Rebase lower partial denture D5730 Reline complete upper denture (chairside) D5731 Reline complete lower denture (chairside)

$125 $125 $125 $125 $150 $150 $150 $150 $150 $150 $0 $0 $0 $0 $15 $15 $15 $15 $15 $15 $15 $15 $100 $100 $50 $50 $50 $50 $40 $40

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Toll Free Customer Service (877) 4DENTAL

Code D5740 D5741 D5750 D5751 D5760 D5761 D5820 D5821 D5850 D5851

Description Reline upper partial denture (chairside) Reline lower partial denture (chairside) Reline complete upper denture (laboratory) Reline complete lower denture (laboratory) Reline upper partial denture (laboratory) Reline lower partial denture (laboratory) Interim partial denture (upper) Interim partial denture (lower) Tissue conditioning, upper Tissue conditioning, lower

Alternative Dentures, Bridges & Relines Most dental offices offer alternative to complete and partial dentures and relines which are marketed under different brand names and maybe avaiable through your California Dental participating provider for the following copayments: Complete Denture Comfort Flex - Complete Upper Denture Comfort Flex - Complete Lower Denture Geneva - Complete Upper Denture Geneva - Complete Lower Denture Simply Natural Partial Denture - Resin Base Comfort Flex - Upper Partial Comfort Flex - Lower Partial Geneva - Upper Partial Geneva - Lower Partial EstheticClasp - Upper Partial EstheticClasp - Lower Partial CuSil - Upper Partial CuSil - Lower Partial Valplast - Upper Partial Valplast - Lower Partial

Copayments

Code

$40 $40 $40 $40 $40 $40 $40 $40 $10 $10

D6241 D6242 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6794 D6930 D6970 D6971 D6972 D6973 D6976 D6977 D6980

$550 $550 $550 $550

$600 $600 $600 $600 $600 $600 $600 $600 $600 $600

Partial Denture - Cast Metal Base with Resin Saddles Comfort Flex - Upper Partial Comfort Flex - Lower Partial Valplast - Upper Partial Valplast - Lower Partial

$600 $600 $600 $600

Denture Relines PermaSoft - Complete Upper Denture (Laboratory) PermaSoft - Complete Lower Denture (Laboratory) PermaSoft - Partial Upper Denture (Laboratory) PermaSoft - Partial Lower Denture (Laboratory)

$100 $100 $100 $100

D5900 - D5999 VII Maxillofacial Prosthetics - Not Covered D6000 - D6199 VIII Implant Services - Not Covered Fixed Prosthodontics D6210 Pontic - cast high noble metal D6211 Pontic - cast predominantly base metal D6212 Pontic - cast noble metal D6214 Pontic - titanium D6240 Pontic - porcelain fused to high noble metal

$250 $100 $200 $250 $250

Description

Copayments

Pontic - porcelain fused to predominantly base metal Pontic - porcelain fused to noble metal Inlay - porcelain/ceramic, 2 surfaces Inlay - porcelain/ceramic, 3 or more surfaces Inlay - cast high noble metal, 2 surfaces Inlay - cast high noble metal, 3 or more surfaces Inlay - cast predominantly base metal, 2 surfaces Inlay - cast predominantly base metal, 3 or more surfaces Inlay - cast noble metal, 2 surfaces Inlay - cast noble metal, 3 or more surface Onlay -porcelain/ceramic, 2 surfaces Onlay - porcelain/ceramic, 3 or more surfaces Onlay - cast high noble metal, 2 surfaces Onlay - cast high noble metal, 3 or more surfaces Onlay - cast predominantly base metal, 2 surfaces Onlay - cast predominantly base metal, 3 or more surfaces Onlay - cast noble metal, 2 surfaces Onlay - cast noble metal, 3 or more surfaces Inlay - titanium Onlay - titanium Crown - porcelain fused to high noble metal Crown - porcelain fused to predominantly base metal Crown - porcelain fused to noble metal Crown - 3/4 cast high noble metal Crown - 3/4 cast predominantly base metal Crown - 3/4 cast noble metal Crown - 3/4 porcelain/ceramic Crown - full cast high noble metal Crown - full cast predominantly base metal Crown - full cast noble metal Crown - titanium Recement fixed partial denture Cast post and core in addition to fixed partial denture retainer Cast post as part of fixed partial denture retainer Prefabricated post and core in addition to fixed partial denture retainer Core build up for retainer, including any pins Each additional cast post - same tooth Each additional prefabricated post - same tooth Fixed partial denture repair, by report

Oral Surgery D7111 Extraction, coronal remnants - deciduous tooth D7140 Extraction, erupted tooth or exposed root D7210 Surgical removal of erupted tooth D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth - partially bony D7240 Removal of impacted tooth - completely bony D7241 Removal of impacted tooth - completely bony, with unusual complications D7250 Surgical removal of residual tooth roots (cutting procedure) D7270 Tooth reimplantation and/or stabilization of accidentally displaced tooth D7310 Alveoloplasty in conjunction with extractions - per quadrant D7311 Alveoloplasty in conjunction with extractions - 1 to 3 teeth/spaces per quadrant D7320 Alveoloplasty not in conjunction with extractions - per quadrant D7321 Alveoloplasty not in conjunction with extractions - 1 to 3 teeth/spaces per quadrant

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Toll Free Customer Service (877) 4DENTAL

$100 $200 $200 $215 $250 $300 $150 $200 $200 $250 $200 $215 $250 $300 $150 $200 $200 $250 $250 $250 $250 $100 $200 $250 $100 $200 $250 $250 $100 $200 $250 $0 $40 $40 $40 $10 $40 $40 $50

$0 $0 $20 $50 $100 $125 $130 $50 $110 $0 $0 $0 $0

Code

Description

Copayments $40

D7510 Incision and drainage of abscess - intraoral soft tissue Orthodontics * - Covered for up to 24 months of active treatment D8020 Limited orthodontic treatment of the transitional dentition* D8030 Limited orthodontic treatment of the adolescent dentition* D8040 Limited orthodontic treatment of the adult dentition* D8050 Interceptive orthodontic treatment of the primary dentition* D8060 Interceptive orthodontic treatment of the transitional dentition* D8070 Comprehensive orthodontic treatment of the transitional dentition* D8080 Comprehensive orthodontic treatment of the adolescent dentition* D8090 Comprehensive orthodontic treatment of the adult dentition* D8660 Pre-orthodontic treatment visit D8680 Orthodontic retention - Per Arch D8999 Orthodontic Treatment Plan and Records(pre/post x-rays, photos, study models) D8999 Active Orthodntic Treatment beyond 24 months - Per Visit Adjunctive General Services * - Covered only for the removal of impacted wisdom teeth (1,16,17 & 32) D9110 Palliative (emergency) treatment of dental pain - minor procedure D9210 Local anesthesia not in conjunction with operative or surgical procedures D9215 Local anesthesia D9220 Deep sedation/general anesthesia - first 30 minutes* D9221 Deep sedation/general anesthesia - each additional 15 minutes* D9230 Analgesia, anxiolysis, inhalation of nitrous oxide* D9241 Intravenous conscious sedation/analgesia - first 30 minutes* D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes* D9310 Consultation & Second Opinion, with prior authorization from Plan D9430 Office visit for observation (during regularly scheduled hours) D9440 Office visit - after regularly scheduled hours D9999 Office visit - during regular office hours in addition to other charges D9630 Other drugs and/or medicaments, (including antimicrobial irrigation) D9910 Application of desensitizing medicament D9911 Application of desensitizing resin for cervical and/or root surface, per tooth D9940 Occlusal guard - Soft D9942 Repair/reline occlusal guard D9951 Occlusal adjustment - limited D9972 External bleaching - per arch D9973 External bleaching - per tooth D9999 Broken Appopintment - less than 24 notice

$1,000 $1,000 $1,000 $1,150 $1,150 $1,775 $1,775 $1,975 $0 $125 $250 $75

$0 $0 $0 $175 $85 $15 $150 $65 $25 $0 $30 $0 $20 $15 $15 $150 $40 $15 $125 $25 $25

California Dental Network, Inc is licensed by the California Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act (License number 933-0286). Oct-06

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Toll Free Customer Service (877) 4DENTAL