Dental Coverage California

Amounts listed are member's responsibility to pay. These copayments apply only to services rendered by a Participating Dentist Services provided by a Participating Specialist are included aona aseparate schedule in the dental plan contract.

General anesthesia is covered if the member's medical contract does not cover it.

Note: The Blue Cross Dental Select HMO Provider Network:

Available in these counties:Alameda, Contra Costa, Los Angeles, Marin, Orange, Sacramento, San Diego, San Francisco, San Joaquin, San Luis Obispo, Santa Barbara, Santa Clara, Solano, and Sonoma.

The Blue Cross Dental SelectHMO Provider Network is available on a limited basis in these counties: El Dorado, Fresno, Kern, Kings, Monterey, Placer, Riverside, San Bernardino, San Mateo, Santa Cruz, Tulare, and Ventura. Contact your agent for more information on the location of participating providers.
Footnotes:
1. First two treatments in 12 consecutive months. All additional treatments within a 12-month period require copays of $44 for adults and $35 for children.
2. You must meet a six-month waiting period before these benefits are payable.

INDIVIDUAL DENTAL SELECTHMO PLANS			VIEW RATES
Individual Dental SelectHMO Plans from Blue Cross of California
Benefits	Saver SelectHMO (ZE6N) Copays	SelectHMO (ZE7N) Copays	Saver SelectHMO (ZE8N) Copays
Office Visit	$5	$5	$5
Diagnostic Care
Oral Exams	No charge	No charge	No charge
X-rays	No charge	No charge	No charge
Preventive Care
Prophylaxis - adult and child	No charge¹	No charge¹	No charge¹
Topical Fluoride - child	No charge¹	No charge¹	No charge¹
Sealant - per tooth	$25	$25	No charge
Restorative Care: Filling - permanent
1 surface amalgam	$54	No charge²	No charge²
2 surfaces amalgam	$64	No charge²	No charge²
Endodontic Care
Root canal - bicuspid	$341	$341	$341
Root canal - molar	$459	$459	$459
Pulpotomy	$62	$62	$62
Periodontal Care
Scaling/root plaining - per quadrant	$101	$101	No charge²
Gingivectomy - per tooth	$72	$72	$72
Gingivectomy - per quadrant	$194	$194	$194
Prosthodontic Care
Crown - porcelain with high noble metal	$432	$432	$432
Oral Surgery
Single extraction	$60	$60	No charge²
Cosmetic Care
Reisin filling - permanent, one surface, posterior	$75	$75	$75
Labial veneer (laminate) - chairside	$187	$187	$187
Orthodontic Care
Child	$2,870	$2,870	$2,870
Adult	$3,045	$3,045	$3,045
Retention	$300	$300	$300