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Pediatric Dental

The amount you pay for pediatric dental care is regulated by Covered California guidelines. This grid shows your co-insurance and co-payment rates:

Pediatric Dental Services (for Members under Age 19 only)

  • Covered Services are subject to Metal Plan Out of Pocket Maximum

Covered Services

Minimum Coverage (Catastrophic Plan)

Bronze, Silver, Gold & Platinum Plans

Diagnostic and Preventive Care:

  • Oral Exam, Preventive Cleaning, X-ray, Sealants, Fluoride Application Space Maintainers – Fixed

No Charge

No Charge

Basic Services:

  • Amalgam Fill – 1 Surface

$0

Co-payment per visit

$25

Co-payment per visit

Major Services:

  • Root Canal - Molar

$0

Co-payment per visit

$300

Co-payment per visit

  • Gingivectomy per Quad

$0

Co-payment per visit

$150

Co-payment per visit

  • Extraction – Single Tooth Root Exposed

$0

Co-payment per visit

$65

Co-payment per visit

  • Extraction – Complete Bony

$0

Co-payment per visit

$160

Co-payment per visit

  • Porcelain with Metal Crown

$0

Coinsurance

$300

Co-payment per visit

Orthodontics:

  • Orthodontia (Medically Necessary)

$0

Co-payment per visit

$1,000

Co-payment per visit

 

Your costs depend on which plan you have. Please see your Agreement or our plans grid for more information.

Please click here to find dentist that can provide covered dental services. ​

The amount you pay for pediatric dental care is regulated by Covered California guidelines. This grid shows your co-insurance and co-payment rates:

Pediatric Dental Services (for Members under Age 19 only)

  • Covered Services are subject to Metal Plan Out of Pocket Maximum

Covered Services

Minimum Coverage (Catastrophic Plan)

Bronze, Silver, Gold & Platinum Plans

Diagnostic and Preventive Care:

  • Oral Exam, Preventive Cleaning, X-ray, Sealants, Fluoride Application Space Maintainers – Fixed

No Charge

No Charge

Basic Services*:

$0

Co-payment per visit

$25

Co-payment per visit

Major Services:

$0

Co-payment per visit

$300

Co-payment per visit

Orthodontics*:

  • Orthodontia (Medically Necessary)

$0

Co-payment per visit

$1,000

Co-payment per visit

 

Your costs depend on which plan you have.

*Please see your Agreement for detailed dental benefit information.

Please click here to find a dentist that can provide covered dental services.

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