Best Dental Plan

There are two types of Dental Plans

We highly suggest checking the provider search websites to see if your Dental Office is IN-Network with the plan you are considering before finalizing your plan choice. Keep in mind that Diagnostic & Preventive care (i.e. X-rays & regular cleanings) are only covered at no charge with IN-Network Dental Offices. HMO plans do not provide any coverage whatsoever for OUT-of-Network dental offices, but PPO plans will provide a reduced level of coverage which is highlighted below under the Out-of-Network column.

Benefits below are for individuals that are 19 and older. Pediatric dental and vision coverage is included in all medical plans for children under the age of 19. However, if you wish to purchase these dental plans for your children who are under the age of 19, please contact us at 818-350-2675 for specific details as this chart does not apply to them.

Key Benefits


The amounts (co-pays) listed in this section of the chart are what you are responsible to pay when visiting the Dental provider for the most common procedures.
The cost for other procedure codes can be found in the detailed summary of benefits located below the chart.


The percentages listed in the chart below are what the Insurance company will pay the Dental provider.
The percentage shown for Out-of-Network providers are paid based on the amount allowed by the Insurance company for that specific service. This amount is not based on how much your dentist charges but rather how much the insurance company will pay toward each service. (see Out-of-Network example)
Procedure Codes /
Type of Service
In-Network Out-Of-Network In-Network Out-Of-Network
Preventive Care
D1110 - Routine cleaning
D1208 - Topical application of fluoride
No Charge Full Cost No Charge 90%1
Diagnostic Services
D0120 - Periodic oral exam D0150 - Comprehensive oral exam
D0210 - Full mouth x-ray
D0220 - Individual tooth x-ray
No Charge Full Cost No Charge 90%1
Basic / Restorative Services
D2140 - Amalgam (silver) filling, 1 surface
$25 Full Cost 80% 70%1
D2330 — Resin-based composite (white), 1 surface, front tooth $30 Full Cost
Major Services
D3330 - Root canal, molar tooth
$300 Full Cost 50% 50%1
D4341 - Periodontal scaling and root planing (four or more teeth per quadrant) $55 Full Cost
D7140 - Extraction (removal) of a fully exposed $65 Full Cost
D7240 - Extraction of fully impacted tooth $160 Full Cost
D2750 - Crown, porcelain and precious metal $300 Full Cost
Orthodontics2 Not Covered by any Adult plan offered on Covered California
Annual Deductible $0 N/A $50 per Person
Annual Maximum Benefit None $1,500 per person
Waiting Period None 6 months for Major Services (waived with proof of prior coverage)3
1 Out-of-Network Dentists are allowed to Balance Bill, which means the actual percentage that is covered will most likely be lower. Please see Out-of-Network example shown below this chart for further explanation.
2 Orthodontic treatment is covered for children under the age of 19 when deemed Medically necessary and receives prior authorization from the Insurance company.
3 Please contact the Insurance company for details on what type of proof is required in order to have the 6 month waiting period waived.
Procedure Codes /
Type of Service
In-Network Out-Of-Network In-Network Out-Of-Network

To find information and brochures about your Dental provider, please visit our Dental Provider Information Links page.

Here’s an example of higher costs for Out-of-Network dental services

This is an example only. Your experience may be different, depending on what your Out-of-Network Dentist charges.
Ted gets a stainless steel crown from an out-of-network dentist, who charges $1,200 for the service and bills your insurance for that amount. The Insurance company's maximum amount for this dental service is $800. This means there will be a $400 difference, which the out-of-network dentist can “balance bill” Ted for. If Ted used an IN-Network dentist there would be no possibility of him being “balance billed” for this extra $400. By using an Out-of-Network Dentist, the total cost of crown doubled to $800! Here is the math:

  • Out-of-Network Dentist Charge: $1,200
  • Insurance company Maximum Allowed: $800
  • Insurance company pays 50% of Maximum Allowed for Major Services: $400
  • Ted pays 50% Coinsurance: $400 - This would be all Ted owed if he used an IN-Network Dentist.
  • Balance Ted owes to Out-of-Network Dentist: $400
  • Ted’s Total Cost: $400 Coinsurance + $400 Out-of-Network Dentist balance = $800
If Ted used an IN-Network dentist his total cost for the crown would have been $400 instead of $800, so the difference in price can be substantial if you choose to use an Out-of-Network dentist.