Summary of Discounts

ADA
Code
Diagnostic & Preventive UCR Cost
Without/Plan
You
Pay
Your
Savings
D0150Comprehensive Oral Evaluation$106No Charge100%
D0120Periodic Oral Evaluation$106No Charge100%
D1330Oral Hygiene Instructions$60No Charge100%
D0210Intraoral - Complete Series Radiographic Images$220No Charge100%
D0220Intraoral - Periapical Each Additional Image$52No Charge100%
D0230Intraoral - Periapical Each Additional Image$30No Charge100%
D1110Prophylaxis - Adult (cleaning & polishing)$139$5955%
D1112Prophylaxis - Child (cleaning & polishing)$139$4965%
D1208Topical Application of Flouride$120$5257%
D1351Sealant - Per Tooth$102$4952%

Restorative-Fillings

Amalgam Fillings (Primary or permanent teeth)
D2140One Surface$219$11050%
D2150Two Surfaces$283$12556%
D2160Three Surfaces$342$16053%
D2161Four Surfaces$416$17558%
Resin-based Composite-Anterior
D2330One Surface$371$14561%
D2331Two Surfaces$396$18553%
D2332Three Surfaces$425$21051%
D2335Four Surfaces$280$24014%
Resin-based Composite-Posterior
D2391One Surface$449$18559%
D2392Two Surfaces$373$25532%
D2393Three Surfaces$438$28535%
D2394Four Surfaces$509$31538%

Restorative-Crowns, Bridges, Inlays/Onlays

D2740Ceramic-Crown (Full porcelain/lava)$1,520$1,13525%
D2750Crown - Porcelain Fused To High Noble Metal$1,499$93538%
D2751Crown - Porcelain Fused To Predominantly Base Metal$1,485$63058%
D2920Recementation, Crown$139$8539%
D2610Inlay-Porcelain$1,185$69541%
D2642Onlay-Porcelain$1,584$65059%

Restorative Other

D2962Veneer - Standard per tooth$1,401$89036%
Veneer - Lumineers per tooth$1200
Bonding- Tooth colored fillings (front teeth)-one surface$550

Endodontics - Done by General Dentist

D3220Therapeutic pulpotomy $268$15542%
D3310Root canal - single root$1132$48557%
D3320Root canal - two roots$1382$58058%
D3330Root canal - three roots or more$1785$69061%
D9110Open and medicate$572$16072%

Periodontics

D4341Periodontal scaling and root planing$343$15056%
D4910Periodontal maintenance - single visit$235$9958%
D4381Arestin – Per Tooth with 1 to 6 sites each$189$7560%
D4921Irrigation (at the time of SRP) per quadrant$244$15039%
Periodontics Packages
Perio maintenance package 3, 6 & 9 month$250
Irrigation (Full Mouth at time of SRP)$150
laser therapy with scaling and root planing package (per quadrant)$200

Prosthodontics- Removable

D5110Complete denture - maxillary (upper)$2254$110051%
D5120Complete denture - mandibular (lower)$2254$110051%
D5211-
D5214
Partial denture (upper or lower)$1903$120037%
D5225Premium Denture (Valplast)$2340$192018%
D5730-
D5741
Reline- Office Process- Cold Cure$516$19063%
D5750-
D5761
Reline- Laboratory Processed$689$35049%
D1510Space Maintainer- Fixed$563$22760%
D1520Space Maintainer- Removable$676$28558%
D5820Stay Plate (teeth & clasps extra)$843$35058%

Oral Surgery - Extractions - Done by General Dentist

D7111Extraction, coronal remnants$218$11547%
D7210Surgical removal of tooth$360$20543%
D7220Impacted tooth- soft tissue$451$25843%
D7230Impacted tooth- partial Bony$686$34550%
D7240Impacted tooth- completely Bony$755$41245%

Orthodontic Services

Orthodontic ConsultationNo Charge
Beginning Records$396
Braces - Standard Case 18-24 Months (including appliances)$3900
Braces - Standard Case 24-30 Months (including appliances)$4600
Phase I - Limited Orthodontic Treatment 6-12 months$1300
Phase I - Limited Orthodontic Treatment 12-24 months$2600
Invisalign$5000
Broken/cancelled appointment w/o 24 hours notice$35
Gold / Clear braces (per arch)$600
Retainer without braces$160
Gold/Clear Braces, Appliances and Special ProceduresAdditional

Other Services

D9940Occlusal guard, by report$450$450
Services listed on Summary of Discounts are performed by your selected general dentist. Specialist services are discounted 20% off the participating specialist’s usual and customary fee for that procedure. Specialty services are only available at select offices.
Dental Alliance Dental Plan 20% Savings*On Specialty Services *Specialist services are discounted 20% off the participating specialist’s usual customary fee for that procedure

Examples of how the Dental Alliance Dental Plan can work for you and your family