Savings to Smile About
Below is a list of common dental services and what you’ll pay with Dental Alliance Dental Plan.
| ADA Code | Procedure Description | Member Pays* |
|---|---|---|
| Preventive & Diagnostic | ||
| D0120 | Periodic Exam | NO CHARGE |
| D0140 | Limited Exam - Problem Focused | NO CHARGE |
| D0150 | Comprehensive Exam | NO CHARGE |
| D0210 | Full-Mouth X-Rays | NO CHARGE |
| D0330 | Panoramic X-Rays | NO CHARGE |
| D1110 | Adult Cleaning | $99.00 |
| D1120 | Child Cleaning | $89.00 |
| Restorative | ||
| D2330 | Filling - 1 Surface, Anterior | $190.00 |
| D2391 | Composite - One Surface, Posterior | $225.00 |
| D2740 | Crown - Porcelain/Ceramic | $1,100.00 |
| D2750 | Crown - Porcelain/High Noble Metal | $995.00 |
| Endodontics & Periodontics | ||
| D3310 | Root Canal - Anterior | $850.00 |
| D3320 | Root Canal - Bicuspid | $950.00 |
| D3330 | Root Canal - Molar | $1075.00 |
| D4341 | Perio Scaling/Root Planing - 4+ Teeth | $200.00 |
| D4910 | Periodontal Maintenance | $180.00 |
| Prosthodontics & Oral Surgery | ||
| D5110 | Complete Denture (Upper) | $1,300.00 |
| D5211 | Partial Denture (Upper) | $1,150.00 |
| D7140 | Simple Extraction | $195.00 |
| D7210 | Surgical Extraction | $260.00 |
| Orthodontic | ||
| D8020 | Invisalign (Clear Aligner) Phase 1 18 months | $3,345.00 |
| D8080/D8090 | Comprehensive orthodontic treatment 6 - 12 months | $3,495.00 |
| D8692 | Replacement of lost or broken retainer | $350.00 |
*Member savings may vary by location. Free exams and x-rays limited to 2x per member/per annual membership term.