Alliance Dental Plan
ADA Code | Description | You Pay |
|
---|---|---|---|
Diagnostic and Preventative | |||
120 | Periodic Oral Evaluation (2 per year) | Select Your State | |
140 | Limited Oral Evaluation - Problem Focused (unlimited) | Select Your State | |
150 | Comprehensive Oral Evaluation (2 per year) | Select Your State | |
210 | X-Ray - Intraoral - Complete Series | Select Your State | |
220 | X-Ray - Intraoral - Periapical - First Image | Select Your State | |
230 | X-Ray - Intraoral - Periapical - Each Add'l Image | Select Your State | |
270 | X-Ray - Bitewing - Single Image | Select Your State | |
272 | X-Ray - Bitewing - Two Images | Select Your State | |
274 | X-Ray - Bitewing - Four Images | Select Your State | |
330 | X-Ray - Panoramic Image (if available) | Select Your State | |
350 | Oral/Facial Photographic Images | Select Your State | |
1330 | Oral Hygiene Instructions | Select Your State | |
431 | Adjunctive Oral Cancer Exam | Select Your State | |
1110 | Prophylaxis - Adult (basic cleaning & polishing) | Select Your State | |
1120 | Prophylaxis - Child (basic cleaning & polishing) | Select Your State | |
1106 | Topical Application Of Fluoride Varnish | Select Your State | |
1108 | Topical Application Of Fluoride | Select Your State | |
1351 | Sealant - per tooth | Select Your State | |
Restorative (Fillings) | |||
2140 | Amalgam - Posterior - One Surface | Select Your State | |
2150 | Amalgam - Posterior - Two Surface | Select Your State | |
2160 | Amalgam - Posterior - Three Surface | Select Your State | |
2330 | Resin-Based Composite - Anterior - One Surface | Select Your State | |
2331 | Resin-Based Composite - Anterior - Two Surfaces | Select Your State | |
2332 | Resin-Based Composite - Anterior - Three Surfaces | Select Your State | |
2335 | Resin-Based Composite - Anterior - Four Surfaces | Select Your State | |
2391 | Resin-Based Composite - Posterior - One Surface | Select Your State | |
2392 | Resin-Based Composite - Posterior - Two Surfaces | Select Your State | |
2393 | Resin-Based Composite - Posterior - Three Surfaces | Select Your State | |
2394 | Resin-Based Composite - Posterior - Four Surfaces | Select Your State | |
Crowns & Bridges | |||
2740/6740 | Crown - Full Porcelain/Ceramic Substrate | Select Your State | |
2750/6750 | Crown - Porcelain Fused To High Noble Metal | Select Your State | |
2751/6751 | Crown - Porcelain Fused Predominantly Base Metal | Select Your State | |
2752 | Crown - Porcelain Fused To Noble Metal | Select Your State | |
6240 | Pontic - Porcelain Fused To High Noble Metal | Select Your State | |
6245 | Pontic - Porcelain/Ceramic | Select Your State | |
2920 | Recementation, Crown | Select Your State | |
2950 | Core Buildup (including pins) | Select Your State | |
2954 | Prefabricated post & core in addition to crown | Select Your State | |
2962 | Veneer - Standard (per tooth) | Select Your State |
ADA Code | Description | You Pay |
|
---|---|---|---|
Endodontics (Performed by General Dentist) | |||
3120 | Pulp Cap - Indirect | Select Your State | |
3310 | Root Canal (anterior) | Select Your State | |
3320 | Root Canal (bicuspid) | Select Your State | |
3330 | Root Canal (molar) | Select Your State | |
Periodontics | |||
4341 | Periodontal Scaling and Root Planning (4+ teeth per quad) | Select Your State | |
4342 | Periodontal Scaling and Root Planning (1-3 teeth per quad) | Select Your State | |
4346 | Gingival Scaling | Select Your State | |
4381 | Arestin (Per tooth) | Select Your State | |
4910 | Periodontal Maintenance | Select Your State | |
4921 | Gingival Irrigation - Per Quad | Select Your State | |
4999 | Gingival Irrigation - Full Mouth | Select Your State | |
Prosthodontics - Removable | |||
5110/5120 | Complete Denture - (upper or lower) | Select Your State | |
5130/5140 | Immediate Denture - (upper or lower) | Select Your State | |
5213/5214 | Partial Denture w/ Metal Frame - (upper or lower) | Select Your State | |
5225/5226 | Partial Denture w/ Flexible Base - (upper or lower) | Select Your State | |
5410/5411 | Adjusted Complete Denture - (upper or lower) | Select Your State | |
5750/5751 | Reline Denture - in laboratory (upper or lower) | Select Your State | |
5820/5821 | Interim Partial Denture - (upper or lower) | Select Your State | |
Oral Surgery (Performed by General Dentist) | |||
7140 | Extraction - Erupted Tooth Or Exposed Root | Select Your State | |
7210 | Surgical Removal Of Erupted Tooth | Select Your State | |
7220 | Extraction - Impacted Tooth - Soft Tissue | Select Your State | |
7230 | Extraction - Impacted Tooth - Partial Bony | Select Your State | |
7240 | Extraction - Impacted Tooth - Full Bony | Select Your State | |
7250 | Surgical Removal Of Residual Roots | Select Your State | |
7953 | Bone Replacement For Ridge Preservation (per site) | Select Your State | |
Orthodontics | |||
8660 | Orthodontic Consult | Select Your State | |
8060 | Early Orthodontic Treatment (up to 12 months) | Select Your State | |
8080/8090 | Comprehensive Orthodontic Treatment (up to 24 months) | Select Your State | |
8080 | Invisalign (up to 24 months) | Select Your State | |
8692 | Replacement Retainers (Essex) | Select Your State | |
Other Services | |||
9230 | Nitrous Oxide | Select Your State | |
9910 | Application Of Desensitizing Medicament | Select Your State | |
9940 | Occlusal Night Guard | Select Your State | |
9972 | Teeth Whitening - In Office (per arch) | Select Your State | |
9975 | Take-Home Whitening Trays (10 Pack) | Select Your State |

For a Complete Summary of Discounts, download it here.