Delta Dental of California is pleased to offer a specially designed dental plan for Costco Executive members. Through our DeltaCare USA plan, Executive Members can enjoy significant cost control while having access to comprehensive dental benefits. DeltaCare USA enrollees have access to one of California’s largest dental HMO networks with over 4,100 participating dentists in more than 2,500 dentist locations across the state. Enrollees simply select a convenient dental office from the list of DeltaCare USA dentists available to them. Best of all, our low turnover rate among DeltaCare USA dentists means enrollees can enjoy a long-term relationship with their dentist.
| Procedure description |
Procedure code |
Enrollee copayment |
Average Fee Range |
 |
| Diagnostic services |
| Intraoral - complete series (including bitewings) |
D0210 |
No Cost |
$90-$125 |
| Preventive services |
| Prophylaxis - adult / child |
D1110, D1120 |
$20 |
$76-$80
$59-$75 |
| Sealants - per tooth |
D1351 |
$20 |
$40-$80 |
| Restorative services |
| Amalgam - one surface, primary or permanent |
D2140 |
$25/ $37 |
$93-$125 |
| Resin-based composite - one surface, anterior |
D2330 |
$60 |
$117-$169 |
| Resin-based composite - one surface, posterior |
D2391 |
$70 |
$123-$175 |
| Crown - resin-based composite (indirect) |
D2710 |
$125.00 |
$265-$700 |
| Crown - porcelain fused to high noble metal |
D2750 |
$425 |
$748-$925 |
| Crown - full cast high noble metal |
D2790 |
$425 |
$758-$908 |
| Crown - full cast noble metal |
D2792 |
$325 |
$733-$877 |
| Cast post and core in addition to crown - includes canal preparation |
D2952 |
$110 |
$192-$350 |
| Endodontics |
| Root canal, anterior (excluding final restoration) |
D3310 |
$250 |
$423-$610 |
| Root canal, molar (excluding final restoration) |
D3330 |
$400 |
$621-$860 |
| Periodontics |
| Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant |
D4260 |
$650 |
$850-$1,300 |
| Periodontal scaling and root planing - four or more teeth per quadrant |
D4341 |
$78 |
$134-$220 |
| Prosthodontics (removable) |
| Complete denture - maxillary / mandibular |
D5110, D5120 |
$450 |
$950-$1,400
$943-$1,400 |
| Maxillary / mandibular partial denture - resin base (including any conventional clasps, rests and teeth) |
D5211, D5212 |
$300 |
$800-$1,200 |
| Maxillary / mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) |
D5213, D5214 |
$550 |
$1,150-$1,592
$1,138-$1,595 |
| Reline complete maxillary denture (laboratory) |
D5750 |
$150 |
$280-$404 |
| Oral and maxillofacial surgery |
| Extraction, erupted tooth or exposed root (elevation and/or forceps removal) |
D7140 |
$40 |
$95-$150 |
| Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth |
D7210 |
$70 |
$145-248 |
| Removal of impacted tooth - soft tissue |
D7220 |
$100.00 |
$184-$280 |
| Removal of impacted tooth - partially bony |
D7230 |
$190.00 |
$239-$350 |
| Orthodontics |
| Limited orthodontic treatment of the adolescent dentition – adolescent to age 19 |
D8030 |
$1,400 |
$1,800-$3,000 |
| Interceptive orthodontic treatment of the primary or transitional dentition |
D8050, D8060 |
$1,650 |
$2,000-$2,500
$2,000-$3,000 |
| Comprehensive orthodontic treatment of the transitional or adolescent dentition – child or adolescent to age 19 |
D8070, D8080 |
$2,500 |
$3,100-$4,800
$3,600-$5,000 |
| Comprehensive orthodontic treatment of the adult dentition – adults, including dependent adult children covered as full-time students |
D8090 |
$2,700 |
$3,600-$5,200 |
| Adjunctive general services |
| Deep sedation / general anesthesia – first 30 minutes |
D9220 |
$165 |
$200-$350 |
| Intravenous conscious sedation / analgesia – first 30 minutes |
D9241 |
$165 |
$207-$375 |
| External bleaching – per arch |
D9972 |
$125 |
$200-$250 |
| Deductible |
|
None |
|
| Annual and Lifetime Maximums |
|
None |
|
