Delta Dental of California is pleased to offer a specially designed dental plan, DeltaCare USA plan CAD15 for Costco Executive members. DeltaCare USA enrollees have access to one of California’s largest dental HMO networks across the state. Enrollees simply select a convenient dental office from the list of DeltaCare USA dentists available to them.

Below is an overview of the plan benefits and copayments

Deductible	n/a	None	n/a
Annual and Lifetime Maximums	n/a	None	n/a
Procedure description	Procedure code	Enrollee copayment	Typical Cost at Dentist’s Office without Insurance
Diagnostic services
Intraoral - complete series (including bitewings)	D0210	$12	$95-$131
Preventive services
Prophylaxis - adult / child (1 per 6 month period)	D1110, D1120	$20	$80-$84 $62-$79
Sealants - per tooth (limited to permanent molars through age 15)	D1351	$22	$42-$84
Restorative services
Amalgam - one surface, primary or permanent	D2140	$32	$98-$131
Resin-based composite - one surface, anterior	D2330	$65	$123-$177
Resin-based composite - one surface, posterior	D2391	$85	$129-$184
Crown - resin-based composite (indirect)	D2710	$125	$278-$735
Crown - porcelain fused to high noble metal (upgrade charges may apply)	D2750	$440	$785-$971
Crown - full cast high noble metal	D2790	$440	$796-$953
Crown - full cast noble metal	D2792	$425	$770-$921
Cast post and core in addition to crown - includes canal preparation	D2952	$95	$202-$368
Endodontics
Root canal – endodontic therapy, anterior (excluding final restoration)	D3310	$250	$444-$641
Root canal – endodontic therapy, molar (excluding final restoration)	D3330	$425	$652-$903
Periodontics
Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant	D4260	$650	$893-$1,365
Periodontal scaling and root planing - four or more teeth per quadrant (limited to 4 quadrants during any 12 consecutive months)	D4341	$88	$141-$231
Prosthodontics (removable)
Complete denture - maxillary / mandibular	D5110, D5120	$495	$998-$1,470 $990-$1,470
Maxillary / mandibular partial denture - resin base (including any conventional clasps, rests and teeth)	D5211, D5212	$400	$840-$1,260
Maxillary / mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)	D5213, D5214	$565	$1,208-$1,672 $1,195-$1,675
Reline complete maxillary denture (laboratory)	D5750	$150	$294-$424
Oral and maxillofacial surgery
Extraction, erupted tooth or exposed root (elevation and/or forceps removal)	D7140	$42	$100-$158
Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth	D7210	$80	$152-260
Removal of impacted tooth - soft tissue	D7220	$100	$193-$294
Removal of impacted tooth - partially bony	D7230	$190	$251-$368
Orthodontics
Limited orthodontic treatment of the adolescent dentition – adolescent to age 19	D8030	$1,400	$1,890-$3,150
Interceptive orthodontic treatment of the primary or transitional dentition	D8050, D8060	$1,650	$2,100-$2,625 $2,100-$3,150
Comprehensive orthodontic treatment of the transitional or adolescent dentition – child or adolescent to age 19	D8070, D8080	$2,500	$3,255-$5,040 $3,780-$5,250
Comprehensive orthodontic treatment of the adult dentition – adults, including covered dependent adult children	D8090	$2,700	$3,780-$5,460
Adjunctive general services
Deep sedation / general anesthesia – first 30 minutes	D9220	$165	$210-$368
Intravenous conscious sedation / analgesia – first 30 minutes	D9241	$165	$217-$394
External bleaching – per arch (limited to one bleaching tray and gel for two weeks of self treatment)	D9972	$125	$210-$263

See the Evidence of Coverage/Disclosure Form for a detailed disclosure of plan copayments, limitations and exclusions.