What dental insurance covers: the classes of service and the share each one pays
Pick a procedure and your state, then set the plan share for its class: the estimator shows the price, the plan payment and your part.
You pay for filling in New York
$69
$145 billed, $76 paid by the plan.
| Estimated dentist charge (full fee) | $294 |
| Estimated in-network price | $145 |
| Plan pays (80 % after deductible) | $76 |
| Deductible | $50 |
| New York Medicaid fee, same codes (2024) | $68 |
Estimate: New York Medicaid fee ÷ 26.1 % (Medicaid pay as a share of dentists' charges, ADA HPI 2024). Brought to September 2026 with the dental services price index (BLS). Not a quote.
| CDT code | Service | Count | Medicaid fee, 2024 |
|---|---|---|---|
| D2392 | Resin composite, two surfaces, posterior | 1 | $67.67 |
Compiled by Radif Partners · How prices are estimated · state Medicaid fee schedules, ADA ratios of 2024, BLS dental price index · not a quote
Dental plans do not pay one rate for everything. They sort each code into a class and pay a different share for each, a pattern often summed up as 100, 80, 50. In the Covered California 2026 adult coinsurance plan used as the example on this site, diagnostic and preventive care such as exams, cleanings and X-rays is paid at 100 % in network, basic services such as fillings and periodontal maintenance at 80 %, and major services, a group that includes root canals, crowns, dentures, bridges, gum treatment other than maintenance and oral surgery, at 50 %. Adult orthodontics is not covered, and cosmetic work such as veneers is outside the plan. Out of network the shares fall to 90 %, 70 % and 50 %. Everything is subject to a $50 deductible and a $1,500 yearly maximum. Children have their own rules: a $75 deductible and an out-of-pocket limit of $350.
Why plans pay by class
A dental plan wants members to come for checkups, which are cheap and catch problems early, and it wants to limit what it spends on large restorations. Paying the first class in full and the last one at half does both. The class of a procedure is set by the plan's own list of codes, not by how serious the problem feels: a root canal, which saves a tooth, sits in the same class as a crown or a denture in many plans, including the example one.
Classes also explain why two quotes for the same tooth can leave very different bills. A large filling and a crown may both repair a broken molar, but the first is usually basic work and the second major work, so the plan's share drops when the treatment moves from one to the other. Asking the office which codes it plans to bill, and looking them up in the plan's class list, is the quickest way to know which percentage applies before the work begins.
The table gives the example plan's shares by class, in and out of network, as published by Covered California for 2026. Your plan may use other percentages and put some codes in another class, which is why the calculators let you choose the share yourself.
| Class | What it includes | Plan pays in network | Plan pays out of network |
|---|---|---|---|
| Diagnostic and preventive | Exams, cleanings, X-rays | 100 % | 90 % |
| Basic services | Restorative procedures, periodontal maintenance | 80 % | 70 % |
| Major services | Periodontics other than maintenance, endodontics, crowns and casts, prosthodontics, oral surgery | 50 % | 50 % |
| Orthodontics | Adults: not covered. Children: medically necessary orthodontia only | Children: 50 % | n/a |
| Cosmetic work | Veneers and other work done for appearance | Not covered | Not covered |
Three procedures, three classes
Run the median network prices of the states this site prices through the example plan and the classes show their effect. A checkup with exam, cleaning and bitewing X-rays costs about $185 in network and the plan pays $185 of it. A two-surface filling, basic work, costs about $158; with the deductible still open the plan pays $87 and you pay $72. A molar root canal, major work, costs about $948; the plan pays $449 and you pay $499.
The deductible counts once a year, so the first treatment of the year carries it and the next ones do not. In the example plan it applies to basic and major work only, so a checkup in network costs nothing even before the deductible is met; plans that charge it on preventive care say so in their benefit summary.
Price and plan share of one procedure in your state
You pay for root canal, molar in New York
$457
| Estimated dentist charge (full fee) | $1,756 |
| Estimated in-network price | $865 |
| Plan pays (50 % after deductible) | $407 |
| Deductible | $50 |
Out of network: two losses at once
Leaving the network costs twice. The plan's share drops, as the table shows for preventive and basic work, and the dentist is free to bill the gap between the full fee and the plan's allowance, called balance billing. On a root canal the full fee median is $1,646 against $948 in network, so the gap alone is $698 before any coinsurance. The dental insurance calculator handles a quote from either kind of office.
Children, orthodontics and cosmetic work
Exchange plans write separate terms for children's dental care. In the example, a child's deductible is $75 and the family's out-of-pocket spending for a child stops at $350 a year in network, a protection adult plans do not have. Orthodontics for children is covered at 50 % only when it is medically necessary, a test the plan applies case by case; ordinary braces for alignment are paid by the family. The braces cost page prices a full treatment by state.
Adult orthodontics is not covered in the example plan, and many employer plans either exclude it or pay it up to a separate lifetime maximum. Veneers and whitening are cosmetic and outside almost every plan; the veneers page gives their full price. When a plan pays for a crown on a tooth that also has a cosmetic reason for treatment, the class follows the code billed, not the reason.
Limits that sit outside the classes
Classes and shares are only part of a benefit summary. Frequency limits restrict how often a plan pays for the same service, for example cleanings in a year or a new crown on the same tooth. Waiting periods delay the major class for new members, 6 months in the example unless earlier coverage is shown; the waiting period page explains them. And the yearly maximum caps the total whatever the class, as the annual maximum page shows. Reading those three clauses next to the class table gives a fair picture of what a plan will do with a given treatment plan. None of this says which treatment is right for you; that is your dentist's call.