Alternative Dental Insurance
PO BOX 1901
Sacramento, CA 95601
FEE SCHEDULE
| ADA CODE | DESCRIPTION | Usual Fee* | You Pay | Plan Discount | Your Savings |
| New Patient Exam | $299.00 | FREE | 100% | $299.00 | |
| 120 | Routine 6-Month Check-up | $80.00 | FREE | 100% | $80.00 |
| 150 | In-Depth Oral Exam | $120.00 | FREE | 100% | $120.00 |
| 210 | Full Mouth Series of X-rays | $179.00 | FREE | 100% | $179.00 |
| 274 | Bitewings (4 x-rays) | $77.00 | $38.00 | 51% | $39.00 |
| 330 | Panoramic x-rays | $123.00 | $74.00 | 40% | $49.00 |
| 1110 | Adult Basic Cleaning | $110.00 | $78.00 | 29% | $32.00 |
| 1120 | Child Basic Cleaning | $76.00 | $47.00 | 38% | $29.00 |
| 1351 | Sealant- Per tooth | $70.00 | $35.00 | 50% | $35.00 |
| 2140 | Silver Filling | $181.00 | $99.00 | 45% | $82.00 |
| 2330 | White (Natural color) Filling | $180.00 | $99.00 | 45% | $81.00 |
| 2950 | Crown Build-up (including pins) | $294.00 | $137.00 | 53% | $157.00 |
| 2750 | Crown | $1,150.00 | $695.00 | 40% | $455.00 |
| 3310 | Root Canal - Anterior | $825.00 | $476.00 | 42% | $349.00 |
| 3320 | Root Canal - Bicusp | $1,007.00 | $584.00 | 42% | $423.00 |
| 3330 | Root Canal - Molar | $1,301.00 | $764.00 | 41% | $537.00 |
| 5110 | Upper Denture (Complete) | $1,781.00 | $798.00 | 55% | $983.00 |
| 6010 | Placement of Impant Body | $2,975.00 | $1500.00 | 50% | $1,475.00 |
| 7120 | Surgical Tooth Extraction | $299.00 | $155.00 | 48% | $144.00 |
| 7220 | Tissue Impacted Wisdom Tooth | $376.00 | $255.00 | 32% | $121.00 |
| * Usual is the average amount charged by neiborhood dentists, actual cost may vary | |||||
| ** A $5 copay will be added to every office visit. Fees may change without any notification and may slighltly vary from a provider to another based on the location | |||||