Alternative Dental Insurance
PO BOX 1901
Sacramento, CA 95601

ADA CODE DESCRIPTION Usual Fee* You Pay Plan Discount Your Savings 
D0120 Periodic oral evaluation $120.00 $- 100% $120.00
D0140 Limited oral evaluation - problem focused $95.00 $- 100% $95.00
D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver $93.00 $- 100% $93.00
D0150 Comprehensive oral evaluation - new or established patient $150.00 $- 100% $150.00
D0170 Re-evaluation-limited; problem focused (established patient; not post-operative visit) $51.00 $- 100% $51.00
D0180 Comprehensive periodontal evaluation - new or established patient $175.00 $- 100% $175.00
D0210 Intraoral complete series ( including bitewings) $179.00 $- 100% $179.00
D0220 Intraoral radiograph - periapical first film $36.00 $15.00 58% $21.00
D0230 Intraoral radiograph - periapical each additional film $29.00 $12.00 59% $17.00
D0240 Intraoral radiograph - occlusal film $52.00 $12.00 77% $40.00
D0270 Bitewing radiograph - single film $34.00 $19.00 44% $15.00
D0272 Bitewings radiograph - two films $55.00 $30.00 45% $25.00
D0273 Bitewings radiograph; three films $67.00 $36.00 46% $31.00
D0274 Bitewings radiograph - four films $77.00 $38.00 51% $39.00
D0277 Vertical bitewings - 7 to 8 films $117.00 $49.00 58% $68.00
D0290 Posterior-anterior or lateral skull and facial bone survey film $192.00 $80.00 58% $112.00
D0321 Radiographs - other temporomandibular joint films $250.00 $120.00 52% $130.00
D0322 Radiographs - tomographic survey $645.00 $350.00 46% $295.00
D0330 Radiograph - panoramic film $160.00 $74.00 54% $86.00
D0340 Radiograph - cephalometric film $175.00 $90.00 49% $85.00
D0350 Oral/facial images $66.00 $37.00 44% $29.00
D0415 Collection of microrganisms for culture and sensitivity. By report, provide copy of test results $83.00 $36.00 57% $47.00
D0425 Caries susceptibility tests. By report, provide copy of test results $39.00 $22.00 44% $17.00
D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures $68.00 $46.00 32% $22.00
D0460 Pulp vitality tests $68.00 $31.00 54% $37.00
D0470 Diagnostic casts or study models $145.00 $56.00 61% $89.00
D0474 Accession of tissue, gross & microscopic examination $338.00 $174.00 49% $164.00
D0486 Accession of brush biopsy sample $158.00 $157.00 1% $1.00
D1110 Prophylaxis - adult $110.00 $78.00 29% $32.00
D1120 Prophylaxis - child - under age 16 $76.00 $47.00 38% $29.00
D1203 Topical application of fluoride - child (prophylaxis not included) under age 16        
D1204 Topical application of fluoride – adult (prophylaxis not included)        
D1208 Topical Flouride Adult/Child $75.00 $45.00 40% $30.00
D1206 Topical fluoride varnish - by report        
D1330 Oral Hygiene instructions        
D1351 Sealant - per tooth - under age 16 on permanent molars only $70.00 $35.00 50% $35.00
D1510 Space maintainer - fixed - unilateral $451.00 $258.00 43% $193.00
D1515 Space maintainer - fixed - bilateral $596.00 $254.00 57% $342.00
D1520 Space maintainer - removable - unilateral $542.00 $269.00 50% $273.00
D1525 Space maintainer - removable - bilateral $767.00 $350.00 54% $417.00
D1550 Re-cementation of space maintainer $97.00 $22.00 77% $75.00
D1555 Removal of fixed space maintainer $120.00 $52.00 57% $68.00
D2140 Amalgam - one surface - primary or permanent $181.00 $99.00 45% $82.00
D2150 Amalgam - two surfaces - primary or permanent $234.00 $115.00 51% $119.00
D2160 Amalgam - three surfaces - primary or permanent $283.00 $130.00 54% $153.00
D2161 Amalgam - four or more surfaces - primary or permanent $345.00 $150.00 57% $195.00
D2330 Resin-based composite - one surface - anterior $180.00 $99.00 45% $81.00
D2331 Resin-based composite - two surfaces - anterior $230.00 $115.00 50% $115.00
D2332 Resin-based composite - three surfaces - anterior $282.00 $147.00 48% $135.00
D2335 Resin-based composite - four or more surfaces or involving incisal angle - anterior $333.00 $147.00 56% $186.00
D2390 Resin-based composite crown - anterior $1,200.00 $695.00 42% $505.00
D2391 Resin-based composite - one surface - posterior $211.00 $99.00 53% $112.00
D2392 Resin-based composite - two surfaces - posterior $276.00 $115.00 58% $161.00
D2393 Resin-based composite - three surfaces - posterior $343.00 $147.00 57% $196.00
D2394 Resin-based composite - four or more surfaces - posterior $421.00 $147.00 65% $274.00
D2610 Porcelain/ceramic inlay - one surface $1,200.00 $695.00 42% $505.00
D2620 Porcelain/ceramic inlay - two surfaces $1,200.00 $695.00 42% $505.00
D2630 Porcelain/ceramic inlay - three or more surfaces $1,200.00 $695.00 42% $505.00
D2642 Porcelain/ceramic onlay - two surfaces $1,475.00 $895.00 39% $580.00
D2643 Porcelain/ceramic onlay - three surfaces $1,475.00 $895.00 39% $580.00
D2644 Porcelain/ceramic onlay - four or more surfaces $1,475.00 $895.00 39% $580.00
D2750 Crown - porcelain fused to high noble metal $1,650.00 $895.00 46% $755.00
D2790 Crown - full cast high noble metal $1,650.00 $895.00 46% $755.00
D2799 Provisional crown $461.00 $179.00 61% $282.00
D2910 Recement inlay, onlay, or partial coverage restoration $112.00 $43.00 62% $69.00
D2915 Recement cast or prefabricated post and core $112.00 $43.00 62% $69.00
D2920 Recement crown $113.00 $43.00 62% $70.00
D2930 Prefabricated stainless steel crown - primary tooth $308.00 $130.00 58% $178.00
D2931 Prefabricated stainless steel crown - permanent tooth $349.00 $137.00 61% $212.00
D2932 Prefabricated resin crown $372.00 $111.00 70% $261.00
D2933 Prefabricated stainless steel crown with resin window $426.00 $160.00 62% $266.00
D2934 Prefabricated esthetic coated stainless steel crown - primary tooth $426.00 $130.00 69% $296.00
D2940 Sedative filling $175.00 $80.00 54% $95.00
D2950 Core buildup - including pins $350.00 $175.00 50% $175.00
D2951 Pin retention - per tooth - in addition to restoration $67.00 $34.00 49% $33.00
D2952 Post and core in addition to crown, indirectly fabricated $465.00 $196.00 58% $269.00
D2954 Prefabricated post and core in addition to crown $372.00 $137.00 63% $235.00
D2960 Labial veneer (resin laminate) - chairside $898.00 $330.00 63% $568.00
D2961 Labial veneer (resin laminate) - laboratory $1,650.00 $900.00 45% $750.00
D2962 Labial veneer (porcelain laminate) - laboratory Cosmetic **** $1,650.00 $900.00 45% $750.00
D2970 Temporary crown (fractured tooth) - by report $350.00 $180.00 49% $170.00
D2971 Additional procedures to construct new crown under existing partial denture framework $178.00 $43.00 76% $135.00
D3110 Pulp cap - direct $82.00 $39.00 52% $43.00
D3120 Pulp cap - indirect $68.00 $37.00 46% $31.00
D3220 Therapeutic pulpotomy $195.00 $100.00 49% $95.00
D3221 Pulpal debridement - primary and permanent teeth $214.00 $92.00 57% $122.00
D3222 Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development $375.00 $181.00 52% $194.00
D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) Primary incisors and cuspids. $375.00 $181.00 52% $194.00
D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) Primary first and second molars. $375.00 $181.00 52% $194.00
D3310 Root canal therapy - anterior - traditional $875.00 $520.00 41% $355.00
D3320 Root canal therapy - bicuspid - traditional $1,007.00 $756.00 25% $251.00
D3330 Root canal therapy - molar - traditional $1,301.00 $950.00 27% $351.00
D3331 Treatment of root canal obstruction; non-surgical access $375.00 $134.00 64% $241.00
D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $634.00 $296.00 53% $338.00
D3333 Internal root repair of perforation defects $354.00 $200.00 44% $154.00
D3346 Retreatment of root canal - anterior $1,110.00 $725.00 35% $385.00
D3347 Retreatment of root canal - bicuspid $1,309.00 $814.00 38% $495.00
D3348 Retreatment of root canal - molar $1,574.00 $1,009.00 36% $565.00
D3410 Apicoectomy/Periradicular surgery - anterior - performed as separate surgical procedure $1,275.00 $890.00 30% $385.00
D3421 Apicoectomy/Periradicular surgery - bicuspid - first root $1,031.00 $696.00 32% $335.00
D3425 Apicoectomy/Periradicular surgery - molar - first root $1,166.00 $702.00 40% $464.00
D3426 Apicoectomy/Periradicular surgery - each additional root $1,031.00 $696.00 32% $335.00
D3430 Retrograde filling - per root - in addition to apicoectomy $286.00 $138.00 52% $148.00
D3450 Root amputation - per root $579.00 $350.00 40% $229.00
D3920 Hemisection (including any root removal) $452.00 $250.00 45% $202.00
D3950 Canal preparation and fitting of preformed dowel or post $206.00 $94.00 54% $112.00
D4210 Gingivectomy or gingivoplasty - 4 or more contiguous teeth or bounded teeth spaces per quadrant $935.00 $520.00 44% $415.00
D4211 Gingivectomy or gingivoplasty - one to three contiguous or bounded teeth spaces per quadrant $524.00 $352.00 33% $172.00
D4230 Anatomical crown exposure - four or more contiguous teeth per quadrant $1,293.00 $726.00 44% $567.00
D4231 Anatomical crown exposure - one to three teeth per quadrant $696.00 $376.00 46% $320.00
D4240 Gingival flap procedure - includes root planing - 4 plus contiguous teeth or bounded teeth spaces per quadrant $1,134.00 $875.00 23% $259.00
D4241 Gingival flap procedure, including root planing - 1 to 3 contiguous teeth or bounded teeth spaces per quadrant $754.00 $364.00 52% $390.00
D4249 Crown lengthening - hard tissue - by report $1,293.00 $593.00 54% $700.00
D4260 Osseous surgery - four or more contiguous teeth or bounded teeth spaces per quadrant $1,890.00 $947.00 50% $943.00
D4261 Osseous surgery (including flap entry and closure)- 1 to 3 contiguous or bounded teeth spaces per quadrant $1,015.00 $507.00 50% $508.00
D4263 Bone replacement graft - first site in quadrant $856.00 $450.00 47% $406.00
D4264 Bone replacement graft - each additional site in quadrant $617.00 $347.00 44% $270.00
D4266 Guided tissue regeneration - resorbable barrier - per site $696.00 $375.00 46% $321.00
D4267 Guided tissue regeneration - nonresorbable barrier - per site (includes membrane removal) $895.00 $390.00 56% $505.00
D4270 Pedicle soft tissue graft procedure $1,353.00 $659.00 51% $694.00
D4271 Free soft tissue graft procedure (including donor site surgery) $1,412.00 $659.00 53% $753.00
D4273 Subepithelial connective tissue graft procedures - per tooth (includes donor site surgery) $1,671.00 $794.00 52% $877.00
D4274 Distal or proximal wedge procedure $895.00 $347.00 61% $548.00
D4275 Soft tissue allograft $1,194.00 $649.00 46% $545.00
D4320 Provisional splinting - intracoronal - by report $375.00 $264.00 30% $111.00
* 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  

 

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