Preventative Dental Care
Cleaning, Exam, Full Series of X-Rays, Fluoride (D0150)
$0-$412
Certain PPO plans may cover 100%
Dental Exams
$49-$81
Periodic Exam (D0120) $49
Comprehensive Exam (D0150) $79
Limited Exam (D0140) $81
Emergency Exam
$0-147
Certain PPO plans may cover 100%
Dental Cleanings (Prophylaxis)
$77-$96
Child Teeth Cleaning (D1120) $77
Adult Teeth Cleaning (D1110) $96
Dental X-Rays
$32-$261
PA (D0220): $34
Addt’l PAs (D0230): $32
1 BWX (D0270): $34
2 BWX (D0272): $54
4 BWX (D0274): $77
Panoramic X-Ray (D0330): $130
CT (D0367): $261
Dental Sealants (D1351)
$51
Fluoride (D1206)
$30
Posterior Composite (White) Fillings
$199-$404
1 surface — $199
2 surface — $253
3 surface — $315
4 surface — $366
5 surface — $404
Certain PPO plans may cover up to 80%
Anterior Composite (White) Fillings
$179-$404
1 surface —$179
2 surface — $221
3 surface — $273
4 surface — $339
5 surface —$404
Certain PPO plans may cover up to 50-80%
Periodontal Maintenance (D4910)
$156
Certain PPO plans may cover up to 80%
Restorative Dental Care
Porcelain Crown
$1,349-$1,650
$1,349 (crown only)
$1,650 (Including the build up)
Certain PPO plans cover up to 80%
Scaling & Root Planing
$183 – $283
1-3 Teeth (D4342): $183
Quad (D4341): $283
Root Canals
$941 – $1,453
Anterior (D3310): $941
Bicuspid (D3320): $1,071
Molar (D3330): $1,453
Tooth Extractions
$211 – $538
Surgical Extraction (D7210): $330
Bone Grafts
$429 – $829
With Extraction (D7953): $429
With Implant Placement: (D7950) $829
Dental Implants (D6010/D6056/D6059)
$4,417
D6010: $2,098
D6057: $7485
D6058: $1,534
Includes 3-D X-ray–certain PPO plans may cover up to 50%
Denture Services
$75 – $1,904
Denture Repair: $75-$300
Denture Reline (D5750 & 5751): $450
Flipper (D5820 & D5821): $500-$1,000
Complete Upper (D5110): $1,813
Complete Lower (D5120): $1,813
Immediate Upper (D5130): $1,883
Immediate Lower (D5140): $1,883
Upper Partial (D5213): $1,904
Lower Partial (D5214): $1,904
Implant-Supported Dentures
$5,500-9,500
2 implant overdenture — $5,500
4 implant overdenture — $9,500
Includes all costs except sedation and tooth extractions
Implant-Supported Bridge
$20,000 / arch
Includes 6 implants per arch and all costs except tooth extraction
Sinus Augmentation
$892 – $2,625
Sinus Bump (D7952): $892
Sinus Lift (D7951): $2,625
Cosmetic Dental
Take-Home Whitening (Custom Trays)
$299
Take-Home Whitening (GO Whitening Package)
$75
Porcelain Veneers
$1,380
Additional Services
Orthodontics (D8090)
$2,500-5,200
Certain PPO plans may cover up to 50%
Nitrous Sedation
$99
Oral Conscious Sedation
$365
IV Sedation
$0-750
Certain PPO plans may cover up to 100%
Full Arch Occlusal Guard (D9944)
$500
Sleep Apnea Appliance
$5,775