Preventative Dental Care
Cleaning, Exam, Full Series Of X-rays, Fluoride (D0150)
$0-170
Certain PPO plans may cover 100%
Dental Exams
$49-69
Periodic Exam (D0120) $69
Comprehensive Exam (D0150) $69
Limited Exam (D0140) $49
Emergency Exam
$0-$49
Certain PPO plans may cover 100%
Dental Cleanings (Prophylaxis)
$69
Adult and Child Teeth Cleaning (D1110 OR D1120) $69
Dental X-rays
$32-$261
PA (D0220): $41
Addt’l PAs (D0230): $36
1 BWX (D0270): $41
2 BWX (D0272): $62
4 BWX (D0274): $89
Panoramic X-Ray (D0330): $154
CT (D0367): $200
Dental Sealants (D1351)
$42
Fluoride (D1206)
$32
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
$229-$424
1 surface —$229
2 surface — $278
3 surface — $338
4 surface — $424
Certain PPO plans may cover up to 50-80%
Periodontal Maintenance (D4910)
$184
Certain PPO plans may cover up to 80%
Restorative Dental Care
Porcelain Crown
$956-$1147
$956 (crown only)
$1147 (Including the build up)
Prices with Membership Plan Discount
Certain PPO plans cover up to 80%
Scaling & Root Planing
$147-169
1-3 Teeth (D4342): $147
Quad (D4341): $169
Prices with Membership plan Discount
Root Canals
$652- $833
Anterior (D3310): $652
Bicuspid (D3320): $673
Molar (D3330): $833
Prices with Membership Plan Discount
Tooth Extractions
$229
Surgical Extraction (D7210): $229
Prices with MEmbership plan discount
Bone Grafts
$337- $800
With Extraction (D7953): $337
Dental Implants (D6010/d6056/d6059)
$3000-4,795
D6010: $2,098
D6057: $1163
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): $394
Flipper (D5820 & D5821): $506
Complete Upper (D5110): $1414
Complete Lower (D5120): $1414
Immediate Upper (D5130): $1414
Immediate Lower (D5140): $1414
Upper Partial (D5213): $1414
Lower Partial (D5214): $1414
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
$800 – $2500
Sinus Bump (D7952): $2500
Sinus Lift (D7951): $800
Cosmetic Dental
Take-home Whitening (Custom Trays)
$250
Take-home Whitening (Go Whitening Package)
$75
Porcelain Veneers
$1500
Additional Services
Orthodontics (D8090)
$2,500-5,200
Certain PPO plans may cover up to 50%