How We Bill at Apex Oral Surgery &
Expected Patient Out of Pocket Information
At Apex Oral Surgery, we know that healthcare costs can be confusing and stressful. Because oral surgery uniquely bridges the gap between dentistry and medicine, we have the rare opportunity to advocate for you across both of your insurance platforms.
We take a completely different—and much more generous—approach to billing than a standard dental office. We utilize a unique "Dual-Billing Waterfall" process. It requires significantly more paperwork behind the scenes, but our expert team handles the heavy lifting because it drastically reduces your out-of-pocket expenses.
Here is exactly how we maximize your benefits and protect your wallet.
The Apex Advantage: Our Dual-Billing Waterfall
When you use dental insurance in a standard office, the plan pays a portion of your care and leaves you to pay the remaining gap out of your own pocket. We do things differently. Whatever your dental insurance doesn’t cover, we generously apply any payouts we receive from your medical insurance directly toward your remaining dental responsibility.
Step 1: The Safety Net. We calculate your maximum out-of-pocket responsibility based on your dental insurance's contracted rates. This becomes your absolute ceiling. Under no circumstances will you ever owe more for a covered procedure than your dental plan’s maximum out-of-pocket rate.
Step 2: The Medical Advantage. Many oral surgery procedures—like complex extractions, bone grafting, biopsies, and trauma care—qualify as medical procedures. We proactively bill your medical insurance first.
Step 3: The Waterfall. When your medical insurance pays us, we don't just bill you for your dental copay anyway. Instead, those medical dollars flow like a waterfall, directly washing away your remaining dental balance.
Step 4: You Save. Because we actively use your medical benefits to offset your personal bill, your final out-of-pocket cost drops significantly—often all the way down to $0.
Understanding Your Coverage Basics
Every insurance plan is highly individualized based on your specific group number, but historically, here is what we see across most plans:
Diagnostics (Exams, Consults, X-Rays): Usually covered at 80–100%.
Surgery & Anesthesia (Extractions, Sedation, Biopsies): Usually covered at 50–80%.
Implants & Bone Grafting: Usually covered at 0–50%.
In-Network vs. Out-of-Network Being "in-network" simply means we provide services at a pre-negotiated, discounted fee with your carrier. Being "out-of-network" means we utilize our standard office fees. However, going out-of-network does not mean you have no coverage! Most plans offer fantastic out-of-network benefits, paying slightly lower percentages on our standard fees.
The Fine Print: Policy Limitations While we fight to get you the maximum coverage, insurance companies do have strict rules. Most plans cap their payouts at a $1,000 to $3,000 maximum per calendar year. If your funds are exhausted, you are responsible for the remaining discounted balance.
Additionally, insurances place strict frequency limits on diagnostics. They typically only cover two exams per year and one full-mouth X-ray every 3 to 5 years. Interestingly, insurances absolutely demand an X-ray to approve your surgical claim, even if they refuse to pay for that X-ray due to a time limit! While exams and X-rays are never complimentary at our office, we will help you navigate these frustrating insurance loopholes to keep your costs as low as possible.
A Quick Guide to Specific Procedures
Tooth Extractions Extraction costs vary tremendously based on how impacted the tooth is. Without an X-ray, it is impossible to quote an exact price, but dental plans usually cover about 80% of the cost. Medical insurance may also step in to contribute toward highly impacted wisdom teeth! (Note: These estimates are for the extraction only and do not include exams, X-rays, or anesthesia).
In-Network Plans (Aetna, BCBS, Delta, MetLife, Guardian, Principal, United, etc.): Typically range from $200 to $750 per tooth.
Out-of-Network Plans: Typically can range from $500 to $900 per tooth.
Oral Biopsies Because multiple highly specialized doctors are involved in a biopsy, this service is billed in two separate parts:
The Surgeon’s Fee (Apex Oral Surgery): This covers Dr. Cappetta removing the lesion and preparing the specimen. We will submit this to both your medical and dental insurances to capture the highest possible coverage.
The Pathology Fee (Independent Laboratory): Your specimen is sent to a specialized lab where a pathologist examines it under a microscope. The independent lab will bill your medical insurance directly for this portion, which is covered by most medical plans.
Our Promise to You
Dr. Cappetta is incredibly reasonable and deeply committed to ensuring you receive world-class care without financial anxiety. We pride ourselves on transparency—providing comprehensive treatment plans so there are no surprise costs.
The best first step is to schedule a consultation. Our insurance team will take it from there, advocating for your benefits, handling the dual-billing, and laying out exactly what you can expect. To make your investment as comfortable as possible, we proudly offer no-interest payment plans for any out-of-pocket costs exceeding $500.