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Network Fee Schedule – General Dentistry

 

Note: For some procedures listed
on this schedule we have posted an alternate, higher fee that may apply
at certain Manhattan practice locations only. Please consult with your
dentist about this.
This Fee Schedule calculates
Member Savings in terms of Actual Savings and Savings Percentage.
Plan members pay fee shown in NETWORK
FEE
column.
General Dentistry Rates & Procedures Regional Fee Network Fee Typical Network Savings Typical % Savings
Diagnostic-Preventive
Visit
: To encourage members to get regular checkups. Oral Exam and Prophylaxis
(cleaning)
Member pays flat fee per visit of $72 – Unlimited utilization for
single members and all covered household members.
$125 – $185 $72 $83 46%
Extended Diagnostic-Preventive Visit, including x-rays. (A),
Oral Exam + Prophylaxis (cleaning) + full mouth X-Rays, including complete
bite wings or Panorex Study
Member pays flat fee per visit of $140
– Unlimited utilization for single members and all covered household members.
$250 – $355 $140 $162 54%
Extended Diagnostic-Preventive Visit, includes x-rays and single visit cosmetic tooth whitening (B),
Oral Exam + Prophylaxis (cleaning) + full mouth Xrays + Cosmetic tooth
whitening, Single visit, high intensity light
Member pays
flat fee per visit of $440
– Unlimited utilization for
single members and all covered household members.
$630-$750 $440 $250 38%
Diagnostic-Preventive Visit + Tooth Whitening
(C)
, Oral Exam + Prophylaxis (cleaning) + Cosmetic tooth
whitening, Single visit, high intensity light.
Member pays flat fee per visit of $365 – Unlimited
utilization for single members and all covered household members
$725 $365 $360 50%
Diagnostic-Preventive Visit + Tooth Whitening
(C)
, Oral Exam + Prophylaxis (cleaning) + Cosmetic tooth
whitening, Single visit, high intensity light.
Alternate Fee – Certain Manhattan Locations Only – Please
consult with your dentist.
$765 $390 $375 49%
Periodic Oral Evaluation $45 – $55 $25 $25 50%
Comprehensive Oral Evaluation $65 – $95 $45 $35 44%
Periapical X-ray $25 $10 $15 60%
X-Ray Bite Wings (4 – complete) $55-$75 $40 $25 38%
X-Ray Panorex $110 – $165 $75 $62 45%
X-Ray Full Mouth, Including Bitewings (complete) $100 – $160 $75 $55 42%
Note on Prophylaxis: If Periodontal Gum
Disease is present, periodic visits for prophylaxis may be recommended
by your dentist. You will note significant NYDN savings on Prophylaxis
procedures.
   
   
Prophylaxis – Adult $80-$140 $55 $55 50%
Prophylaxis – Child $75 $50 $25 37%
Palliative Care: Please Note
Office visit for emergency or painful condition May include Periapical
or more extended Xrays, Rx for antibiotics, preparation for procedure,
after hours visit
Palliative Care, extended:
Emergency Office Visit, may include after hours office visit, Periapical
or more expanded X-ray study, Antibiotics Rx (variable services, please
consult with dentist for details)
$155 – 225
$105
$85.00
45%
Full mouth debridement/scaling $250 $150 $100 40%
Scaling per quadrant/extended $150-$200 $80 $95 54%
Chemotherapeutic agent (per tooth or site) $65 – $90 $45 $22 42%
Chemotherapeutic agents, per quadrant $160 – $220 $115 $75 40%
Bacterial Study (microscopic) $25 $20 $5 20%
Fluoride application – Child $55 – $65 $30 $30 50%
Sealant (occlusal surface) per tooth $55 $35 $20 36%
Desensitizing (per quad) $60 – $75 $50 $18 26%
Night Guard (rubber) $300 – $450 $215 $160 43%
Night Guard (acrylic – laboratory processed) $550 – $700 $375 $250 40%
Dental Extractions
may range from relatively simple soft tissue extractions to partially erupted
teeth, some of which emerge at difficult angles, to partially bony impactions,
to more complicated full bony impactions. See separate Oral Surgery schedule
on this website for more complicated extractions.
Wisdom Teeth are
the molars found at the ends of the upper and lower mandible.
Wisdom teeth are so named because they usually appear between the ages of
16-25, long after all other teeth have appeared. Wisdom teeth that fail
to erupt through the gum line are called Impacted.
Single tooth extraction (simple) $160 – $190 $115 $60 34%
Single tooth extraction (surgical) $300 – $425 $185 $177 49%
Intra-Oral Incision and Drainage of Abcess $250 – $400 $175 $150 46%
Dental
Fillings or Restorations
, including replacement of old or lost fillings,
whether White Resin or Silver Amalgam, will be billed as shown below. Actual
cost of the procedure will depend on choice of material used and the number
of tooth surfaces affected by the new procedure.
Silver Amalgam Fillings
Silver Amalgam filling – 1 surface $100 – $140 $75 $45 37%
Silver Amalgam filling – 2 surface $150 – $225 $115 $72 39%
Silver Amalgam filling – 3 surface $200 – $250 $140 $85 38%
White
Bonded Composite Fillings:
– Composite resin is an important component
of restorative and cosmetic dentistry. Color matching is of particular importance
in anterior (front) fillings and in a variety of bonding applications.

White Composite Resin Fillings – Anterior
White composite resin filling – 1 surface – anterior $135 $85 $50 37%
White composite resin filling – 2 surface – anterior $155-$185 $120 $50 29%
White composite resin filling – 3 surface – anterior $200 – $330 $145 $120 45%
White composite resin filling – 4 surface – anterior $350 – $380 $255 $105 37%
White Composite Resin Fillings – Posterior
White composite resin filling – 1 surface – posterior $125 – $155 $100 $40 26%
White composite resin filling – 2 surface – posterior $165 – $235 $130 $70 35%
White composite resin filling – 3 surface – posterior $225 – $355 $155 $135 47%
White composite resin filling – 4 surface – posterior $350- $450 $275 $125 32%
Bonding Note: Bonding utilizes white composite
resin, with special attention to cosmetic considerations. In some cases
bonding is used for relatively small repairs and in other cases a larger
portion of tooth surface is involved. Fees will vary accordingly and Network
savings will be in the range of 33% for all bonding procedures.
Bonding, per tooth (see notes above – fees will vary depending on extent
of bonding required)
$350 $235 $115 33%
Gold Foil Restoration
– Two Surfaces
$470 – $580 $345 $180 34%
Inlays
and Onlays:
A dental inlay is an indirect restoration (filling) consisting
of a solid substance (gold or porcelain) fitted to a cavity in a tooth and
cemented into place. An onlay is the same as an inlay, except that it extends
to replace a cusp or edge of a tooth. Crowns (listed separately) are onlays
which completely cover all surfaces of a tooth.
Inlay Metallic – Two Surfaces $640 – $720 $470 $210 31%
Inlay Metallic – Three or more Surfaces $715 – $805 $535 $225 30%
Onlay Metallic – Two Surfaces $740 – $860 $550 $310 36%
Onlay Metallic – Four or more Surfaces $780 – $940 $540 $320 27%
Inlay Porcelain/Ceramic, Two Surfaces $690 – $970 $505 $325 39%
Inlay Porcelain/Ceramic Three or more Surfaces $785 – $945 $605 $260 30%
Onlay, Porcelain/Ceramic, Two Surfaces $775 – $905 $585 $255 30%
Onlay, Porcelain/Ceramic, Four or more Surfaces $860 – $1080 $695 $285 28%
Inlay, Composite/Resin, Two Surface (Lab Proc) $620 – $660 $435 $205 32%
Onlay, Composite/Resin – Two Surface (Lab Proc) $720 – $780 $520 $230 31%
Note on Crowns: A typical crown
procedure includes two office visits to prepare the tooth, take impressions,
install temporary crown, and install permanent crown. Lab fees are included
in rates shown. In some cases, fees may vary due to cost of gold or other
materials selected. To determine member savings, please ask your dentist
to confirm his/her UCR fee. Please see separate fees for post and core,
sometimes needed in addition to crown.

Crown – porcelain fused to noble metal $950 – $1250 $675 $425 39%
Crown – porcelain fused to high noble metal
More
info. on Crowns and Crown Materials
$950 – $1350 $730 $430 37%
Crown – porcelain fused to high noble metal (Manhattan offices) $1000 – $1400 $740 $460 38%
Crown – porcelain/ceramic substrate $1100 – $1500 $820 $480 37%
Crown – porcelain/ceramic substrate (Manhattan offices) $1200 – $1600 $840 $560 40%
Crown – Recement Crown $65 – $80 $45 $25 35%
Prefab. post
and core
(in addition to crown)
$280 – $360 $220 $100 31%
Cast post and core
(in addition to crown) some procedures require a custom (or cast) post and
core. Your dentist will explain the differences.
$450 $350 $100 32%
Core Buildup (strengthen core for crown application) $325 – $375 $235 $115 33%
Flipper is a temporary tooth used
during denture or implant dentistry to fill a gap created during restoration
work:
Flipper
– More information
Flipper
Note: cost will vary depending upon location and technical difficulty
$250 – 500 $175 –
350
$145 30%
Root Canal therapy:
Treatment for the pulp of a tooth to avoid or eliminate infection and deterioration
of the tooth, its root, and underlying bone structure.
Fees for Root
Canal Therapy
and Retreatment
vary based upon tooth location and degree of difficulty. The dentist will
confirm his or her UCR fee and in this way you can determine the network
savings.
Root Canal Therapy – Anterior $600 – $750 $450 $225 33%
Root Canal Therapy – Bicuspid $725 – $925 $575 $225 31%
Root Canal Therapy – Molar $850 – $1250 $680 $370 35%
Root Canal Therapy– Molar (Manhattan offices) $850 – $1350 $750 $375 37%
Implants:
The first step of the Implant procedure is placement into the jaw of a threaded
titanium post that will anchor the implant abutment and crown. In some cases,
it may be necessary to do bone grafting to build up bone density at implant
site.
Implants –
More information
The Crown will be attached to the Implant via an abutment. In many cases,
the Crown and a custom abutment will be fabricated in a dental lab, to assure
the best fit and long term durability.
Dental Implant
(complete)
Includes Implant, Crown, and Custom Abutment
Note: Please see variables, including Bone Graft info.
$3150 – $4150 $2625 $1025 28%
Dental Implant
(Surgical Fee) Includes placement of the titanium post. Does not include
Crown or Abutment
$1600 – $2400 $1400 $600 30%
Crown + Abutment. Porcelain fused to noble metal + Custom Abutment
$1650-$1950 $ 1325 $475 26%
Implant Abutment
Noble Metal, Custom Cast. This entry shows cost of abutment only.
$450 – $750 $350-$650 $100 17%
Implant Abutment
Custom Cad Titanium. This entry shows cost of custom abutment only. Note:
In some cases the crown + custom abutment are fabricated together in same
lab, and combined cost is shown above.
$550 – $1050 $300 –
$950
$175 22%
Implant Bone Graft: An implant
bone graft procedure will be necessary if the (jaw) bone at the implant
site is not sufficiently dense to support the implant. For more information
on this procedure and wide cost variation:
Implant
bone grafts – More information
Implant Bone Graft
Note: Per the above article on Implant Bone Grafts, rates shown here are
for illustration only, as actual cost may be higher or lower, depending
upon amount of bone density reinforcement needed.
$250 – $900 $175 –
$650
$163 28%
Dentures: Some dentures can be completed
in two visits and other dentures will require five or six visits. Please
consult with your dentist about variations in cost, materials (acrylic or
custom) and time required for each procedure.
Full Denture (Acrylic – Per Arch)
This is a special rate for Seniors, age 60+
see box below for rate that applies to all others
$1800 – 2200 $900 $1100 45%
Full Denture (Acrylic – Per Arch) $1800 – 2200 $960 $1040 48%
Interim Partial Denture (Temporary Denture) $750 $600 $150 20%
Repair of Partial Denture $200 – $275 $150 $87 37%
Relining Dentures (Chairside – Both Arches) $350 $200 –
$250
$125 36%
Relining Dentures (Lab Processed – Both Arches) $450 $350 $100 32%
Note: Cost for Implant Overdenture will vary
based upon time and materials. Please consult with your dentist about this
item and note that member cost will be approximately 26% lower than the
UCR fee normally charged by the dentist for same procedure.
Implant Overdenture (Complete – Per Arch) $2000 – $3000 $1450 –
$2250
$650 26%
Partial Denture (Metal Base with Saddles) $1350 – $1850 $1120 $455 29%
Full Denture (Custom Materials and Lab Work – Per Arch) $1400 – $1800 $1200 $400 25%
Fixed Bridge Pontic (Replaces Missing Tooth) $900 – $1200 $725 –
$975
$225 21%
Fixed Bridge Abutment (Crown) $900 – $1300 $775 $325 25%
Labial Veneer (Resin Laminate – Chairside) $475 $300 $175 36%
Veneers: In some cases, Lab fees for Porcelain
Veneers may increase network rate shown by 10% to 15%. Dentist will confirm
UCR fee and variables, if any, upon request.
Labial Veneer (Porcelain Laminate – incl. Lab Fees) $950 – $1250 $825 $275 25%
Anesthesia
and Analgesia – In some cases, the cost of Inhalation Analgesia (nitrous
oxide) may be included in cost of the procedure. In other cases, a separate
fee, as shown on this schedule, may apply. In general, fees for Analgesia
and for IV Sedation are based upon time required for each procedure. In
some dental procedures, conventional medical insurance may cover a portion
of the surgical or anesthesia fees. Consult with your dentist about his/her
fees for Analgesia and Anesthesia to determine network savings.
       
Inhalation Analgesia (Nitrous Oxide) $65 – $95 $45 $35 44%
IV Conscious Sedation (first 30 minutes) $350 – $500 $250 $175 41%
IV Conscious Sedation (additional 15 minutes) $180 – $220 $100 $100 50%
*Tooth Whitening/Bleaching exam notes: Your
dentist must determine that teeth and gums are in suitable conditon, and
which process may be most appropriate, prior to cosmetic tooth whitening.
If prophylaxis has not been performed recently, your dentist may require
same. The additional fee for prophylaxis, if necessary, will be the adult
or child prophylaxis fee shown on this schedule. Note also that some dental
offices offer a (range) of cosmetic tooth whitening options, based upon
different shades of whitening. There appears to be a fairly wide range of
cost associated with treatment options. To avoid confusion, this schedule
concerns itself with complete, full-range whitening.
Cosmetic Tooth Whitening: Includes Oral Exam, Two office visits, Full
mouth impressions and models, Whitening trays, All materials, At home application
of whitening material (See exam* and prophylaxis notes below.)
$350 – $500 $275 $150 35%
Cosmetic Tooth Whitening: Accelerated tooth whitening procedure using
high intensity light, includes one or more office visits, Oral Exam, All
materials. This is complete, full range whitening, not a limited application.(See exam* and prophylaxis notes below.)
$500 – $650 $330 $245 43%
Cosmetic Tooth Whitening: Accelerated tooth whitening
procedure using high intensity light, includes one or more office visits,
Oral Exam, All materials. This is complete, full range whitening, not
a limited application.See exam* and prophylaxis notes below. (Manhattan offices)
$550 – $680 $345 $270 44%
Cosmetic Tooth Whitening: Accelerated tooth whitening procedure using
high intensity light, includes one or more office visits, Oral Exam, Full
mouth impressions and models, Whitening Trays, All materials for at-home
follow up. Combines office and take-home procedures shown above. (See exam*
and prophylaxis notes below.)
$650 – $800 $500 –
$550
$200 28%

*Regional fees posted are representative of usual and customary
fees charged by New York Dental Network, LLC participating dentists for patients
who do not participate in a dental benefits plan. Some fee variation was found
due to differences in office overhead, materials, lab fees, and other professional
considerations.

*Network fees shown are the actual fees members will pay to the participating dentist. For procedures not shown, or variations of listed procedures, similar network fee reductions will apply in most cases. An exception may apply in the case of certain brand name dental products or services. Additionally, fee variations may be based upon degree of difficulty and time and materials involved in treatment. Please consult with your dentist prior to course of treatment.

*When a network fee range is shown, the usual and customary fee (UCR) of the dentist will determine the network fee to be paid by NYDN member. For example, if the dentist’s UCR fee falls in the middle of regional fee range, the dentist will charge NYDN member a fee in the middle of network fee range. If the dentist’s usual fee for a given procedure is lower than the stated network fee, the dentist agrees to charge usual fee, resulting in additional savings for network members.

For more information on Dentisty, the links below may be useful:

American Dental Association
ada.org

American Academy of General Dentistry
agd.com