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Dental Fee Survey for New York City Metro area
Network Fee Schedule – Pediatric Dentistry / Pedodontics

The schedule below is a comprehensive survey of regional
Usual and Customary Fees (UCR) compared with Reduced Fees paid by Network
Members.

To facilitate access to regular dental care and maintenance for all
household members, you will note exceptional savings on Preventive and
Diagnostic services, including Cleaning, Oral Exams, X-rays, Fluoride
Application, and Sealants, wherever these services appear on a fee schedule.

Member savings range from approximately 20% to 60% across the entire
plan. If there is a question about any fees posted, ask your dentist
about his or her Usual Fee (UCR) so that you can compare same with the
posted Network Fee.

Fees posted may change, without notice, from time to time to reflect
changes in Professional Fees in the NYC Metro area. It is important
that both the member and the dentist refer to the Professional Fee schedules
posted on this website on a regular basis to be sure fees discussed
are current.

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.

Pediatric Dentistry Rates & Procedures
Services are provided by a Pediatric Dentist, a Specialist with additional
training in this field.
Regional Fee Network Fee Typical Network Savings Typical % Savings
Periodic Oral Evaluation $65 $25 $40 62%
Initial Oral Evaluation $95 $55 $40 42%
First Periapical X-ray $25 $15 $10 40%
Each Additional Periapical X-ray $20 $10 $10 50%
X-Ray Bite Wings (2) $40 $20 $20 40%
X-Ray Bite Wings (4) $70 $45 $25 31%
X-Ray Panorex $120 $80 $40 33%
X-Ray Full Mouth $120 $80 $40 33%
Prophylaxis, routine $90 $50 $40 44%
Prophylaxis, extended $110 $70 $40 34%
Prophylaxis, extended (scaling) $145 $95 $50 34%
Fluoride Application $55 $30 $25 46%
Ortho Fluoride Rinse $15 $10 $5 33%
Professional Strength Whitening Strips $95 $65 $30 32%
Sealant Per Tooth $60 $45 $15 25%
Desensitizing (per quad) $60 – $75 $50 $18 25%
White Composite Resin Fillings – Anterior        
White composite resin filling – 1 surface – anterior $155 – $180 $110 –
$125
$50 34%
White composite resin filling – 2 surface – anterior $200 $140 $60 30%
White composite resin filling – 3 surface – anterior $250 $195 $55 22%
White composite resin filling – 4 surface – anterior $295 $240 $55 19%
White Composite Resin Fillings – Posterior (excluding sealants)        
White composite resin filling – 1 surface – posterior – excluding sealant $160 $110 $50 31%
White composite resin filling – 2 surface – posterior – excluding sealant $205 $150 $55 27%
White composite resin filling – 3 surface – posterior – excluding sealant $255 $175 $80 32%
White composite resin filling – 4 surface – posterior – excluding sealant $315 $255 $60 19%
White Composite Resin Fillings – Posterior (including sealants)        
White composite resin filling – 1 surface – posterior – including sealant $175 $130 $45 26%
White composite resin filling – 2 surface – posterior – including sealant $225 $170 $55 24%
White composite resin filling – 3 surface – posterior – including sealant $275 $195 $80 30%
White composite resin filling – 4 surface – posterior – including sealant $335 $275 $60 18%
Amalgam filling – 1 surface $130 $95 $35 27%
Amalgam filling – 2 surface $160 $105 $55 34%
Amalgam filling – 3 surface $175 $125 $50 29%
Amalgam filling – 4 surface $265 $200 $65 25%
Crown – Stainless Steel $350 $275 $75 21%
Single tooth extraction (simple) $160 $115 $145 28%
Coronal Remnants Extraction $85 $60 $25 29%
*Note: Fees for mouthguard may vary based on Lab charges, materials
used, and guarantee offered.
       
Occlusal (athletic) mouth guard $125 – $350 $75 –
$250
$74 32%
*Note: Fees for space maintainers may vary based on Lab charges,
materials used, and degree of difficulty.
       
Space Maintainer – Bilateral $350 – $650 $250 –
$450
$150 30%
Space Maintaner – Unilateral $250 – $450 $175 –
$325
$100 29%
Endodontic Procedures (pediatric)        
Direct Pulp Cap $95 $65 $30 32%
Indirect Pulp Cap $60 $40 $20 33%
Therapeutic Pulpotomy $150 – $200 $75 –
$150
$63 36%
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. (See exam* and prophylaxis notes below.)
$450 – $550 $325 $175 35%
Cosmetic Tooth Whitening: Accelerated tooth whitening
procedure using high intensity light, includes one or more office visits,
Oral Exam, All materials. (See exam* and prophylaxis notes below.)

Alternate Fee – Certain Manhattan Locations Only
– Please consult with your dentist.
$550 – $650 $375 $225 37%
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%
*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 $50.
       

*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 Pediatric Dentistry
aapd.org/