New York General Dentist Fee Schedule

** Any treatment provided by a participating specialist, if available, in Oral Surgery, Orthodontics, Periodontics, Pedodontics, Prosthodontics or Endodontics, will be charged at a 25% reduction of participating specialist’s fees for that particular case.

ADADiagnosticsAmount
120Periodic Oral Evaluation20
140Limited Oral Evaluation – Problem Focused (Emergency)35
150Comprehensive Oral Evaluation25
210X-Rays Intraoral – Complete Series (Incl. Bitewings)50
220X-Rays Intraoral – Periapical – First Film10
230X-Rays Intraoral – Periapical – Each Additional Film7
240X-Rays – Intraoral – Occlusal Film19
270X-Rays – Bitewing – Single Film12
272X-Rays – Bitewing – Two Films15
274X-Rays – Bitewing – Four Films28
330X-Ray Panoramic Film52
ADAPreventativeAmount
1110Dental Prophylaxis Adult(Cleaning)42
1120Dental Prophylaxis Children35
1208Topical Fluoride Application15
1351Topical Sealants – Per Tooth24
ADARestorative (fillings)Amount
2140Amalgam – 1 Surface, Permanent52
2150Amalgam – 2 Surfaces, Permanent65
2160Amalgam – 3 Surfaces, Permanent80
2161Amalgam – 4 or more Surfaces, Permanent105
2330Resin – 1 Surface, Anterior65
2331Resin – 2 Surfaces, Anterior85
2332Resin – 3 Surfaces, Anterior105
2335Resin – 4+ Surf Or Inv. Incisal Angle130
2380Resin – 1 Surface – Posterior – Primary65
2381Resin – 2 Surfaces – Posterior – Primary90
2382Resin – 3+ Surfaces – Posterior – Primary120
2391Resin – 1 Surface – Posterior – Permanent90
2392Resin – 2 Surfaces – Posterior – Permanent120
2393Resin – 2 Surfaces – Posterior – Permanent130
2394Resin – 4+ Surfaces – Posterior – Permanent150
ADACrowns (lab fees additional)Amount
2740Crown – Porcelain/Ceramic Substrate635
2750Crown – Porcelain/High Noble Metal595
2751Crown – Porcelain/Predominate Base Metal570
2752Crown – Porcelain/Noble Metal580
2790Crown – Full Cast High Noble Metal585
2791Crown – Full Cast Predominantly Base Metal575
2920Re-cement Crown50
2930Prefabricated Stainless Steel Crown – Primary Tooth125
2931Prefabricated Stainless Steel Crown – Perm Tooth140
2932Prefab Resin Crown155
2950Core Buildup, Including Any Pins110
2951Pin Retention Per Tooth (W/O Restoration)28
2952Cast Post/Core (Addition to Crown)190
2954Prefabricated Post and Core (Addition to Crown)150
2970Temporary Crown (Fractured Tooth)150
ADAEndodontics (General Dentist) exc. Final RestorationAmount
3220Therapeutic Pulpotomy69
3310Root Canal Anterior350
3320Root Canal Bicuspid430
3330Root Canal Molar560
ADAProsthodontics (Performed by a General Dentist)Amount
4210Gingivectomy/Gingivoplasty – 4+ contiguous teeth315
4341Perio. Scaling & Root Planning per Quad125
4355Full Mouth Debridement75
4910Periodontal Maintenance80
ADAProsthodontics, Removable (lab fees additional)Amount
5110Complete Upper Denture675
5120Complete Lower Denture675
5130Immediate Upper745
5140Immediate Lower745
5211Upper Partial-Resin Base515
5212Lower Partial-Resin Base515
5213Partial Upper Cast Metal Base699
5214Partial Lower Cast Metal Base699
5410Adjust Denture (Upper)38
5411Adjust Denture (Lower)38
5510Repair Broken Complete Denture Base95
5520Repair Missing or Broken Teeth/Each Tooth65
5610Repair Resin Denture Base85
5630Repair or Replace Broken Clasp80
5640Repair Broken Teeth – Per Tooth60
5650Add Tooth to Existing Partial Denture70
5660Add Clasp to Existing Partial Denture90
5730Reline Upper Denture – Chairside130
5731Reline Lower Denture – Chairside130
ADAProsthodontics, Fixed (lab fees additional)Amount
6240Pontic – Porcelain/High Noble Metal525
6241Pontic – Porcelain/Predominate Base Metal485
6242Pontic – Porcelain/Noble Metal495
6750Crown – Porcelain/High Noble Metal545
6751Crown – Procelain/Predominate Base Metal495
6752Crown – Porcelain/Noble Metal495
6930Re-cement Bridge60
ADAOral SurgeryAmount
7140Single Tooth Extraction75
7120Each Additional Extraction55
7210Surgical Removal of Erupted Tooth155
7220Removal of Impacted Tooth/Soft Tissue145
7230Removal of Impacted Tooth/Partially Bony185
7240Removal of Impacted Tooth/Completely Bony235
7250Surgical Removal of Residual Tooth Roots125
7510Incision & Drainage of Abscess/Intraoral85
ADAOrthodonticsAmount
8080Comprehensive Treatment – Adolescent25% off
8090Comprehensive Treatment – Adult25% off
ADAAdjunctive ServicesAmount
9110Palliative Treatment (emergency) Pain-minor50
9610Therapeutic Drug Injection45

*Please see a professional dentist for full treatment plan.

*** Same day enrollment is available.

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