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.

120Periodic Oral Evaluation14
140Limited Oral Evaluation – Problem Focused (Emergency)32
150Comprehensive Oral Evaluation21
210X-Rays Intraoral – Complete Series (Incl. Bitewings)39
220X-Rays Intraoral – Periapical – First Film9
230X-Rays Intraoral – Periapical – Each Additional Film7
240X-Rays – Intraoral – Occlusal Film19
270X-Rays – Bitewing – Single Film8
272X-Rays – Bitewing – Two Films15
274X-Rays – Bitewing – Four Films28
330X-Ray Panoramic Film42

1110Dental Prophylaxis Adult(Cleaning)34
1120Dental Prophylaxis Children29
1204Topical Fluoride Application15
1351Topical Sealants – Per Tooth18

ADARestorative (fillings)Amount
2110Amalgam – 1 Surface, Primary35
2120Amalgam – 2 Surfaces, Primary50
2140Amalgam – 1 Surface, Permanent42
2150Amalgam – 2 Surfaces, Permanent53
2160Amalgam – 3 Surfaces, Permanent74
2161Amalgam – 4 or more Surfaces, Permanent91
2330Resin – 1 Surface, Anterior55
2331Resin – 2 Surfaces, Anterior79
2332Resin – 3 Surfaces, Anterior94
2335Resin – 4+ Surf Or Inv. Incisal Angle115
2380Resin – 1 Surface – Posterior – Primary52
2381Resin – 2 Surfaces – Posterior – Primary70
2382Resin – 3+ Surfaces – Posterior – Primary90
2391Resin – 1 Surface – Posterior – Permanent72
2392Resin – 2 Surfaces – Posterior – Permanent95
2393Resin – 2 Surfaces – Posterior – Permanent110
2394Resin – 4+ Surfaces – Posterior – Permanent125

ADACrowns (lab fees additional)Amount
2740Crown – Porcelain/Ceramic Substrate535
2750Crown – Porcelain/High Noble Metal495
2751Crown – Porcelain/Predominate Base Metal460
2752Crown – Porcelain/Noble Metal470
2790Crown – Full Cast High Noble Metal485
2791Crown – Full Cast Predominantly Base Metal415
2920Re-cement Crown40
2930Prefabricated Stainless Steel Crown – Primary Tooth125
2931Prefabricated Stainless Steel Crown – Perm Tooth130
2932Prefab Resin Crown141
2950Core Buildup, Including Any Pins95
2951Pin Retention Per Tooth (W/O Restoration)24
2952Cast Post/Core (Addition to Crown)190
2954Prefabricated Post and Core (Addition to Crown)150
2960Labial Veneer (Resin-Laminate) Chairside229
2961Labial Veneer (Resin-Laminate) Laboratory300
2962Labial Veneer (Porcelain-Laminate) Laboratory369
2970Temporary Crown (Fractured Tooth)105

ADAEndodontics (General Dentist) exc. Final RestorationAmount
3220Therapeutic Pulpotomy69
3310Root Canal Anterior295
3320Root Canal Bicuspid385
3330Root Canal Molar485

ADAProsthodontics (Performed by a General Dentist)Amount
4210Gingivectomy/Gingivoplasty – 4+ contiguous teeth295
4260Osseous Surgery (W/ Flap Entry & Closure) P/Quad455
4341Perio. Scaling & Root Planning per Quad115
4355Full Mouth Debridement65
4910Periodontal Maintenance60

ADAProsthodontics, Removable (lab fees additional)Amount
5110Complete Upper Denture575
5120Complete Lower Denture575
5130Immediate Upper659
5140Immediate Lower659
5211Upper Partial-Resin Base460
5212Lower Partial-Resin Base460
5213Partial Upper Cast Metal Base639
5214Partial Lower Cast Metal Base639
5410Adjust Denture (Upper)34
5411Adjust Denture (Lower)34
5510Repair Broken Complete Denture Base80
5520Repair Missing or Broken Teeth/Each Tooth59
5610Repair Resin Denture Base79
5630Repair or Replace Broken Clasp69
5640Repair Broken Teeth – Per Tooth60
5650Add Tooth to Existing Partial Denture65
5660Add Clasp to Existing Partial Denture80
5730Reline Upper Denture – Chairside115
5731Reline Lower Denture – Chairside115

ADAProsthodontics, Fixed (lab fees additional)Amount
6240Pontic – Porcelain/High Noble Metal495
6241Pontic – Porcelain/Predominate Base Metal440
6242Pontic – Porcelain/Noble Metal455
6750Crown – Porcelain/High Noble Metal495
6751Crown – Procelain/Predominate Base Metal450
6752Crown – Porcelain/Noble Metal440
6930Re-cement Bridge60

ADAOral SurgeryAmount
7140Single Tooth Extraction62
7120Each Additional Extraction55
7210Surgical Removal of Erupted Tooth110
7220Removal of Impacted Tooth/Soft Tissue125
7230Removal of Impacted Tooth/Partially Bony160
7240Removal of Impacted Tooth/Completely Bony195
7250Surgical Removal of Residual Tooth Roots105
7510Incision & Drainage of Abscess/Intraoral69

8080Comprehensive Treatment – Adolescent25% off
8090Comprehensive Treatment – Adult25% off

ADAAdjunctive ServicesAmount
9110Palliative Treatment (emergency) Pain-minor34
9610Therapeutic Drug Injection21

*Please see a professional dentist for full treatment plan.

*** Same day enrollment is available.

Print Friendly, PDF & Email