Pediatric Dentistry: All Locations
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About This Schedule: We have included most common procedures that apply to the dental specialty shown. If a procedure is not listed, or if your dentist needs to perform a variation of a listed procedure, the NYDN participating dentist will charge a fee that is consistent with rate reductions shown on this schedule. There may be some exception for certain brand name products. Network fees for professional services may change from time time, without prior notice, and we encourage our participating dentists and members to review fee schedules posted on this website for updates that may apply.
 
If a Fee Range is shown - this reflects variation that cannot be reduced readily to a single average fee. Professional fees may vary due to expenses associated with office location, support staff and special equipment. We suggest that you ask your dentist about his/her UCR (usual, customary and reasonable fee) for the procedure in question - in this way you will be able to determine the savings afforded by the network fee charged.

The last two columns on the right show typical savings per procedure and percentage of rate reduction for each procedure.


This is a Cooperative Dental Plan. If your membership fee is not returned thru Plan Savings, we are not meeting our minimum goal. We seek member feedback on dental fees and all aspects of the plan. Savings shown for Diagnostic and Preventive visits alone should cover all or most of membership cost. Utilization of additional Dental Services or Coordination of Benefits with conventional dental insurance plans should result in greater savings.

To track plan utilization and member savings, NYDN may ask participating dentists to document NYDN fees actually charged, compared to usual and customary fees. NYDN may remit an administrative fee to dentists for this service, where applicable. Results of this fee survey will be made available to dentists and members to illustrate the cost effectiveness of this plan. For reasons of confidentiality, NYDN never collects or distributes medical or dental information; we are concerned only with fee information.

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.

Dentists: Please Verify Member Status at each member visit.
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.