General Dentistry Rates & Procedures
|
Regional Fee
|
Network Fee
|
Typical Network Savings |
Typical % Savings |
Diagnostic-Preventive Visit: Oral Exam and Prophylaxis (cleaning)
Member pays flat fee per visit of $65 - Unlimited utilization for single members and all covered household members.
|
$125 - $175 |
$65 |
$85 |
57% |
Extended Diagnostic-Preventive Visit, 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% |
| 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, quarterly visits for Prophylaxis may be recommended by your dentist. You will note significant NYDN savings on Prophylaxis procedures. |
|
|
|
|
| Prophylaxis - Adult |
$80-$140 |
$65 |
$35 |
41% |
| Prophylaxis - Child |
$75 |
$50 |
$25 |
33% |
| 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 |
$235 |
$140 |
37% |
| Night Guard (acrylic - laboratory processed) |
$600 - $700 |
$450 |
$200 |
31% |
| Single tooth extraction (simple) |
$160 |
$105 |
$55 |
34% |
| Single tooth extraction (surgical) |
$300 - $425 |
$185 |
$177 |
49% |
| Intra-Oral Incision and Drainage of Abcess |
$250 - $400 |
$175 |
$150 |
46% |
| 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 |
$155 |
$70 |
31% |
| Note: Replacement of old or lost fillings with white resin material will be billed as shown below. Actual cost of the procedure will depend on number of tooth surfaces affected by the new procedure. |
|
|
|
|
| White Composite Resin Fillings - Anterior |
- |
- |
- |
- |
| White composite resin filling - 1 surface - anterior |
$100 - $170 |
$85 |
$60 |
39% |
| White composite resin filling - 2 surface - anterior |
$150 - $200 |
$120 |
$55 |
31% |
| White composite resin filling - 3 surface - anterior |
$220 - $300 |
$165 |
$95 |
37% |
| White composite resin filling - 4 surface - anterior |
$350 |
$275 |
$75 |
21% |
| White Composite Resin Fillings - Posterior |
- |
- |
|
- |
| White composite resin filling - 1 surface - posterior |
$130 - $180 |
$100 |
$55 |
35% |
| White composite resin filling - 2 surface - posterior |
$175 - $225 |
$130 |
$70 |
35% |
| White composite resin filling - 3 surface - posterior |
$225 - $325 |
$170 |
$105 |
38% |
| 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) |
$450 |
$300 |
$150 |
33% |
| Note on Crowns: A typical crown procedure includes three office visits to prepare the tooth, take impressions, install temporary crown, and install permanent crown. In some cases, fees shown for crowns may vary by 10% to 15% due to lab fees and material cost, including the cost of gold. 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 high noble metal |
$900 - $1300 |
$775 |
$325 |
25% |
Crown - porcelain fused to high noble metal Alternate Fee - Certain Manhattan Locations Only - Please consult with your dentist. |
$1000 - $1500 |
$850 |
$400 |
32% |
| Crown - porcelain fused to semi-precious metal |
$800 - $1150 |
$675 |
$300 |
31% |
| Crown - porcelain/ceramic substrate |
$1100 - $1500 |
$875 |
$425 |
33% |
Crown - porcelain/ceramic substrate Alternate Fee - Certain Manhattan Locations Only - Please consult with your dentist. |
$1200 - $1600 |
$925 |
$475 |
34% |
| Crown - Recement Crown |
$65 - $80 |
$45 |
$25 |
35% |
| Prefab. post and core (in addition to crown) |
$350 |
$270 |
$80 |
23% |
| Cast post and core (in addition to crown) |
$450 |
$350 |
$100 |
32% |
| Core Buildup (strengthen core for crown application) |
$325 - $375 |
$235 |
$115 |
33% |
| *Crown Abutments: for implant supported crown may be custom or prefab depending upon details of each case. Cost will vary based upon degree of difficulty, time, materials and lab charges, if applicable. Please ask your dentist about UCR so that you can determine savings in network. |
- |
- |
- |
- |
| Custom *Abutment in addition to Crown |
$550 - $1050 |
$300 - $950 |
$175 |
22% |
| Prefab *Abutment in addition to Crown |
$450 - $750 |
$250 - $450 |
$250 |
46% |
| Implants: |
- |
- |
- |
- |
Dental Implant (Surgical Fee) Does not include Crown or Abutment |
$1600 - $2200 |
$1400 |
$500 |
26% |
| Implant Supported Crown (does not include abutment) |
$900 - $1300 |
$775 |
$325 |
25% |
| Flipper |
$500 |
$400 |
$100 |
20% |
| Root Canal Therapy - Anterior |
$550 - $750 |
$450 |
$200 |
31% |
| Root Canal Therapy - Bicuspid |
$725 - $925 |
$575 |
$225 |
31% |
| Root Canal Therapy - Molar |
$800 - $1200 |
$650 |
$350 |
35% |
Root Canal Therapy - Molar Alternate Fee - Certain Manhattan Locations Only - Please consult with your dentist. |
$800 - $1350 |
$750 |
$325 |
30% |
| 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. |
- |
- |
- |
- |
| 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) |
$1250 - $1400 |
$900 - $1000 |
$375 |
28% |
| Full Denture (Acrylic - Per Arch) |
$950 - $1650 |
$700 - $1000 |
$450 |
35% |
| 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% |
| 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 |
$300 |
$200 |
40% |
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 |
$325 |
$275 |
46% |
| 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 the adult or child prophylaxis fee shown on this schedule. |
- |
- |
- |
- |