Pediatric Dentistry Rates & Procedures
|
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. |
- |
- |
- |
- |