This schedule is valid at time of printing. Participating dentists and network members should check fee schedules posted on this website of for future changes and updates.

Pediatric Dentistry

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. - - - -
 

 
*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.