Northeast General Dentists
Fee Schedule I
Last Printing April 2002
(all procedures as performed by a general Dentist)
| DIAGNOSTIC & PREVENTATIVE PROCEDURES | NDPA FEE | USUAL FEE |
| Single x-ray (any type) | $8.00 | $18.00 |
| X-rays (up to full mouth, or at least 3 films taken) | $35.00 | $90.00 |
| Panarex | $35.00 | $90.00 |
| Oral Examination and Diagnosis | No Charge | $50.00 |
| Child Cleaning & Polishing - Excluding Fluoride | $30.00 | $70.00 |
| Adult Cleaning, Polishing and Scaling | $45.00 | $100.00 |
| Topical Fluoride Treatment for Children | $20.00 | $42.00 |
| Palliative Treatment (Emergency Treatment of Pain) | $30.00 | $62.00 |
| Sealants (Pit & Fissure, Per Tooth) | $20.00 | $43.00 |
| Consultation (including 2nd opinion and/or a very extensive examination) | $35.00 | $62.00 |
| RESTORATIVE PROCEDURES (FILLINGS) | NDPA FEE | USUAL FEE |
| Silver Amalgams: Primary | ||
| One Surface | $45.00 | $64.00 |
| Two Surfaces | $52.00 | $81.00 |
| Three Surfaces | $63.00 | $100.00 |
| Four Surfaces or more | $73.00 | $123.00 |
| Silver Amalgams: Permanent | ||
| One Surface | $49.00 | $88.00 |
| Two Surfaces | $61.00 | $118.00 |
| Three Surfaces | $70.00 | $140.00 |
| Four Surfaces or more | $88.00 | $168.00 |
| Composite Resins: Anterior | ||
| One Surface | $60.00 | $92.00 |
| Two Surfaces | $75.00 | $135.00 |
| Three Surfaces | $90.00 | $168.00 |
| Four Surfaces or more or involving incisal angle | $109.00 | $198.00 |
| Composite Resins: Posterior | ||
| One Surface | $63.00 | $105.00 |
| Two Surfaces | $85.00 | $148.00 |
| Three Surfaces or more | $127.00 | $215.00 |
| Pin retention, per pin | $27.00 | $55.00 |
| Sedative Filling | $40.00 | $65.00 |
| COSMETIC PROCEDURES | NDPA FEE | USUAL FEE |
| Bonding/Veneers (per tooth) | ||
| Full face buildup (chairside) | $210.00 | $350.00 |
| Laminate veneer - porcelain - laboratory | $435.00 | $800.00 |
| ENDODONTICS (performed by General Dentists) | NDPA FEE | USUAL FEE | |||||||||||||||||||||||||||
| Pulp capping (excl. final restoration) | $31.00 | $59.00 | |||||||||||||||||||||||||||
| Pulpotomy (excl. final restoration) | $65.00 | $115.00 | |||||||||||||||||||||||||||
| Root Canal Therapy | |||||||||||||||||||||||||||||
| Anterior | $320.00 | $500.00 | |||||||||||||||||||||||||||
| Bicuspid | $365.00 | $690.00 | |||||||||||||||||||||||||||
| Molar | $480.00 | $750.00 | |||||||||||||||||||||||||||
| PERIODONTICS (performed by General Dentists) | NDPA FEE | USUAL FEE |
|
Periodontal scaling and root planing, in the presence of periodontal disease, (per quadrant) |
$65.00 | $145.00 |
| Osseous or mucogingival surgery (per quadrant) | $465.00 | $780.00 |
| Perio maintenance | $55.00 | $85.00 |
| ORAL SURGERY (performed by General Dentists) | USUAL FEE | |
| Extraction: Simple | ||
| Single tooth | $60.00 | $105.00 |
| (each additioal tooth) | $49.00 | $80.00 |
| Complex | $88.00 | $175.00 |
| Incision and drainage | $65.00 | $150.00 |
| Root removal | $75.00 | $120.00 |
| Surgical Extractions: | ||
| Soft tissue impaction | $140.00 | $235.00 |
| Partial bony impaction | $185.00 | $335.00 |
| Full bony impaction | $230.00 | $435.00 |
| FIXED PROSTHODONTICS | NDPA FEE | USUAL FEE |
| Porcelain on non-precious metal crown | $425.00 | $768.00 |
| All metal crown (not gold) | $435.00 | $768.00 |
| Pontics | $585.00 | $880.00 |
| Porcelain on semi to high noble metal crown | $585.00 | $880.00 |
| Post and core (chairside) | $149.00 | $220.00 |
| Core buildup - including pins | $125.00 | $195.00 |
| Cast post (non-gold) laboratory | $215.00 | $325.00 |
| Re-cement crown | $37.00 | $75.00 |
| Re-cement bridge - per abutment | $50.00 | $80.00 |
| Maryland Bridge (without pontic - per wing) | $280.00 | $435.00 |
| Laboratory processed temporary (per tooth) | $90.00 | $150.00 |
| Temporary Crown (as part of crown procedure) | NO CHARGE | |
| REMOVABLE PROSTHODONTICS | NDPA FEE | USUAL FEE |
| Complete Maxillary denture (includ. adjustments) | $635.00 | $990.00 |
| Complete Mandibular denture (includ. adjustments) | $635.00 | $990.00 |
| Partials: | ||
| Acrylic (upper or lower metal clasps) | $475.00 | $895.00 |
| Cast alloy with palatal or lingual bar | $690.00 | $1005.00 |
| Uuilateral (Nesbeth appliance) | $410.00 | $600.00 |
| Precision or Semi-Precision Partial | ||
| With two attachments | $1260.00 | $2150.00 |
| With three attachments | $1840.00 | $2800.00 |
| Denture adjustments (for dentures made at another office) | $40.00 | $66.00 |
| Nite guard or flipper | $280.00 | 430.00 |
| Reline: | ||
| In office | $160.00 | $230.00 |
| Laboratory processed | $220.00 | $315.00 |
| Broken Denture (no teeth involved) | $83.00 | $124.00 |
| Replace tooth on denture | $70.00 | $120.00 |
| Space Maintainers | ||
| Unilateral | $200.00 | $280.00 |
| Bilateral | $240.00 | $315.00 |
 | Please Note: Rates are Subject to Periodic Change Without Prior Notification |