Northeast General Dentists
Fee Schedule II
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 | $14.00 |
| X-rays (up to full mouth, or at least 3 films taken) | $35.00 | $75.00 |
| Panarex | $35.00 | $95.00 |
| Oral Examination and Diagnosis | No Charge | $45.00 |
| Child Cleaning & Polishing - Excluding Fluoride | $30.00 | $65.00 |
| Adult Cleaning, Polishing and Scaling | $45.00 | $100.00 |
| Topical Fluoride Treatment for Children | $20.00 | $40.00 |
| Palliative Treatment (Emergency Treatment of Pain) | $30.00 | $55.00 |
| Sealants (Pit & Fissure, Per Tooth) | $20.00 | $40.00 |
| Consultation (Including 2nd Opinion and/or Extensive Examination) | $35.00 | $55.00 |
| RESTORATIVE PROCEDURES (FILLINGS) | NDPA FEE | USUAL FEE |
| Silver Amalgams: Primary | ||
| One Surface | $41.00 | $57.00 |
| Two Surfaces | $47.00 | $72.00 |
| Three Surfaces | $60.00 | $85.00 |
| Four Surfaces or more | $70.00 | $105.00 |
| Silver Amalgams: Permanent | ||
| One Surface | $44.00 | $82.00 |
| Two Surfaces | $53.00 | $115.00 |
| Three Surfaces | $64.00 | $134.00 |
| Four Surfaces or more | $83.00 | $159.00 |
| Composite Resins: Anterior | ||
| One Surface | $54.00 | $82.00 |
| Two Surfaces | $68.00 | $128.00 |
| Three Surfaces | $82.00 | $153.00 |
| Four Surfaces or more or involving incisal angle | $103.00 | $182.00 |
| Composite Resins: Posterior | ||
| One Surface | $58.00 | $88.00 |
| Two Surfaces | $76.00 | $128.00 |
| Three Surfaces | $105.00 | $192.00 |
| Pin retention, per pin | $24.00 | $50.00 |
| Sedative Filling | $34.00 | $55.00 |
| COSMETIC PROCEDURES | NDPA FEE | USUAL FEE |
| Bonding/Veneers (per tooth) | ||
| Full face buildup (chairside) | $185.00 | $315.00 |
| Laminate veneer - porcelain - laboratory | $390.00 | $695.00 |
| ENDODONTICS (performed by General Dentists) | NDPA FEE | USUAL FEE | |||||||||||||||||||||||||||
| Pulp capping (excl. final restoration) | $27.00 | $55.00 | |||||||||||||||||||||||||||
| Pulpotomy (excl. final restoration) | $55.00 | $90.00 | |||||||||||||||||||||||||||
| Root Canal Therapy | |||||||||||||||||||||||||||||
| Anterior | $282.00 | $450.00 | |||||||||||||||||||||||||||
| Bicuspid | $345.00 | $555.00 | |||||||||||||||||||||||||||
| Molar | $450.00 | $725.00 | |||||||||||||||||||||||||||
| PERIODONTICS (performed by General Dentists) | NDPA FEE | USUAL FEE |
|
Periodontal scaling and root planing, in the presence of periodontal disease, (per quadrant) |
$65.00 | $115.00 |
| Osseous or mucogingival surgery (per quadrant) | $420.00 | $695.00 |
| Perio maintenance | $50.00 | $75.00 |
| ORAL SURGERY (performed by General Dentists) | NDPA FEE | USUAL FEE |
| Extraction: Simple | ||
| Single tooth | $55.00 | $95.00 |
| (each additioal tooth) | $44.00 | $72.00 |
| Complex | $77.00 | $160.00 |
| Incision and drainage | $55.00 | $135.00 |
| Root removal | $65.00 | $145.00 |
| Surgical Extractions: | ||
| Soft tissue impaction | $125.00 | $215.00 |
| Partial bony impaction | $165.00 | $335.00 |
| Full bony impaction | $205.00 | $430.00 |
| FIXED PROSTHODONTICS | NDPA FEE | USUAL FEE |
| Porcelain on non-precious metal crown | $370.00 | $685.00 |
| All metal crown (not gold) | $370.00 | $685.00 |
| Pontics | $465.00 | $875.00 |
| Porcelain on semi to high noble metal crown | $465.00 | $875.00 |
| Post and core (chairside) | $115.00 | $210.00 |
| Core buildup - including pins | $95.00 | $175.00 |
| Cast post (non-gold) laboratory | $175.00 | $325.00 |
| Re-cement crown | $30.00 | $70.00 |
| Re-cement bridge - per abutment | $40.00 | $72.00 |
| Redo existing crown facing-crown build up | $85.00 | N/A |
| Maryland Bridge (without pontic - per wing) | $225.00 | $395.00 |
| Laboratory processed temporary (per tooth) | $77.00 | $120.00 |
| Temporary Crown (as part of crown procedure) | NO CHARGE | |
| REMOVABLE PROSTHODONTICS | NDPA FEE | USUAL FEE |
| Complete Maxillary denture (including adjustments) | $595.00 | $895.00 |
| Complete Mandibular denture (including adjustments) | $595.00 | $895.00 |
| Partials: | ||
| Acrylic (upper or lower metal clasps) | $450.00 | $805.00 |
| Cast alloy with palatal or lingual bar | $615.00 | $955.00 |
| Uuilateral (Nesbeth appliance) | $355.00 | $595.00 |
| Precision or Semi-Precision Partial | ||
| With two attachments | $1185.00 | $2050.00 |
| With three attachments | $1580.00 | $2700.00 |
| Denture adjustments (for dentures made in another office) | $33.00 | $60.00 |
| Nite guard or flipper | $250.00 | 400.00 |
| Reline: | ||
| In office | $145.00 | $205.00 |
| Laboratory processed | $195.00 | $305.00 |
| Broken Denture (no teeth involved) | $77.00 | $110.00 |
| Replace tooth on denture | $65.00 | $107.00 |
| Space Maintainers | ||
| Unilateral | $187.00 | $280.00 |
| Bilateral | $240.00 | $310.00 |
 | Please Note: Rates are Subject to
Periodic Change Without Prior Notification |