|
|
A code
|
Procedure
|
Typical
Fee
|
You
Pay
|
| 0120 |
periodic oral evaluation - established
patient |
$56
|
$12
|
| 0150 |
comprehensive oral evaluation - new patient |
$97
|
FREE
|
| 0210 |
intraoral - complete series (including
bitewings) |
$142
|
$25
|
| 0220 |
intraoral - periapical first film |
$32
|
$7
|
| 0230 |
intraoral - periapical each additional film |
$28
|
$3
|
| 0270 |
bitewing - single film |
$31
|
$6
|
| 0272 |
bitewings - two films |
$50
|
$10
|
| 0273 |
bitewings - three films |
$60
|
$13
|
| 0274 |
bitewings - four films |
$71
|
$19
|
| 0330 |
panoramic film |
$120
|
$28
|
| PREVENTIVE (Cleanings, etc.) |
|
ADA
code
|
Procedure
|
Typical
Fee
|
You
Pay
|
| 1110 |
prophylaxis - adult |
$102
|
$27
|
| 1120 |
prophylaxis - child |
$74
|
$20
|
| 1351 |
sealant - per tooth |
$59
|
$19
|
| 1510 |
space maintainer - fixed - unilateral |
$351
|
$81
|
| 1515 |
space maintainer - fixed - bilateral |
$487
|
$105
|
| 1520 |
space maintainer - removable - unilateral |
$430
|
$100
|
| 1525 |
space maintainer - removable - bilateral |
$549
|
$110
|
| RESTORATIVE (Fillings) |
|
ADA
code
|
Procedure
|
Typical
Fee
|
You
Pay
|
| 2140 |
amalgam - one surface, primary or permanent |
$153
|
$40
|
| 2150 |
amalgam - two surfaces, primary or permanent |
$196
|
$50
|
| 2160 |
amalgam - three surfaces, primary or
permanent |
$238
|
$65
|
| 2161 |
amalgam - four or more surfaces, primary or
permanent |
$283
|
$70
|
| 2330 |
resin-based composite - one surface,
anterior |
$181
|
$45
|
| 2331 |
resin-based composite - two surfaces,
anterior |
$221
|
$59
|
| 2332 |
resin-based composite - three surfaces,
anterior |
$276
|
$79
|
| 2335 |
resin-based composite - four or more surfaces or
involving incisal angle (anterior) |
$340
|
$99
|
| 2391 |
resin-based composite - one surface,
posterior |
$198
|
$50
|
| 2392 |
resin-based composite - two surfaces,
posterior |
$255
|
$70
|
| 2393 |
resin-based composite - three surfaces,
posterior |
$316
|
$90
|
| 2394 |
resin-based composite - four or more surfaces,
posterior |
$379
|
$99
|
| RESTORATIVE (Crowns) |
|
ADA
code
|
Procedure
|
Typical
Fee
|
You
Pay
|
| 2750 |
crown - porcelain fused to high noble metal |
$1187
|
$515
|
| 2752 |
crown - porcelain fused to noble metal |
$1125
|
$498
|
| 2930 |
prefabricated stainless steel crown - primary
tooth |
$494
|
$195
|
| 2952 |
post and core in addition to crown,
PRE-Fabricated |
$467
|
$228
|
| 2954 |
CAST- post and core in addition to crown |
$376
|
$288
|
| ENDODONTICS (Root Canals, etc.) |
|
ADA
code
|
Procedure
|
Typical
Fee
|
You
Pay
|
| 3110 |
pulp cap - direct (excluding final
restoration) |
$90
|
$24
|
| 3120 |
pulp cap - indirect (excluding final
restoration) |
$91
|
$24
|
| 3220 |
therapeutic pulpotomy (excluding final restoration) -
removal of pulp coronal to the dentinocemental junction and application of
medicament |
$224
|
$58
|
| 3310 |
endodontic therapy, anterior tooth (excluding final
restoration) |
$792
|
$299
|
| 3320 |
endodontic therapy, bicuspid tooth (excluding final
restoration) |
$921
|
$390
|
| 3330 |
endodontic therapy, molar (excluding final
restoration) |
$1105
|
$425
|
| PERIODONTICS (Scaling / Deep Cleaning / Root Planing,
etc.) |
|
ADA
code
|
Procedure
|
Typical
Fee
|
You
Pay
|
| 4210 |
occlusal nite guard |
$525
|
$285
|
| 4341 |
periodontal scaling and root planing - four or more
teeth per quadrant |
$273
|
$95
|
| 4910 |
periodontal maintenance |
$153
|
$50
|
PROSTHODONTICS (Dentures -
Removable, Partials, etc.)
|
|
ADA
code
|
Procedure
|
Typical
Fee
|
You
Pay
|
| 5110 |
complete denture - maxillary |
$1850
|
$785
|
| 5120 |
complete denture - mandibular |
$1861
|
$785
|
| 5130 |
immediate denture - maxillary |
$1979
|
$885
|
| 5140 |
immediate denture - mandibular |
$1990
|
$885
|
| 5211 |
maxillary partial denture - resin base (including any
conventional clasps, rests and teeth) |
$1444
|
$599
|
| 5212 |
mandibular partial denture - resin base (including any
conventional clasps, rests and teeth) |
$1450
|
$599
|
| 5213 |
maxillary partial denture - cast metal framework with
resin denture bases (including any conventional clasps, rests and
teeth) |
$1922
|
$699
|
| 5214 |
mandibular partial denture - cast metal framework with
resin denture bases (including any conventional clasps, rests and
teeth) |
$1922
|
$699
|
| 5410 |
adjust complete denture - maxillary |
$97
|
$38
|
| 5411 |
adjust complete denture - mandibular |
$97
|
$38
|
| 5510 |
repair broken complete denture base |
$227
|
$60
|
| 5520 |
replace missing or broken teeth - complete denture (each
tooth) |
$205
|
$58
|
| 5630 |
repair or replace broken clasp |
$294
|
$69
|
| 5650 |
add tooth to existing partial denture |
$253
|
$60
|
| 5660 |
add clasp to existing partial denture |
$300
|
$76
|
| 5730 |
reline complete maxillary denture
(chairside) |
$411
|
$143
|
| 5731 |
reline complete mandibular denture
(chairside) |
$410
|
$143
|
| 5740 |
reline maxillary partial denture (chairside) |
$406
|
$120
|
| 5741 |
reline mandibular partial denture
(chairside) |
$407
|
$120
|
| 5750 |
reline complete maxillary denture
(laboratory) |
$513
|
$170
|
| 5751 |
reline complete mandibular denture
(laboratory) |
$517
|
$165
|
| PROSTHODONTICS - FIXED
(Bridges, Dentures, etc.) |
|
ADA
code
|
Procedure
|
Typical
Fee
|
You
Pay
|
| 6240 |
pontic - porcelain fused to high noble metal |
$1216
|
$513
|
| 6242 |
pontic - porcelain fused to noble metal |
$1131
|
$508
|
| 6750 |
crown - porcelain fused to high noble metal |
$1187
|
$599
|
| 6752 |
crown - porcelain fused to noble metal |
$1125
|
$500
|
| ORAL SURGERY (Tooth Extractions, etc.) |
|
ADA
code
|
Procedure
|
Typical
Fee
|
You
Pay
|
| 7140 |
extraction, erupted tooth or exposed root (elevation
and/or forceps removal) |
$188
|
$51
|
| 7220 |
removal of impacted tooth - soft tissue |
$351
|
$99
|
| 7230 |
removal of impacted tooth - partially bony |
$436
|
$110
|
| 7240 |
removal of impacted tooth - completely bony |
$537
|
$198
|
| 7250 |
surgical removal of residual tooth roots (cutting
procedure) |
$340
|
$99
|
| 7310 |
alveoloplasty in conjunction with extractions - four or
more teeth or tooth spaces, per quadrant |
$332
|
$85
|
| 7320 |
alveoloplasty not in conjunction with extractions - four
or more teeth or tooth spaces, per quadrant |
$510
|
$103
|
| 7510 |
incision and drainage of abscess - intraoral soft
tissue |
$258
|
$62
|
| ORTHODONTICS (Braces - Children and Adults, etc.) |
|
ADA
code
|
Procedure
|
Typical
Fee
|
You
Pay
|
| 8070 |
comprehensive orthodontic treatment of the transitional
dentition |
$5805
|
20% Discount
|
| 8080 |
comprehensive orthodontic treatment of the adolescent
dentition |
$5934
|
20% Discount
|
| 8090 |
comprehensive orthodontic treatment of the adult
dentition |
$6208
|
20% Discount
|
| ADJUNCTIVE SERVICES (Anesthesia, Analgesia, etc.) |
|
ADA
code
|
Procedure
|
Typical
Fee
|
You
Pay
|
| 9110 |
palliative (emergency) treatment of dental pain - minor
procedure |
$142
|
$29
|
| 9215 |
local anesthesia |
$74
|
$9
|
| 9230 |
analgesia, anxiolysis, inhalation of nitrous
oxide |
$90
|
$20
|
| 9951 |
occlusal adjustment - limited |
$204
|
$48
|
| 9952 |
occlusal adjustment - complete |
$718
|
$185
|
| COSMETICS |
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
|
| DISCLAIMERS |
| *
Typical fees based on the 80th percentile of the National Dental Advisory
Service Comprehensive Fee Report for 2009
General Information
- This schedule applies to services provided by a
participating NYDiscount.com, LLC General Dentist. The purpose of this
schedule is to establish the fee that a General Dentist will charge for each
procedure. Member is responsible for all charges at the time of service.
- Procedures not listed on this schedule will be
discounted at 20% off of the General Dentist's normal fee.
- If the General Dentist's normal fee for any procedure is
less than the fee listed on this schedule, the dentist will charge 20%
off of their normal fee for that procedure.
- Work in progress prior to signing up on the dental plan
must be completed by the dentist who started the work and is subject to no
discount.
- The dollar amount specified adjacent to each procedure
may not be the only cost incurred for a given treatment - many treatments may
require more than one dental procedure. Please consult your provider for
a detailed treatment plan prior to beginning any work.
- It is the Member's responsibility to verify that the
dentist is a participating Provider before seeking any treatment. Any dental
procedures performed by a non-participating dentist are not discounted and are
charged at the dentist's normal fees.
- NYDiscountdental.com, LLC can not guarantee the
continued participation of any dentist. If the dentist leaves the plan, you will
need to select another participating provider. Not all types of dentists may be
available in your area.
- While all participating NYDiscountdental.com
providers are professionally licensed in the state in which they practice,
NYDiscountdental.com, LLC does not guarantee the quality of service of
the providers. Any quality of care concerns involving any participating
provider should be directed by email to NYDiscountdental@GMAIL.com
specialists
Participating Specialists (Board Certified or Advanced
Degree) do not charge according to a fee schedule. Participating Specialists
will give up to a 20% discount off of their normal fees. Fee schedules are
subject to change without prior notification to members.
|
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