NYDISCOUNTDENTAL 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 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.

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