ADA Code	ENDODONTIST	NDPA FEE	USUAL FEE
D0150	Comprehensive Oral Evaluation	$55.00	$110.00
D3110	Pulp Capping	$90.00	$165.00
D3220	Pulpotomy	$145.00	$236.50
	Root Canal Therapy (excluding final restoration)
D3310	Anterior	$550.00	$874.50
D3320	Bicuspid	$660.00	$1,012.00
D3330	Molar	$790.00	$1,111.00
D3410	Apicoectomy - (anterior)	$500.00	$770.00
D3421	Apicoectomy - (bicuspid-first root)	$530.00	$770.00
D3425	Apicoectomy - (molar-first root)	$610.00	$770.00
D3426	Each additional root	$292.00	$456.50
D3430	Retrograde filling per-root	$220.00	$363.00
D3920	Root Resection - per root (HEMISECTION)	$375.00	$550.00
D7510	Incision and Drainage	$170.00	$286.00
	*Root canal treatment fees include filling the canals. It does not include final restorations (which are sometimes called fillings) *Retreatment of a Root Canal is performed at 25% courtesy fee

ADA Code	ORAL SURGEON	NDPA FEE	USUAL FEE
D0150	Comprehensive Oral Evaluation	$60.00	$110.00
	Simple Extraction (single tooth)	$116.00	$198.00
	(each additional tooth)	$99.00	$159.50
D7210	Surgical Extraction	$198.00	$313.50
D7220	Soft Tissue Impaction	$237.00	$357.50
D7230	Partial Bony Impaction	$303.00	$478.50
D7240	Full Bony Impaction	$424.00	$577.50
D7241	Full Bony Impaction w/ unusual surgical complications	$515.00	$1,034.00
D0330	Panorex	$83.00	$159.50
D9220	General Anesthesia - First unit	$176.00	$286.00
D9221	(additional 15 min)	$77.00	$165.00

ADA Code	ORTHODONTICS	NDPA FEE	USUAL FEE
	Diagnosis/Records Work-up, including full mouth series, Models, Photographs and a second visit for discussion and presentation	$215.00	$396.00
	Class I Malocclusion (comprehensive dentition)	$3,869.00	$5,500.00
	Class II Malocclusion (comprehensive dentition)	$4,247.00	$6,033.50
	Class III - available at 15% off Dentist's usual fee
D8750	Post-Treatment Stabilization - each retainer	$255.00	$418.00
	Partial Case - Evaluated on an individual basis

ADA Code	PERIODONTIST	NDPA FEE	USUAL FEE
	Initial Consultation-Not including diagnosis	$60.00	$100.00
	Diagnosis/Records/Charting
D0150	including 5 or more x-rays	$175.00	$302.50
D0150	including 4 x-rays or less	$164.00	$236.50
D4341	Periodontal Scaling/per quadrant (root planing - curettage)	$195.00	$291.50
D4355	Scaling (full mouth)	$175.00	$253.00
D4211	Gingivectomy or gingivoplasty - per tooth	$220.00	$319.00
D4210	Gingivectomy or gingivoplasty - per quadrant	$515.00	$693.00
D4240	Gingival flap procedure (including root planing - per quadrant)	$600.00	$847.00
D4260	Osseous Surgery (including flap entry and closure) per quadrant	$815.00	$1,166.00
D4270	Pedicle soft tissue graft procedure	$620.00	$902.00
D4271	Free Soft Tissue Graft Procedure (including donor site)	$600.00	$990.00
D4245	Apically repositioned flap procedure	$630.00	$891.00
	Occlusal Equilibration:
	A. As part of a full surgical case	No Charge
D9952	B. As a separate procedure, not to exceed 3 visits	$185.00	$286.00
D4910	Perio Maintenence Procedure, includes exam (following active therapy)	$135.00	$192.50
	Full Surgical Case:
	Includes 4 Quadrants of osseous surgery, occlusal adjustment, 4 quadrants of periodontal scaling (not to exceed...)	$4,195.00	$5,500.00
	Partial Cases: Are based upon above fee schedule.

PROSTHODONTIST

Participating Prosthodontists will provide a 30% discount off their usual rates for all NDPA members.

PEDODONTIST

All Pedodontists will provide a 20% discount off their usual rates for all NDPA members.

TMJ SPECIALIST

(Temporomandibular Joint Syndrome)

Providers who treat TMJ will provide a 20% discount off their usual rates for all NDPA members.

IMPLANTOLOGY

Participating Dentists will provide a 20% discount off their usual rates for all NDPA members.

Northeast Dental Plan of America is in no way Affiliated with Northeast Delta Dental or affiliates thereof.