COVERAGE · PENNSYLVANIASHEET 39 / 51

Pennsylvania, measured.

14,278 licensed dental providers on record, refreshed monthly from the federal registry. The Medicaid floors below come from the official state fee-for-service schedule, effective August 1, 2025 (view the source document). Practice costs index at 0.998 against the 1.000 national baseline.

EFFECTIVE AUGUST 1, 2025 · FLOORS 22 OF 25 CODES Official schedule on file
14,278Licensed providers
22Medicaid fee rows
0.998Geo cost index / 1.000
$18 to $1,000Floor range
FEE SPECTRUM25 BENCHMARK CDT CODES

The Pennsylvania fee table

ProcedureMedicaid floorInsurer typicalPrivate-pay p50Private-pay p90
Diagnostic
Routine checkup (existing patient)$20$43$60$93
Comprehensive exam (new patient)$20$72$100$155
Full-mouth X-ray series$45$115$160$232
Bitewing X-rays (set of 4)$28$50$70$102
Panoramic X-ray$37$101$140$203
Emergency
Emergency visit for pain relief$30$104$145$225
Endodontics
Root canal, front tooth$275$683$948$1,469
Root canal, molar$500$919$1,277$1,979
Implants
Dental implant placementNo published floor$1,473$2,046$3,171
Oral surgery
Simple tooth extraction$65$140$195$302
Surgical tooth extraction$65$237$329$510
Orthodontics
Full braces treatment, adolescent$1,000$4,096$5,689$7,680
Periodontics
Deep cleaning below gumline (per quadrant)$75$183$254$394
Ongoing gum maintenance visit$44$115$160$248
Preventive
Adult teeth cleaning$36$76$105$163
Child teeth cleaning$30$58$80$124
Fluoride varnish treatment$18$36$50$78
Protective tooth sealant$25$40$55$85
Restorative
Metal filling (1 surface)$45$112$155$240
Tooth-colored filling, front tooth$50$140$195$302
Tooth-colored filling, back tooth (1 surface)$50$151$210$326
Tooth-colored filling, back tooth (2 surfaces)$60$180$250$388
Ceramic crown$500$1,006$1,397$2,165
Porcelain-on-metal crownNo published floor$827$1,148$1,779
Crown foundation buildupNo published floor$215$299$463

Floor. Official Pennsylvania Medicaid fee-for-service dental schedule, effective August 1, 2025. View the source document.

Bands. Modeled: the national median billed charge for each procedure, scaled by the Pennsylvania geographic cost index (0.998 against a 1.000 national baseline), with the insurer-typical amount modeled at roughly 72 percent of area billed charges. Estimates, not quotes.

HOW TO READ IT

Reading this table

The Medicaid floor is the exact fee on the state schedule: the lowest rate a practice accepts for that procedure, and the anchor of the revenue spectrum. Insurer typical models what a commercial plan tends to allow, about 72 percent of area billed charges. Private-pay p50 and p90 are modeled billed-charge bands: the national median scaled by the state cost index, and the top of the usual range. Where a practice actually lands depends on its payer mix. The floor is owned data; the bands are estimates.

CROSS REFERENCE
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