Dental Fee Schedule for Phoenix Metro and Tucson areas |
Effective: December 1st, 2018 |
 |
| Preventive Services | Member Pays |
| Dental exam & diagnosis (one per membership year) | No Charge |
| Bitewings/Pariapical x-rays (set of 4) | No Charge |
| Dental Instruction | No Charge |
| Each additional film | 8 |
| Complete Series x-rays | 72 |
| Panoramic x-ray | 64 |
| Routine Cleanings* (Adult) | 54 |
| Routine Cleanings* (Child under 14) | 47 |
| Difficult Cleanings** (heavier scaling, non-perio) | 77 |
| Periodic exams (including problem focused) | 27 |
| Topical Fluoride (separate or added to cleaning) | 21 |
| Sealants (per tooth, includes etch) | 27 |
| Emergency treatment palliative, per visit | 54 |
| Materials/Sterilization fee (per patient, per visit) | 12 |
| Cosmetics | |
| Evaluation photograph | No charge |
| Whitening/bleaching | cash discounted prices |
| Laminates/Vaneers | cash discounted prices |
| Extractions | |
| Simple local anesthetic (non-surgical) | 82 |
| Complex and/or heavily decayed | 101 |
| Root Tip Simple | 139 |
| Soft Tissue Impaction | 165 |
| Restorative Dentistry | |
| Amalgam primary/permanent (includes base): | |
| Cavities involving one surface | 71 |
| Cavities involving two surfaces | 86 |
| Cavities involving three surfaces | 104 |
| Composite primary/permanent teeth (includes acid etch): | |
| One surface filling (anterior) | 87 |
| Two surfaces filling (anterior) | 102 |
| Three surfaces filling (anterior) | 122 |
| Composite Restorations: permanent teeth only (includes acid etch): | |
| One surface filling (posterior) | 95 |
| Two surface filling (posterior) | 121 |
| Pin retention (each tooth) | 39 |
| Crown and Bridge (per unit) | |
| (Includes preparation, temporary, lab fees and adjustments) | |
| Porcelain w/semi-precious metal | 592 |
| Porcelain w/high noble (includes metal) | 738 |
| Full Crown (non & semi-precious) | 687 |
| Stainless Steel (Primary or Permanent) | 158 |
| Recement Crown | 55 |
| Post & Core, Pin Buildup | 144 |
| Pontics (Bridges)(per Unit) | |
| Full cast (non & semi-precious) | 599 |
| Porcelain w/semi precious (includes metal) | 639 |
| Porcelain w/high noble (includes metal) | 753 |
| Recementation (per unit) | 55 |
| Periodontics | |
| Perio Hygiene Instruction | No Charge |
| Re-evaluation (post treatment) | No Charge |
| Perio Charting* | 68 |
| Perio Cleaning (following therapy) | 83 |
| Full Mouth Debridement (calc below gumline) | 114 |
| Curettage, scaling or planing (per quadrant) | 145 |
| Gingivectomy per quadrant (includes post surgical visits) | 278 |
| Osseous or muco-gingival surgery (per quadrant, includes post surgical visits) | 442 |
| Gingivectomy (treatment per tooth) | 118 |
| Endodontics | |
| Pulp capping | 62 |
| Pulpotomy | 91 |
| Root Canals: | |
| Anterior root canal therapy | 432 |
| Bicuspid root canal therapy | 498 |
| Molar root canal therapy | 631 |
| Apicoectomy (separate procedure, excludes molars) | 329 |
| Prosthetics | |
| Resin/Acrylic Partial w/cast clasps | 679 |
| Cast partial, resin saddles (6 teeth, 2 clasps) (additional teeth $20 ea., additional clasps $50 ea.) |
978 |
| Stayplate/Flipper (u/l, up to 2 teeth, office) | 372 |
| Basic Quality upper/lower denture (each) | 689 |
| High quality upper/lower denture (teeth and base, each) | 1022 |
| Immediate Denture (at time of extraction) added to above choice (will need to be relined) | 140 |
| Denture adjustments | 53 |
| Reline, complete or partial (office) | 174 |
| Reline, complete or partial (laboratory) | 241 |
| Broken denture repair (no teeth involved) | 118 |
| Replace tooth (in office) | 84 |
| Any procedure not listed is available at the usual cash discounted price. | |
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* Routine cleanings include polishing and light coronal scaling, above gumline.
** Dentist will explain level of cal/tartar deposits (possible periodontal problems). |
| Special Notes: |
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| copyright American Dental Plan 2019 |