American Dental Plan - Phx/Tucson Dental Fee Schedule

Dental Fee Schedule for Members
The procedures listed below as performed by a Phx Metro or Tucson general practitioner
rev 12/01

Preventive Services	MEMBER PAYS
Oral exam & diagnosis (initial visit)	*No Charge
Bitewings/Pariapical x-rays (set of 4)	*No Charge
Each additional film	3
Panoramic x-ray	45
Initial Routine Cleaning per Year (Adult)	30
(Child under 14)	20
Routine Cleaning (active recall)	**No Charge
Difficult Cleanings (heavier scaling, non-perio)	49
Addt'l exams (any exam after initial visit each yr)	17
Topical Fluoride (separate or added to cleaning)	12
Sealants (per tooth, includes etch)	15
Emergency treatment palliative (per visit)	24
Materials/Sterilization fee (per patient, per visit)	10
Extractions
Simple local anesthetic, first (non-surgical)	39
each additional (at same visit)	35
Complex and/or heavily decayed	64
Root Tip Simple	68
Soft Tissue Impaction (with exposed tooth)	87
Restorative Dentistry
Amalgam primary & perm. teeth (excludes base):
Cavities involving one surface	19
Cavities involving two surfaces	33
Cavities involving three surfaces (prim teeth)	43
Cavities involving three surfaces (perm teeth)	53
Composite primary & perm teeth (excludes acid etch):
One surface filling (anterior)	35
Two surface filling (anterior)	45
Three surface filling (anterior)	65
Composite per. teeth only (excludes acid etch):
One surface filling (posterior)	47
Two surface filling (posterior)	67
Acid Etch (added to composite fillings, each tooth)	10
Sedative Base (each tooth)	10
Pin retention (each tooth)	22
Crown and other Restorative (per unit)
(Includes preparation, lab fee, temporary and adjustments)
Porcelain with metal crown (non-precious)	324
Porcelain w/semi-precious (includes metal)	428
Porcelain w/high noble (includes metal)	528
Full Crown (non-precious)	288
Stainless Steel (Primary or Permanent)	80
Recement Crown	25
Dowel Pin, Post & Core, Pin Buildup	89
Bonding System w/buildup	40

Pontics (Bridges)(per Unit)	MEMBER PAYS
Full Cast (non-precious)	288
Porcelain w/metal (non-precious)	324
Porcelain w/semi precious (includes metal)	428
Porcelain w/high noble (includes metal)	528
Recementation (per unit)	25
Periodontics
Perio Hygiene Instruction	No Charge
Re-evaluation (post treatment)	No Charge
Perio Charting	48
Perio Cleaning (following therapy)	49
Full Mouth Debridement (calc below gumline)	95
Curettage, scaling, or planing (per quadrant)	65
Gingivectomy (per quadrant, includes post surgical visits)	169
Osseous or muco-gingival surgery (per quadrant, includes post surgical visits)	298
Gingivectomy (treatment per tooth)	58
Endodontics
Pulp capping	21
Pulpotomy	42
Root Canals:
Anterior root canal therapy	195
Bicuspid root canal therapy	248
Molar root canal therapy	379
Apicoectomy (separate procedure) (excludes molars)	199
Prosthetics
Basic Quality upper/lower denture (each)	399
High Quality u/l denture (teeth & base) (each)	488
Immediate Denture (at time of extraction) added to above choice (will need to be relined)	60
Stayplate (u/l, up to 2 teeth, office)	145
Denture adjustments	18
Reline, complete or partial (office)	86
Reline, complete or partial (laboratory)	128
Broken denture repair (no teeth involved)	49
Replace tooth (plus lab fee)	45

All materials used are ADA approved.

Any procedure not listed is available on a fee-for-service basis.

(additional fees may be added for higher quality materials used)

There are no maximum benefits per year.

copyright American Dental Plan 2001

ANY PROCEDURE NOT LISTED IS AVAILABLE ON A FEE FOR SERVICE BASIS.
Special Notes:	A fee will be charged for broken appointments w/o 24 hour notice. Payment is due at time of service. Doctor may require deposit prior to services. Doctor will explain level of calc/tartar deposits (possible periodontal problems). No charge for these services once a year. (X-rays remain property of dentist.) Routine cleanings include polishing and light coronal scaling, above gumline. Active Recall is defined as 2nd routine cleaning within 6-8 months of initial routine cleaning. Subsequent routine cleanings (after the free cleaning) are provided at the reduced rate. Fee schedule subject to change without written notice to members. Consult a participating specialist for services not performed by a general dentist. Dentist assumes full responsibility for all dental services provided to member. Some general dentists may perform services as specialists and will offer only 20% off UCR.
Some dentists may require a more extensive initial diagnosis which may include pano x-rays & perio charting.

ANY PROCEDURE NOT LISTED IS AVAILABLE ON A FEE FOR SERVICE BASIS.

Special Notes:

A fee will be charged for broken appointments w/o 24 hour notice.
Payment is due at time of service. Doctor may require deposit prior to services.
*Doctor will explain level of calc/tartar deposits (possible periodontal problems).
*No charge for these services once a year. (X-rays remain property of dentist.)
**Routine cleanings include polishing and light coronal scaling, above gumline.
**Active Recall is defined as 2nd routine cleaning within 6-8 months of initial routine cleaning.
Subsequent routine cleanings (after the free cleaning) are provided at the reduced rate.
Fee schedule subject to change without written notice to members.
Consult a participating specialist for services not performed by a general dentist.
Dentist assumes full responsibility for all dental services provided to member.
Some general dentists may perform services as specialists and will offer only 20% off UCR.

Some dentists may require a more extensive initial diagnosis which may include pano x-rays & perio charting.