Dental Fee Schedule for Members
For Flagstaff, Prescott, and other Rural Areas in Arizona
The procedures listed below as performed by a general practitioner
rev Jan '02

Preventive Services MEMBER PAYS
Oral exam & diagnosis (initial visit) *No Charge
Bitewings/Pariapical x-rays (set of 4) *No Charge
Each additional film 6
Routine Cleanings** (Adult) 36
(Child under 14) 27
Difficult Cleanings (heavier scaling)** 61
Addt'l exams (any exam after initial visit) 21
Emergency treatment palliative, per visit 36
Topical Fluoride (separate or added to cleaning) 18
Sealants (per tooth, includes etch) 19
Infection Control (per patient, per visit) 10
Extractions
Simple local anesthetic, first (non-surgical) 52
each additional (at same visit) 43
Complex and/or heavily decayed 72
Root Tip Simple 81
Soft Tissue Impaction 103
Restorative Dentistry
Amalgam restoration primary teeth (excludes base):
Cavities involving one surface 35
Cavities involving two surfaces 45
Cavities involving three surfaces 58
Amalgam restorations permanent teeth (excludes base):
Cavities involving one surface 42
Cavities involving two surfaces 53
Cavities involving three surfaces 75
Composite Restorations (excludes acid etch):
One surface filling (anterior) 52
Two surface filling (anterior) 74
Sedative Base (per tooth) 12
Acid Etch (added to composite fillings, each tooth) 12
Pin retention per tooth 29
Crown and Bridge (per unit)
(Includes preparation, temporary and adjustments)
Porcelain w/ non-precious metal crown 364*
Porcelain w/semi-precious 440*
Porcelain w/high noble 465*
Full Crown (non-precious) 315*
Stainless Steel (Primary or Permanent) 92
Dowel Pin, Post & Core, Pin Buildup 103
Recement Crown 35
*(+lab fee not to exceed $95)
Pontics (Bridges)(per Unit) MEMBER PAYS
Full Cast (non-precious) 322*
Porcelain w/non-precious metal 364*
Porcelain w/semi-precious metal 440*
Porcelain w/high noble 465*
Recementation (per unit) 35
*(+lab fee not to exceed $95)
Periodontics
Perio Hygiene Instruction No Charge
Re-evaluation (post treatment) No Charge
Perio Charting* 67
Perio Cleaning (following therapy) 62
Full Mouth Debridement 124
Curettage, scaling or planing (per quadrant) 83
Gingivectomy per quadrant (includes post surgical visits) 223
Osseous or muco-gingival surgery (per quadrant, includes post surgical visits) 340
Gingivectomy (per tooth) 71
Endodontics
Pulp capping 37
Pulpotomy 65
Root Canals:
Anterior root canal therapy 243
Bicuspid root canal therapy 318
Molar root canal therapy 440
Apicoectomy (separate procedure, excludes molars) 215
Prosthetics
Complete upper/lower denture 499
Immediate Denture (will need to be relined) 570
Stayplate (upper or lower) 164
Denture adjustments 33
Reline, complete or partial (office) 94
Reline, complete or partial (laboratory) 175
Broken denture repair (no teeth involved) 68
Replace tooth (includes lab fee) 54

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 2002

Special Notes: A fee will be charged for broken appointments w/o 24 hour notice.
Payment due at time of service. Doctor may require deposit prior to services.
*Doctor will explain level of calc/tartar deposits (possible periodontal problems).
**Routine cleanings include polishing and light coronal scaling, above gumline.
Fee schedule subject to change without written notice to members.
Membership year from date of enrollment. Consult a participating specialist for services not performed by a general dentist.
Participating Dentists assume full responsibility for services offered and performed.
You may need to visit a Specialist in Pheonix for certain dental procedures.

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