American Dental Plan: Benefits Fee Schedules

Dental Fee Schedule for Members
For Rural Communities in Arizona

Effective: August 1st 2024

Preventive Services	Member Pays
Oral exam & diagnosis (one per year)	No Charge*
Bitewings/Pariapical x-rays (set of 4) available once each membership year	No Charge
Each additional film	11
Addt'l' Exams	43
Panoramic x-rays	104
Full Series (non-pano)	114
Routine Cleanings** (Adult)	85
Routine Cleanings** (Child under 14)	68
Difficult Cleanings (heavier scaling)**	124
Emergency treatment palliative, per visit	98
Topical Fluoride (separate or added to cleaning)	44
Sealants (per tooth, includes etch)	40
Materials/Sterilization fee(per patient, per visit)	12

Extractions
Simple local anesthetic, (non-surgical)	113
Complex and/or heavily decayed	130
Root Tip Simple	124
Soft Tissue Impaction	259

Restorative Dentistry
Amalgam primary/permanent (includes base):
Cavities involving one tooth surface	121
Cavities involving two tooth surfaces	152
Cavities involving three tooth surfaces	198

Composite primary/permanent (includes base):
One surface (anterior)	142
Two surfaces (anterior)	174
Three surfaces (anterior)	199

*Composite Restorations: permanent only (includes etch):*
One surface filling (posterior)	173
Two surface filling (posterior)	202

Pin retention per tooth	48

Crown and Bridge (per unit)
(Includes prep, temporary, lab fees and adjustments)
Porcelain w/semi-precious	972
Porcelain w/high noble	1088
Full Crown (non-precious)	841
Stainless Steel (Primary or Permanent)	241
Crown build-up w/pin	233
Recement Crown	82

Bridges (per Unit)
Porcelain w/semi-precious metal	972
Porcelain w/high noble	1088
Recementation (per unit)	93

Periodontics
Perio Hygiene Instruction	No Charge
Re-evaluation (post treatment)	No Charge
Crown Lengthening	712
Perio Charting*	91
Perio Cleaning (following therapy)	138
Full Mouth Debridement	235
Curettage, scaling or planing (per quadrant)	221
Gingivectomy per quadrant (includes post surgical visits)	492
Osseous or muco-gingival surgery (per quadrant, includes post surgical visits)	699
Gingivectomy (per tooth)	167

Endodontics
Pulp capping	84
Pulpotomy	195
Anterior root canal therapy	641
Bicuspid root canal therapy	765
Molar root canal therapy	958
Apicoectomy (separate procedure, excludes molars)	584

Prosthetics
Resin/Acrylic Partial w/cast clasps	1228
Cast Partial, resin saddles (6 teeth, 2 clasps) (additional teeth $25 each, additional saddles $60 each)	1363
Stayplate/Flipper(u/l up to 2 teeth, office only)	509
High quality upper/lower denture (each)	1333
Immediate Denture (will need to be relined)	1457
Reline, denture or partial (office)	261
Reline, denture or partial (laboratory)	367
Denture adjustments	72
Broken denture repair (no teeth involved)	142
Replace tooth (includes lab fee)	138


*All materials used are ADA approved. Any procedure not listed is available* *at the usual cash discounted price.*

Special Notes:

There are no maximum benefits per year.
* Routine cleanings include polishing and light coronal scaling, above gumline.
** Dentist will explain level of calc/tartar deposits (possible periodontal problems).
New patient initial cleaning may be considered a difficult cleaning.
Dentist may charge for first exam, recall exam with then be no charge.
Dentist may take as many as 16 x-rays. The first four are no charge.
Payment is due at time of service. Office may require deposit prior to rendering services.
A fee will be charged for broken appointments w/o 24 hour notice. All materials used are ADA approved.
Dentist may charge a higher fee for higher quality materials used. Consult a participating Specialist for services not performed by a general dentist.
Dentist assumes full responsibility for all dental services provided to member.
Standards of Care suggest clinical exam, x-rays, diagnosis and treatment plan.