American Dental Plan: Benefits Fee Schedules

Dental Fee Schedule for Members
For Rural Communities in Arizona

Effective: Feb 1st 2023

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	10
Periodic Exams	38
Limited Exams	52
Panoramic x-rays	89
Full Series (non-pano)	99
Routine Cleanings** (Adult)	77
Routine Cleanings** (Child under 14)	63
Difficult Cleanings (heavier scaling)**	108
Emergency treatment palliative, per visit	82
Topical Fluoride (separate or added to cleaning)	41
Sealants (per tooth, includes etch)	38
Materials/Sterilization fee(per patient, per visit)	12

Extractions
Simple local anesthetic, (non-surgical)	110
Complex and/or heavily decayed	125
Root Tip Simple	105
Soft Tissue Impaction	239

Restorative Dentistry
Amalgam primary/permanent (includes base):
Cavities involving one tooth surface	107
Cavities involving two tooth surfaces	135
Cavities involving three tooth surfaces	182

Composite primary/permanent (includes base):
One surface (anterior)	133
Two surfaces (anterior)	157
Three surfaces (anterior)	178

*Composite Restorations: permanent only (includes etch):*
One surface filling (posterior)	149
Two surface filling (posterior)	179

Pin retention per tooth	44

Crown and Bridge (per unit)
(Includes prep, temporary, lab fees and adjustments)
Porcelain w/semi-precious	889
Porcelain w/high noble	998
Full Crown (non-precious)	788
Stainless Steel (Primary or Permanent)	236
Crown build-up w/pin	216
Recement Crown	72

Bridges (per Unit)
Porcelain w/semi-precious metal	889
Porcelain w/high noble	998
Recementation (per unit)	77

Periodontics
Perio Hygiene Instruction	No Charge
Re-evaluation (post treatment)	No Charge
Crown Lengthening	627
Perio Charting*	84
Perio Cleaning (following therapy)	129
Full Mouth Debridement	233
Curettage, scaling or planing (per quadrant)	192
Gingivectomy per quadrant (includes post surgical visits)	457
Osseous or muco-gingival surgery (per quadrant, includes post surgical visits)	648
Gingivectomy (per tooth)	148

Endodontics
Pulp capping	76
Pulpotomy	177
Anterior root canal therapy	528
Bicuspid root canal therapy	689
Molar root canal therapy	849
Apicoectomy (separate procedure, excludes molars)	487

Prosthetics
Resin/Acrylic Partial w/cast clasps	1099
Cast Partial, resin saddles (6 teeth, 2 clasps) (additional teeth $25 each, additional saddles $60 each)	1290
Stayplate/Flipper(u/l up to 2 teeth, office only)	497
High quality upper/lower denture (each)	1245
Immediate Denture (will need to be relined)	1310
Denture adjustments	68
Reline, denture or partial (office)	219
Reline, denture or partial (laboratory)	328
Broken denture repair (no teeth involved)	118
Replace tooth (includes lab fee)	127


*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.