Dental Fee Schedule for Members
For Rural Communities in Arizona



Effective: Feb 1st 2022  
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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.
 
copyright American Dental Plan 2022