American Dental Plan: Benefits Fee Schedules

Dental Fee Schedule for Members
For Rural Communities in Arizona

Effective: Jan 1st 2019

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	7
Addt'l exams ( includes periodic & comprehensive )	33
Panoramic x-rays	71
Full Series (non-pano)	95
Routine Cleanings** (Adult)	69
Routine Cleanings** (Child under 14)	58
Difficult Cleanings (heavier scaling)**	97
Emergency treatment palliative, per visit	68
Topical Fluoride (separate or added to cleaning)	38
Sealants (per tooth, includes etch)	36
Materials/Sterilization fee(per patient, per visit)	12

Extractions
Simple local anesthetic, (non-surgical)	88
Complex and/or heavily decayed	107
Root Tip Simple	98
Soft Tissue Impaction	215

Restorative Dentistry
Amalgam primary/permanent (includes base):
Cavities involving one tooth surface	95
Cavities involving two tooth surfaces	127
Cavities involving three tooth surfaces	138

Composite primary/permanent (includes base):
One surface (anterior)	114
Two surfaces (anterior)	140
Three surfaces (anterior)	162

*Composite Restorations: permanent only (includes etch):*
One surface filling (posterior)	138
Two surface filling (posterior)	164

Pin retention per tooth	38

Crown and Bridge (per unit)
(Includes prep, temporary, lab fees and adjustments)
Porcelain w/semi-precious	842
Porcelain w/high noble	896
Full Crown (non-precious)	712
Stainless Steel (Primary or Permanent)	229
Crown build-up w/pin	184
Recement Crown	59

Bridges (per Unit)
Porcelain w/semi-precious metal	842
Porcelain w/high noble	896
Recementation (per unit)	59

Periodontics
Perio Hygiene Instruction	No Charge
Re-evaluation (post treatment)	No Charge
Crown Lengthening	527
Perio Charting*	78
Perio Cleaning (following therapy)	119
Full Mouth Debridement	221
Curettage, scaling or planing (per quadrant)	182
Gingivectomy per quadrant (includes post surgical visits)	432
Osseous or muco-gingival surgery (per quadrant, includes post surgical visits)	610
Gingivectomy (per tooth)	134

Endodontics
Pulp capping	63
Pulpotomy	177
Anterior root canal therapy	468
Bicuspid root canal therapy	587
Molar root canal therapy	712
Apicoectomy (separate procedure, excludes molars)	419

Prosthetics
Resin/Acrylic Partial w/cast clasps	899
Cast Partial, resin saddles (6 teeth, 2 clasps) (additional teeth $25 each, additional saddles $60 each)	1012
High quality upper/lower denture (per arch)	1108
Immediate Denture (will need to be relined)	1255
Stayplate/Flipper(u/l up to 2 teeth, office only)	445
Denture adjustments	59
Reline, denture or partial (office)	189
Reline, denture or partial (laboratory)	266
Broken denture repair (no teeth involved)	93
Replace tooth (includes lab fee)	108


*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.