Dental Fee Schedule for Members
For Rural Communities in Arizona

Effective: Jan 1st 2019  
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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 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
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
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
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
Resin/Acrylic Partial w/cast clasps 899
Cast Partial, resin saddles (6 teeth, 2 clasps)
(additional teeth $25 each, additional saddles $60 each)
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.
© copyright American Dental Plan 2019