Dental Fee Schedule for Phoenix Metro and Tucson areas
The procedures listed below as performed by a general practitioner

Effective: May 1st,  2017
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Preventive Services Member Pays
Dental exam & diagnosis (one per membership year) No Charge
Bitewings/Pariapical x-rays (set of 4) No Charge
Dental Instruction No Charge
Each additional film 7
Panoramic x-ray 61
Routine Cleanings* (Adult) 49
Routine Cleanings* (Child under 14) 41
Difficult Cleanings** (heavier scaling, non-perio) 75
Periodic exams (including problem focused) 25
Topical Fluoride (separate or added to cleaning) 19
Sealants (per tooth, includes etch) 25
Emergency treatment palliative, per visit 48
Materials/Sterilization fee (per patient, per visit) 12
Evaluation photograph No charge
Whitening/bleaching cash discounted prices
Laminates/Vaneers cash discounted prices
Simple local anesthetic (non-surgical) 78
Complex and/or heavily decayed 98
Root Tip Simple 134
Soft Tissue Impaction 158
Restorative Dentistry
Amalgam  primary/permanent (includes base):
Cavities involving one surface 68
Cavities involving two surfaces 84
Cavities involving three surfaces 104
Composite primary/permanent teeth (includes acid etch):
One surface filling (anterior) 83
Two surfaces filling (anterior) 97
Three surfaces filling (anterior) 118
Composite Restorations: permanent teeth only (includes acid etch):
One surface filling (posterior) 92
Two surface filling (posterior) 118
Pin retention (each tooth) 36
Crown and Bridge (per unit)
(Includes preparation, temporary, lab fees and adjustments)
Porcelain w/semi-precious metal 538
Porcelain w/high noble (includes metal) 679
Full Crown (non & semi-precious) 628
Stainless Steel (Primary or Permanent) 134
Recement Crown 48
Post & Core, Pin Buildup 132
Pontics (Bridges)(per Unit)
Full cast (non & semi-precious) 569
Porcelain w/semi precious (includes metal) 625
Porcelain w/high noble (includes metal) 685
Recementation (per unit) 48
Perio Hygiene Instruction No Charge
Re-evaluation (post treatment) No Charge
Perio Charting* 68
Perio Cleaning (following therapy) 79
Full Mouth Debridement (calc below gumline) 108
Curettage, scaling or planing (per quadrant) 127
Gingivectomy per quadrant (includes post surgical visits) 269
Osseous or muco-gingival surgery (per quadrant, includes post surgical visits) 425
Gingivectomy (treatment per tooth) 106
Pulp capping 54
Pulpotomy 82
Root Canals:
Anterior root canal therapy 425
Bicuspid root canal therapy 487
Molar root canal therapy 618
Apicoectomy (separate procedure, excludes molars) 315
Resin/Acrylic Partial w/cast clasps 652
Cast partial, resin saddles (6 teeth, 2 clasps)
(additional teeth $20 ea., additional clasps $50 ea.)
Stayplate/Flipper (u/l, up to 2 teeth, office) 330
Basic Quality upper/lower denture (each) 670
High quality upper/lower denture (teeth and base, each) 998
Immediate Denture (at time of extraction) added to above choice (will need to be relined) 125
Denture adjustments 47
Reline, complete or partial (office) 168
Reline, complete or partial (laboratory) 226
Broken denture repair (no teeth involved) 103
Replace tooth (in office) 78
Any procedure not listed is available at the usual cash discounted price.
* Routine cleanings include polishing and light coronal scaling, above gumline.
** Dentist will explain level of cal/tartar deposits (possible periodontal problems).
Special Notes:
  • There are no maximum benefits per year.
  • Initial cleaning may be considered a difficult cleaning.
  • Payment due at time of service. Doctor may require deposit prior to services.
  • A fee will be charged for broken appointments without 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.
Some dentists may require a more extensive initial diagnosis which may include pano x-rays & perio charting.
copyright American Dental Plan 2017