Dental Fee Schedule for Members
For Rural Communities in Arizona

Effective: Feb 1st 2017  
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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 6
Addt'l exams ( includes periodic & comprehensive ) 31
Panoramic x-rays 65
Full Series (non-pano) 84
Routine Cleanings** (Adult) 61
Routine Cleanings** (Child under 14) 43
Difficult Cleanings (heavier scaling)** 82
Emergency treatment palliative, per visit 51
Topical Fluoride (separate or added to cleaning) 36
Sealants (per tooth, includes etch) 34
Materials/Sterilization fee(per patient, per visit) 12
Simple local anesthetic, (non-surgical) 79
Complex and/or heavily decayed 93
Root Tip Simple 92
Soft Tissue Impaction 189
Restorative Dentistry
Amalgam  primary/permanent (includes base):
Cavities involving one tooth surface 83
Cavities involving two tooth surfaces 105
Cavities involving three tooth surfaces 128
Composite primary/permanent  (includes base):
One surface (anterior) 101
Two surfaces (anterior) 140
Three surfaces (anterior) 152
Composite Restorations: permanent only (includes etch):
One surface filling (posterior) 124
Two surface filling (posterior) 152
Pin retention per tooth 32
Crown and Bridge (per unit)
(Includes prep, temporary, lab fees and adjustments)
Porcelain w/semi-precious 798
Porcelain w/high noble 878
Full Crown (non-precious) 690
Stainless Steel (Primary or Permanent) 229
Crown build-up w/pin 158
Recement Crown 55
Bridges (per Unit)
Porcelain w/semi-precious metal 798
Porcelain w/high noble 878
Recementation (per unit) 55
Perio Hygiene Instruction No Charge
Re-evaluation (post treatment) No Charge
Crown Lengthening 508
Perio Charting* 74
Perio Cleaning (following therapy) 109
Full Mouth Debridement 210
Curettage, scaling or planing (per quadrant) 178
Gingivectomy per quadrant (includes post surgical visits) 415
Osseous or muco-gingival surgery (per quadrant, includes post surgical visits) 590
Gingivectomy (per tooth) 120
Pulp capping 49
Pulpotomy 177
Anterior root canal therapy 440
Bicuspid root canal therapy 550
Molar root canal therapy 688
Apicoectomy (separate procedure, excludes molars) 390
Resin/Acrylic Partial w/cast clasps 885
Cast Partial, resin saddles (6 teeth, 2 clasps)
(additional teeth $25 each, additional saddles $60 each)
High quality upper/lower denture (per arch) 1048
Immediate Denture (will need to be relined) 1148
Stayplate/Flipper(u/l up to 2 teeth, office only) 407
Denture adjustments 59
Reline, denture or partial (office) 173
Reline, denture or partial (laboratory) 242
Broken denture repair (no teeth involved) 82
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 2017