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

Effective: December 1st,  2018
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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 8
Complete Series x-rays 72
Panoramic x-ray 64
Routine Cleanings* (Adult) 54
Routine Cleanings* (Child under 14) 47
Difficult Cleanings** (heavier scaling, non-perio) 77
Periodic exams (including problem focused) 27
Topical Fluoride (separate or added to cleaning) 21
Sealants (per tooth, includes etch) 27
Emergency treatment palliative, per visit 54
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) 82
Complex and/or heavily decayed 101
Root Tip Simple 139
Soft Tissue Impaction 165
Restorative Dentistry
Amalgam  primary/permanent (includes base):
Cavities involving one surface 71
Cavities involving two surfaces 86
Cavities involving three surfaces 104
Composite primary/permanent teeth (includes acid etch):
One surface filling (anterior) 87
Two surfaces filling (anterior) 102
Three surfaces filling (anterior) 122
Composite Restorations: permanent teeth only (includes acid etch):
One surface filling (posterior) 95
Two surface filling (posterior) 121
    Pin retention (each tooth) 39
Crown and Bridge (per unit)
(Includes preparation, temporary, lab fees and adjustments)
Porcelain w/semi-precious metal 592
Porcelain w/high noble (includes metal) 738
Full Crown (non & semi-precious) 687
Stainless Steel (Primary or Permanent) 158
Recement Crown 55
Post & Core, Pin Buildup 144
Pontics (Bridges)(per Unit)
Full cast (non & semi-precious) 599
Porcelain w/semi precious (includes metal) 639
Porcelain w/high noble (includes metal) 753
Recementation (per unit) 55
Perio Hygiene Instruction No Charge
Re-evaluation (post treatment) No Charge
Perio Charting* 68
Perio Cleaning (following therapy) 83
Full Mouth Debridement (calc below gumline) 114
Curettage, scaling or planing (per quadrant) 145
Gingivectomy per quadrant (includes post surgical visits) 278
Osseous or muco-gingival surgery (per quadrant, includes post surgical visits) 442
Gingivectomy (treatment per tooth) 118
Pulp capping 62
Pulpotomy 91
Root Canals:
Anterior root canal therapy 432
Bicuspid root canal therapy 498
Molar root canal therapy 631
Apicoectomy (separate procedure, excludes molars) 329
Resin/Acrylic Partial w/cast clasps 679
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) 372
Basic Quality upper/lower denture (each) 689
High quality upper/lower denture (teeth and base, each) 1022
Immediate Denture (at time of extraction) added to above choice (will need to be relined) 140
Denture adjustments 53
Reline, complete or partial (office) 174
Reline, complete or partial (laboratory) 241
Broken denture repair (no teeth involved) 118
Replace tooth (in office) 84
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 2019