CAREINGTON Dental - 500 Series
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Plan
501 Schedule
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ADA | DIAGNOSTIC | MEMBER |
| 0120 | PERIODIC ORAL EVALUATION |
$14 |
| 0140 | LIMITED ORAL EVALUATION-PROBLEM FOCUSED |
$18 |
| 0150 | COMPREHENSIVE ORAL EVALUATION-NEW OR ESTABLISHED PATIENT |
$18 |
| 0210 | INTRAORAL-COMPLETE SERIES INCLUDING BITEWINGS |
$40 |
| 0220 | INTRAORAL-PERIAPICAL-FIRST FILM |
$10 |
| 0230 | INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM |
$6 |
| 0270 | BITEWING-SINGLE FILM |
$10 |
| 0272 | BITEWINGS-TWO FILMS |
$13 |
| 0273 | BITEWINGS-THREE FILMS |
$17 |
| 0274 | BITEWINGS-FOUR FILMS |
$20 |
| 0330 | PANORAMIC FILM |
$40 |
PREVENTIVE | ||
| 1110 | ADULT CLEANING (PROPHYLAXIS) |
$29 |
| 1120 | CHILD CLEANING (PROPHYLAXIS) |
$21 |
| 1351 | SEALANT-PER TOOTH |
$20 |
| 1510 | SPACE MAINTAINER-FIXED-UNILATERAL |
$87 |
| 1515 | SPACE MAINTAINER-FIXED-BILATERAL |
$127 |
| 1520 | SPACE MAINTAINER-REMOVABLE-UNILATERAL |
$113 |
| 1525 | SPACE MAINTAINER-REMOVABLE-BILATERAL |
$143 |
RESTORATIVE | ||
| 2140 | AMALGAM FILLING-ONE SURFACE, PRIMARY OR PERMANENT |
$40 |
| 2150 | AMALGAM FILLING-TWO SURFACES, PRIMARY OR PERMANENT |
$51 |
| 2160 | AMALGAM FILLING-THREE SURFACES, PRIMARY OR PERMANENT |
$60 |
| 2161 | AMALGAM FILLING-FOUR OR MORE SURFACES, PRIMARY OR PERMANENT |
$73 |
| 2330 | RESIN-BASED COMPOSITE FILLING-ONE SURFACE, ANTERIOR |
$51 |
| 2331 | RESIN-BASED COMPOSITE FILLING-TWO SURFACES, ANTERIOR |
$61 |
| 2332 | RESIN-BASED COMPOSITE FILLING-THREE SURFACES, ANTERIOR |
$77 |
| 2335 | RESIN-BASED COMPOSITE FILLING-FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE, ANTERIOR |
$98 |
| 2391 | RESIN-BASED COMPOSITE FILLING-ONE SURFACE, POSTERIOR |
$64 |
| 2392 | RESIN-BASED COMPOSITE FILLING-TWO SURFACES, POSTERIOR |
$94 |
| 2393 | RESIN-BASED COMPOSITE FILLING-THREE SURFACES, POSTERIOR |
$119 |
| 2394 | RESIN-BASED COMPOSITE FILLING-FOUR OR MORE SURFACES, POSTERIOR |
$138 |
| 2710 | CROWN-RESIN BASED COMPOSITE (INDIRECT) | $191 |
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2720 | CROWN-RESIN WITH HIGH NOBLE METAL | $403 |
| 2750 | CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL | $473 |
| 2751 | CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL | $428 |
| 2752 | CROWN-PORCELAIN FUSED TO NOBLE METAL | $447 |
| 2790 | CROWN-FULL CAST HIGH NOBLE METAL | $465 |
| 2791 | CROWN-FULL CAST PREDOMINANTLY BASE METAL | $417 |
| 2930 | PREFABRICATED STAINLESS STEEL CROWN-PRIMARY | $88 |
| 2931 | PREFABRICATED STAINLESS STEEL CROWN-PERMANENT | $100 |
| 2950 | CORE BUILD-UP, INCLUDING ANY PINS | $93 |
| 2951 | PIN RETENTION/TOOTH, IN ADDITION TO RESTORATION | $23 |
| 2952 | CAST POST AND CORE IN ADDITION TO CROWN | $146 |
| 2954 | PREFABRICATED POST AND CORE IN ADDITION TO CROWN | $114 |
ENDODONTICS | ||
| 3110 | PULP CAP-DIRECT (EXCLUDING FINAL RESTORATION) | $21 |
| 3120 | PULP CAP-INDIRECT (EXCLUDING FINAL RESTORATION) | $21 |
| 3220 | THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) | $51 |
| 3310 | ROOT CANAL-ANTERIOR (EXCLUDING FINAL RESTORATION) | $272 |
| 3320 | ROOT CANAL-BICUSPID (EXCLUDING FINAL RESTORATION) | $322 |
| 3330 | ROOT CANAL-MOLAR (EXCLUDING FINAL RESTORATION) | $406 |
PERIODONTICS | ||
| 4210 | GINGIVECTOMY OR GINGIVOPLASTY-FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUADRANT | $271 |
| 4341 | PERIODONTAL SCALING AND ROOT PLANING-FOUR OR MORE TEETH PER QUADRANT | $94 |
| 4910 | PERIODONTAL MAINTENANCE | $60 |
PROSTHODONTICS (REMOVABLE) | ||
| 5110 | COMPLETE DENTURE-MAXILLARY | $595 |
| 5120 | COMPLETE DENTURE-MANDIBULAR | $595 |
| 5130 | IMMEDIATE DENTURE-MAXILLARY | $619 |
| 5140 | IMMEDIATE DENTURE-MANDIBULAR | $619 |
| 5211 | MAXILLARY PARTIAL DENTURE-RESIN BASE (CLASP/RESTS) | $583 |
| 5212 | MANDIBULAR PARTIAL DENTURE-RESIN BASE (CLASP/RESTS) | $583 |
| 5213 | MAXILLARY PARTIAL DENTURE-METAL FRAME WITH RESIN BASE | $675 |
| 5214 | MANDIBULAR PARTIAL DENTURE-METAL FRAME WITH RESIN BASE | $675 |
| 5410 | ADJUST COMPLETE DENTURE-MAXILLARY | $34 |
| 5411 | ADJUST COMPLETE DENTURE-MANDIBULAR | $34 |
| 5510 | REPAIR BROKEN COMPLETE DENTURE BASE | $53 |
| 5520 | REPLACE MISSING OR BROKEN TEETH-COMPLETE DENTURE (EACH TOOTH) | $51 |
| 5630 | REPAIR OR REPLACE BROKEN CLASP, PARTIAL DENTURE | $61 |
| 5650 | ADD TOOTH TO EXISTING PARTIAL DENTURE | $53 |
| 5660 | ADD CLASP TO EXISTING PARTIAL DENTURE | $68 |
| 5730 | RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) | $126 |
| 5731 | RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) | $126 |
| 5740 | RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) | $120 |
| 5741 | RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE) | $120 |
| 5750 | RELINE COMPLETE MAXILLARY DENTURE (LABORATORY) | $165 |
| 5751 | RELINE COMPETE MANDIBULAR DENTURE (LABORATORY) | $165 |
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IMPLANTS (6000 THROUGH 6096): 20% Discount
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PROSTHODONTICS (FIXED) | ||
| 6240 | PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL | $411 |
| 6241 | PONTIC-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL | $379 |
| 6242 | PONTIC-PORCELAIN FUSED TO NOBLE METAL | $395 |
| 6750 | CROWN-RETAINER-PORCELAIN FUSED TO HIGH NOBLE METAL | $453 |
| 6751 | CROWN-RETAINER-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL | $408 |
| 6752 | CROWN-RETAINER-PORCELAIN FUSED TO NOBLE METAL | $424 |
ORAL SURGERY | ||
| 7140 | EXTRACTION-ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPTS REMOVAL) | $51 |
| 7210 | SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING ELEVATION OF MUCOPERIOSTEAL | $130 |
| 7220 | REMOVAL OF IMPACTED TOOTH-SOFT TISSUE | $104 |
| 7230 | REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY | $136 |
| 7240 | REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY | $196 |
| 7250 | SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE) | $104 |
| 7310 | ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS-PER QUADRANT | $87 |
| 7320 | ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS-PER QUADRANT | $125 |
| 7510 | INCISION AND DRAINAGE ABSCESS-INTRAORAL SOFT TISSUE | $64 |
ORTHODONTICS | ||
| 8070 | COMPLETE ORTHODONTIC TREATMENT-TRANSITIONAL DENTITION | 20% Discount |
| 8080 | COMPLETE ORTHODONTIC TREATMENT-ADOLESCENT DENTITION | 20% Discount |
| 8090 | COMPLETE ORHTODONTIC TREATMENT-ADULT DENTITION | 20% Discount |
ADJUNCTIVE SERVICES | ||
| 9110 | PALLIATIVE (EMERGENCY) TREATMENT-DENTAL PAIN-MINOR PROCEDURE | $34 |
| 9215 | LOCAL ANESTHESIA | $12 |
| 9230 | ANALGESIA | $24 |
| 9951 | OCCLUSAL ADJUSTMENT-LIMITED | $47 |
| 9952 | OCCLUSAL ADJUSTMENT-COMPLETE | $188 |
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*This schedule applies to services provided by a participating CAREINGTON General Dentist. The purpose of this schedule is to establish the fee that a General Dentist will charge for each procedure. Member is responsible for all charges at the time of service. Participating Specialists (Board Certified or Advanced Degree) do not charge according to a fee schedule. Participating Specialists will give up to a 20% discount off of their normal fees. Fee schedules are subject to change without prior notification to members. *Procedures not listed on this schedule will be discounted at 20% off of the General Dentist's normal fee. *If the General Dentist's normal fee for any procedure is less than the fee listed on this schedule, the dentist will charge 20% off of their normal fee for that procedure. *Any procedure involving lab fees will incur additional costs. All applicable lab fees are the responsibility of the member and are subject to no discount. *While all participating CAREINGTON providers are professionally licensed in the state in which they practice, CAREINGTON does not guarantee the quality of service of the providers. Any quality of care concerns involving any participating CAREINGTON provider should be directed in writing to: CAREINGTON International, Attn. Provider Relations, PO Box 2568, Frisco, Texas 75034. |
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