| Please Call 800-290-0523 | ||||||
| for Member Verification | ||||||
| ADA CODE | DIAGNOSTIC AND PREVENTIVE SERVICES | MEMBER PAYS | ADA CODE | PROSTHODONTICS | MEMBER PAYS | |
| 0120 | PERIODIC ORAL EVALUATION | $13.00 | 5410 | ADJUST COMPLETE DENTURE-MAXILLARY | $30.00 | |
| 0140 | LIMITED ORAL EVALUATION-PROBLEM FOCUS | $16.00 | 5411 | ADJUST COMPLETE DENTURE-MANDIBULAR | $30.00 | |
| 0150 | COMPREHENSIVE ORAL EVALUATION | $16.00 | 5510 | REPAIR BROKEN COMPLETE DENTURE BASE | $52.00 | |
| 0210 | X-RAYS-INTRAORAL-COMPLETE SERIES (INCLUDING BITEWINGS) | $39.00 | 5520 | REPLACE MISSING OR BROKEN TEETH | $49.00 | |
| 0220 | X-RAYS-INTRAORAL-PERIAPICAL-1ST FILM | $9.00 | 5630 | REPAIR OR REPLACE BROKEN CLASP | $60.00 | |
| 0230 | X-RAYS-INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM | $5.00 | 5650 | ADD TOOTH TO EXISTING PARTIAL DENTURE | $52.00 | |
| 0270 | BITEWING X-RAY-SINGLE FILM | $9.00 | 5660 | ADD CLASP TO EXISTING PARTIAL DENTURE | $67.00 | |
| 0272 | BITEWINGS-TWO FILMS | $12.00 | 5730 | RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) | $123.00 | |
| 0274 | BITEWINGS-FOUR FILMS | $20.00 | 5731 | RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) | $123.00 | |
| 0330 | PANORAMIC FILM | $39.00 | 5740 | RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) | $117.00 | |
| 1110 | PROPHY-ADULT CLEANING | $29.00 | 5741 | RELINE MANDIBULAR PARTIAL DENT (CHAIRSIDE) | $117.00 | |
| 1120 | PROPHY-CHILD CLEANING | $21.00 | 5750 | RELINE COMPLETE MAXILLARY DENTURE (LAB) | $161.00 | |
| 1201 | TOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHY)-CHILD | $29.00 | 5761 | RELINE COMPLETE MANDIBULAR DENTURE (LAB) | $161.00 | |
| 1351 | SEALANT-PER TOOTH | $20.00 | FIXED PROSTHETICS | |||
| 1510 | SPACE MAINTAINER-FIXED-UNILATERAL | $84.00 | 6240 | PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL | $399.00 | |
| 1515 | SPACE MAINTAINER-FIXED-BILATERAL | $124.00 | 6241 | PONTIC-PORCELAIN FUSED TO PREDOM BASE METAL | $371.00 | |
| 1520 | SPACE MAINTAINER-REMOVEABLE-UNILATERAL | $110.00 | 6242 | PONTIC-PORCELAIN FUSED TO NOBLE METAL | $388.00 | |
| 1525 | SPACE MAINTAINER-REMOVEABLE-BILATERAL | $140.00 | 6750 | CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL | $443.00 | |
| RESTORATIVE (FILLINGS) | 6751 | CROWN-PORCELAIN FUSED TO PREDOM BASE METAL | $399.00 | |||
| 2110 | AMALGAM-ONE SURFACE PRIMARY | $33.00 | 6752 | CROWN-PORCELAIN FUSED TO NOBLE METAL | $414.00 | |
| 2120 | AMALGAM-TWO SURFACES PRIMARY | $44.00 | ORAL SURGERY | |||
| 2130 | AMALGAM-THREE SURFACES PRIMARY | $53.00 | 7110 | SINGLE TOOTH EXTRACTION | $49.00 | |
| 2131 | AMALGAM-FOUR OR MORE SURFACES PRIMARY | $62.00 | 7120 | EACH ADDITIONAL TOOTH | $47.00 | |
| 2140 | AMALGAM-ONE SURFACE PERMANENT | $39.00 | 7130 | ROOT REMOVAL-EXPOSED ROOTS | $61.00 | |
| 2150 | AMALGAM-TWO SURFACES PERMANENT | $49.00 | 7220 | REMOVAL OF IMPACTED TOOTH-SOFT TISSUE | $101.00 | |
| 2160 | AMALGAM-THREE SURFACES PERMANENT | $59.00 | 7230 | REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY | $132.00 | |
| 2161 | AMALGAM-FOUR OR MORE SURFACES PERMANENT | $71.00 | 7240 | REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY | $185.00 | |
| 2330 | RESIN-ONE SURFACE ANTERIOR | $49.00 | 7250 | SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS | $102.00 | |
| 2331 | RESIN-TWO SURFACES ANTERIOR | $60.00 | 7310 | ALVEOLOPLASTY IN CONJUNCT W/ EXTRACTIONS/QUAD | $84.00 | |
| 2332 | RESIN-THREE SURFACES ANTERIOR | $76.00 | 7320 | ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTION PER QUAD | $122.00 | |
| 2335 | RESIN-FOUR OR MORE SURFACES | $94.00 | 7510 | INCISION/DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE | $62.00 | |
| 2385 | RESIN-ONE SURFACE POSTERIOR PERMANENT | $65.00 | ORTHODONTICS | |||
| 2386 | RESIN-TWO SURFACES POSTERIOR PERMANENT | $95.00 | 8070 | COMPLETE ORTHODONTIC TREATMENT-TRANSITIONAL DENTITION | 20% Discount | |
| 2387 | RESIN-THREE OR MORE SURFACES POSTERIOR PERMANENT | $117.00 | 8080 | COMPLETE ORTHODONTIC TREATMENT-ADOLESCENT DENTITION | 20% Discount | |
| CROWNS | 8090 | COMPLETE ORHTODONTIC TREATMENT-ADULT DENTITION | 20% Discount | |||
| 2750 | CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL | $463.00 | MISCELLANEOUS SERVICES | |||
| 2751 | CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL | $420.00 | 9110 | PALLIATIVE TREATMENT DENTAL PAIN-MINOR PROCEDURE | $32.00 | |
| 2752 | CROWN-PORCELAIN FUSED TO NOBLE METAL | $437.00 | 9215 | LOCAL ANESTHESIA | $12.00 | |
| 2790 | CROWN-FULL CAST HIGH NOBLE METAL | $456.00 | 9230 | ANALGESIA | $22.00 | |
| 2791 | CROWN-FULL CAST PREDOMINANTLY BASE METAL | $425.00 | 9951 | OCCLUSAL ADJUSTMENT LIMITED | $46.00 | |
| 2930 | PREFABRICATED STAINLESS STEEL CROWN-PRIMARY | $91.00 | 9952 | OCCLUSAL ADJUSTMENT COMPLETE | $183.00 | |
| 2931 | PREFABRICATED STAINLESS STEEL CROWN-PERMANENT | $104.00 | *This schedule applies to services provided by a participating CAREINGTON General Dentist. The purpose of this schedule is to establish the maximum 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. | |||
| 2950 | CORE BUILDUP-INCLUDING ANY PINS | $91.00 | ||||
| 2951 | PIN RETENTION PER TOOTH IN ADDITION TO RESTORATION | $22.00 | ||||
| 2952 | CAST POST AND CORE IN ADDITION TO CROWN | $143.00 | ||||
| 2954 | PREFABRICATED POST AND CORE IN ADDITION TO CROWN | $112.00 | *It is the Member’s responsibility to verify that the dentist is a participating Provider before seeking any treatment. Any dental procedures performed by a non-participating dentist are not discounted and are charged at the dentist's normal fees. | |||
| 3110 | PULP CAP DIRECT (EXCLUDING FINAL RESTORATION) | $20.00 | ||||
| 3120 | PULP CAP INDIRECT (EXCLUDING FINAL RESTORATION) | $20.00 | *The dollar amount specified adjacent to each procedure may not be the only cost incurred for a given treatment - many treatments may require more than one dental procedure. Please consult your CAREINGTON provider for a detailed treatment plan prior to beginning any work. | |||
| 3220 | THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) | $49.00 | ||||
| 3310 | ROOT CANAL-ANTERIOR (EXCLUDING FINAL RESTORATION) | $267.00 | ||||
| 3320 | ROOT CANAL-BICUSPID (EXCLUDING FINAL RESTORATION) | $316.00 | *Procedures not listed on this schedule will be discounted at 20% off of the General Dentist's normal fee. | |||
| 3330 | ROOT CANAL-MOLAR (EXCLUDING FINAL RESTORATION) | $397.00 | *Implants and some whitening procedures will not be discounted by all participating CAREINGTON providers. Implants and some whitening procedures will only be discounted if the participating CAREINGTON provider has agreed to discount these procedures as part of their contract. These services will be offered, when applicable, at a 15% discount off of the provider's normal fee. Please call 800-290-0523 for assistance. | |||
| PERIODONTICS | ||||||
| 4210 | GINGIVECTOMY OR GINGIVOPLASTY PER QUADRANT | $271.00 | ||||
| 4341 | PERIODONTAL SCALING AND ROOT PLANING PER QUADRANT | $90.00 | ||||
| 4910 | PERIODONTAL MAINTENANCE (FOLLOWING ACTIVE THERAPY) | $55.00 | *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. | |||
| PROSTHODONTICS | ||||||
| 5110 | COMPLETE DENTURE-MAXILLARY | $582.00 | *Work in progress prior to enrollment on the dental plan must be completed by the dentist who started the work and is subject to no discount. | |||
| 5120 | COMPLETE DENTURE-MANDIBULAR | $582.00 | ||||
| 5130 | IMMEDIATE DENTURE-MAXILLARY | $606.00 | *CAREINGTON can not guarantee the continued participation of any dentist. If the dentist leaves the plan, you will need to select another participating CAREINGTON provider. Not all types of dentists may be available in your area. | |||
| 5140 | IMMEDIATE DENTURE-MANDIBULAR | $606.00 | ||||
| 5211 | MAXILLARY PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) | $530.00 | *Any procedure involving lab fees will incur additional costs. All applicable lab fees are the responsibility of the member. | |||
| 5212 | MANDIBULAR PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) | $530.00 | *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. Please call 800-290-0523 if you have any further questions. | |||
| 5213 | MAXILLARY PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS OR TEETH) | $660.00 | ||||
| 5214 | MANDIBULAR PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS, AND TEETH) | $660.00 | ||||