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ADA CODE DIAGNOSTIC AND PREVENTIVE SERVICES MEMBER PAYS ADA CODE PROSTHODONTICS MEMBER PAYS
0120 PERIODIC ORAL EVALUATION $14.00 5410 ADJUST COMPLETE DENTURE-MAXILLARY $35.00
0140 LIMITED ORAL EVALUATION-PROBLEM FOCUS $16.00 5411 ADJUST COMPLETE DENTURE-MANDIBULAR $35.00
0150 COMPREHENSIVE ORAL EVALUATION $16.00 5510 REPAIR BROKEN COMPLETE DENTURE BASE $55.00
0210 X-RAYS-INTRAORAL-COMPLETE SERIES (INCLUDING BITEWINGS) $41.00 5520 REPLACE MISSING OR BROKEN TEETH $53.00
0220 X-RAYS-INTRAORAL-PERIAPICAL-1ST FILM $9.00 5630 REPAIR OR REPLACE BROKEN CLASP $63.00
0230 X-RAYS-INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM $5.00 5650 ADD TOOTH TO EXISTING PARTIAL DENTURE $55.00
0270 BITEWING X-RAY-SINGLE FILM $9.00 5660 ADD CLASP TO EXISTING PARTIAL DENTURE $70.00
0272 BITEWINGS-TWO FILMS $13.00 5730 RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) $131.00
0274 BITEWINGS-FOUR FILMS $21.00 5731 RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) $131.00
0330 PANORAMIC FILM $41.00 5740 RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) $124.00
1110 PROPHY-ADULT CLEANING $30.00 5741 RELINE MANDIBULAR PARTIAL DENT (CHAIRSIDE) $124.00
1120 PROPHY-CHILD CLEANING $25.00 5750 RELINE COMPLETE MAXILLARY DENTURE (LAB) $171.00
1201 TOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHY)-CHILD $35.00 5761 RELINE COMPLETE MANDIBULAR DENTURE (LAB) $171.00
1351 SEALANT-PER TOOTH $21.00 FIXED PROSTHETICS
1510 SPACE MAINTAINER-FIXED-UNILATERAL $90.00 6240 PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL $425.00
1515 SPACE MAINTAINER-FIXED-BILATERAL $132.00 6241 PONTIC-PORCELAIN FUSED TO PREDOM BASE METAL $393.00
1520 SPACE MAINTAINER-REMOVEABLE-UNILATERAL $117.00 6242 PONTIC-PORCELAIN FUSED TO NOBLE METAL $412.00
1525 SPACE MAINTAINER-REMOVEABLE-BILATERAL $150.00 6750 CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL $465.00
RESTORATIVE (FILLINGS) 6751 CROWN-PORCELAIN FUSED TO PREDOM BASE METAL $423.00
2110 AMALGAM-ONE SURFACE PRIMARY $36.00 6752 CROWN-PORCELAIN FUSED TO NOBLE METAL $440.00
2120 AMALGAM-TWO SURFACES PRIMARY $47.00 ORAL SURGERY
2130 AMALGAM-THREE SURFACES PRIMARY $56.00 7110 SINGLE TOOTH EXTRACTION $53.00
2131 AMALGAM-FOUR OR MORE SURFACES PRIMARY $67.00 7120 EACH ADDITIONAL TOOTH $49.00
2140 AMALGAM-ONE SURFACE PERMANENT $41.00 7130 ROOT REMOVAL-EXPOSED ROOTS $64.00
2150 AMALGAM-TWO SURFACES PERMANENT $53.00 7220 REMOVAL OF IMPACTED TOOTH-SOFT TISSUE $108.00
2160 AMALGAM-THREE SURFACES PERMANENT $62.00 7230 REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY $140.00
2161 AMALGAM-FOUR OR MORE SURFACES PERMANENT $76.00 7240 REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY $197.00
2330 RESIN-ONE SURFACE ANTERIOR $53.00 7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS $102.00
2331 RESIN-TWO SURFACES ANTERIOR $63.00 7310 ALVEOLOPLASTY IN CONJUNCT W/ EXTRACTIONS/QUAD $90.00
2332 RESIN-THREE SURFACES ANTERIOR $81.00 7320 ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTION PER QUAD $130.00
2335 RESIN-FOUR OR MORE SURFACES $101.00 7510 INCISION/DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE $67.00
2385 RESIN-ONE SURFACE POSTERIOR PERMANENT $69.00 ORTHODONTICS
2386 RESIN-TWO SURFACES POSTERIOR PERMANENT $99.00 8070 COMPLETE ORTHODONTIC TREATMENT-TRANSITIONAL DENTITION 20% Discount
2387 RESIN-THREE OR MORE SURFACES POSTERIOR PERMANENT $125.00 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 $495.00 MISCELLANEOUS SERVICES
2751 CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL $450.00 9110 PALLIATIVE TREATMENT DENTAL PAIN-MINOR PROCEDURE $35.00
2752 CROWN-PORCELAIN FUSED TO NOBLE METAL $483.00 9215 LOCAL ANESTHESIA $13.00
2790 CROWN-FULL CAST HIGH NOBLE METAL $484.00 9230 ANALGESIA $23.00
2791 CROWN-FULL CAST PREDOMINANTLY BASE METAL $450.00 9951 OCCLUSAL ADJUSTMENT LIMITED $48.00
2930 PREFABRICATED STAINLESS STEEL CROWN-PRIMARY $97.00 9952 OCCLUSAL ADJUSTMENT COMPLETE $194.00
2931 PREFABRICATED STAINLESS STEEL CROWN-PERMANENT $110.00 *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 $97.00
2951 PIN RETENTION PER TOOTH IN ADDITION TO RESTORATION $23.00
2952 CAST POST AND CORE IN ADDITION TO CROWN $152.00
2954 PREFABRICATED POST AND CORE IN ADDITION TO CROWN $118.00 *It is the Memberís 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) $22.00
3120 PULP CAP INDIRECT (EXCLUDING FINAL RESTORATION) $22.00 *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) $53.00
3310 ROOT CANAL-ANTERIOR(EXCLUDING FINAL RESTORATION) $283.00
3320 ROOT CANAL-BICUSPID (EXCLUDING FINAL RESTORATION) $336.00 *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) $421.00 *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 $282.00
4341 PERIODONTAL SCALING AND ROOT PLANING PER QUADRANT $100.00
4910 PERIODONTAL MAINTENANCE (FOLLOWING ACTIVE THERAPY) $60.00 *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 $619.00 *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 $619.00
5130 IMMEDIATE DENTURE-MAXILLARY $643.00 *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 $643.00
5211 MAXILLARY PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) $605.00 *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) $605.00 *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 Box2568, 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) $702.00
5214 MANDIBULAR PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS, AND TEETH) $702.00