Careington - Plan 501 Schedule

ADA
CODE

DIAGNOSTIC (Exams, X-Rays)

MEMBER
PAYS

0120

PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT

$15

0140

LIMITED ORAL EVALUATION - PROBLEM FOCUS

$19

0150

COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED PATIENT

$19

0210

X - RAYS - INTRAORAL - COMPLETE SERIES (INCLUDING BITEWINGS)

$43

0220

X - RAYS - INTRAORAL - PERIAPICAL - 1ST FILM

$11

0230

X - RAYS - INTRAORAL - PERIAPICAL - EACH ADDITIONAL FILM

$6

0270

BITEWING - SINGLE FILM

$11

0272

BITEWINGS - TWO FILMS

$14

0273

BITEWINGS - THREE FILMS

$18

0274

BITEWINGS - FOUR FILMS

$22

0330

PANORAMIC FILM

$43

PREVENTIVE (Cleanings, etc.)

1110

PROPHYLAXIS - ADULT CLEANING

$31

1120

PROPHYLAXIS - CHILD CLEANING

$23

1351

SEALANT - PER TOOTH

$22

1510

SPACE MAINTAINER - FIXED - UNILATERAL

$94

1515

SPACE MAINTAINER - FIXED - BILATERAL

$137

1520

SPACE MAINTAINER - REMOVEABLE - UNILATERAL

$122

1525

SPACE MAINTAINER - REMOVEABLE - BILATERAL

$154

RESTORATIVE (Fillings)

2140

AMALGAM - ONE SURFACE, PRIMARY OR PERMANENT

$43

2150

AMALGAM - TWO SURFACES, PRIMARY OR PERMANENT

$55

2160

AMALGAM - THREE SURFACES, PRIMARY OR PERMANENT

$65

2161

AMALGAM - FOUR OR MORE SURFACES, PRIMARY OR PERMANENT

$79

2330

RESIN - BASED COMPOSITE - ONE SURFACE, ANTERIOR

$55

2331

RESIN - BASED COMPOSITE - TWO SURFACES, ANTERIOR

$66

2332

RESIN - BASED COMPOSITE - THREE SURFACES, ANTERIOR

$83

2335

RESIN - BASED COMPOSITE - FOUR OR MORE SURFACES, ANTERIOR

$106

2391

RESIN - BASED COMPOSITE - ONE SURFACE, POSTERIOR

$69

2392

RESIN - BASED COMPOSITE - TWO SURFACES, POSTERIOR

$102

2393

RESIN - BASED COMPOSITE - THREE SURFACES, POSTERIOR

$129

2394

RESIN - BASED COMPOSITE - FOUR OR MORE SURFACES, POSTERIOR

$149

RESTORATIVE (Crowns)

2710

CROWN - RESIN-BASED COMPOSITE (INDIRECT)

$206

2720

CROWN- RESIN WITH HIGH NOBLE METAL

$435

2750

CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL

$511

2751

CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

$462

2752

CROWN - PORCELAIN FUSED TO NOBLE METAL

$483

2790

CROWN - FULL CAST HIGH NOBLE METAL

$502

2791

CROWN - FULL CAST PREDOMINANTLY BASE METAL

$450

2930

PREFABRICATED STAINLESS STEEL CROWN - PRIMARY

$100

2931

PREFABRICATED STAINLESS STEEL CROWN - PERMANENT

$114

2950

CORE BUILDUP - INCLUDING ANY PINS

$100

2951

PIN RETENTION PER TOOTH IN ADDITION TO RESTORATION

$25

2952

POST AND CORE IN ADDITION TO CROWN, INDIRECTLY FABRICATED

$158

2954

PREFABRICATED POST AND CORE IN ADDITION TO CROWN

$123

ENDODONTICS (Root Canals, etc.)

3110

PULP CAP DIRECT (EXCLUDING FINAL RESTORATION)

$23

3120

PULP CAP INDIRECT (EXCLUDING FINAL RESTORATION)

$23

3220

THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION)

$55

3310

ROOT CANAL - ANTERIOR (EXCLUDING FINAL RESTORATION)

$294

3320

ROOT CANAL - BICUSPID (EXCLUDING FINAL RESTORATION)

$348

3330

ROOT CANAL - MOLAR (EXCLUDING FINAL RESTORATION)

$438

PERIODONTICS (Scaling / Deep Cleaning / Root Planing, etc.)

4210

GINGIVECTOMY OR GINGIVOPLASTY - FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUADRANT

$293

4341

PERIODONTAL SCALING AND ROOT PLANING - FOUR OR MORE TEETH PER QUADRANT

$102

4910

PERIODONTAL MAINTENANCE

$65

PROSTHODONTICS - REMOVABLE (Dentures, Partials, etc.)

5110

COMPLETE DENTURE - MAXILLARY

$643

5120

COMPLETE DENTURE - MANDIBULAR

$643

5130

IMMEDIATE DENTURE - MAXILLARY

$669

5140

IMMEDIATE DENTURE - MANDIBULAR

$669

5211

MAXILLARY PARTIAL DENTURE - RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)

$630

5212

MANDIBULAR PARTIAL DENTURE - RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)

$630

5213

MAXILLARY PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)

$729

5214

MANDIBULAR PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)

$729

5410

ADJUST COMPLETE DENTURE - MAXILLARY

$37

5411

ADJUST COMPLETE DENTURE - MANDIBULAR

$37

5510

REPAIR BROKEN COMPLETE DENTURE BASE

$57

5520

REPLACE MISSING OR BROKEN TEETH

$55

5630

REPAIR OR REPLACE BROKEN CLASP

$66

5650

ADD TOOTH TO EXISTING PARTIAL DENTURE

$57

5660

ADD CLASP TO EXISTING PARTIAL DENTURE

$73

5730

RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE)

$136

5731

RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE)

$136

5740

RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE)

$130

5741

RELINE MANDIBULAR PARTIAL DENT (CHAIRSIDE)

$130

5750

RELINE COMPLETE MAXILLARY DENTURE (LAB)

$178

5751

RELINE COMPLETE MANDIBULAR DENTURE (LAB)

$178

PROSTHODONTICS - FIXED (Bridges, Implants, etc.)

6040

SURGICAL PLACEMENT: EPOSTEAL IMPLANT

20% Discount

6050

SURGICAL PLACEMENT: TRANSOSTEAL IMPLANT

20% Discount

6065

IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWN

20% Discount

6066

IMPLANT SUPPORTED PORCELAIN FUSED TO METAL CROWN (TITANIUM, TITANIUM ALLOY, HIGH NOBLE METAL)

20% Discount

6067

IMPLANT SUPPORTED METAL CROWN (TITANIUM, TITANIUM ALLOY, HIGH NOBLE METAL)

20% Discount

6240

PONTIC - PORCELAIN FUSED TO HIGH NOBLE METAL

$444

6241

PONTIC - PORCELAIN FUSED TO PREDOM BASE METAL

$409

6242

PONTIC - PORCELAIN FUSED TO NOBLE METAL

$427

6750

CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL

$489

6751

CROWN - PORCELAIN FUSED TO PREDOM BASE METAL

$441

6752

CROWN - PORCELAIN FUSED TO NOBLE METAL

$458

ORAL SURGERY (Tooth Extractions, etc.)

7140

EXTRACTION,ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPTS

$55

7210

SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING ELEVATION OF MUCOPERIOSTEAL

$140

7220

REMOVAL OF IMPACTED TOOTH - SOFT TISSUE

$112

7230

REMOVAL OF IMPACTED TOOTH - PARTIALLY BONY

$147

7240

REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY

$212

7250

SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS

$112

7310

ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTION PER QUAD

$94

7320

ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTION PER QUAD

$135

7510

INCISION/DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE

$69

ORTHODONTICS (Braces - Children and Adults, etc.)

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 (Anesthesia, Analgesia, etc.)

9110

PALLIATIVE TREATMENT DENTAL PAIN - MINOR PROCEDURE

$37

9215

LOCAL ANESTHESIA

$13

9230

ANALGESIA

$26

9951

OCCLUSAL ADJUSTMENT LIMITED

$51

9952

OCCLUSAL ADJUSTMENT COMPLETE

$203

*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 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 full 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. Please call 800-372-7615 if you have any further questions.