ADA CODE

DIAGNOSTIC AND PREVENTIVE SERVICES

MEMBER PAYS

0120

PERIODIC ORAL EVALUATION

$23

0140

LIMITED ORAL EVALUATION-PROBLEM FOCUS

$34

0150

COMPREHENSIVE ORAL EVALUATION-NEW OR ESTABLISHED PATIENT

$38

0210

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

$66

0220

X-RAYS-INTRAORAL-PERIAPICAL-1ST FILM

$12

0230

X-RAYS-INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM

$9

0270

BITEWING X-RAY-SINGLE FILM

$12

0272

BITEWINGS-TWO FILMS

$20

0273

BITEWINGS-THREE FILMS

$24

0274

BITEWINGS-FOUR FILMS

$28

0330

PANORAMIC FILM

$58

1110

PROPHYLAXIS-ADULT CLEANING

$46

1120

PROPHYLAXIS-CHILD CLEANING

$32

1201

TOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHYLAXIS)-CHILD

$46

1351

SEALANT-PER TOOTH

$26

1510

SPACE MAINTAINER-FIXED-UNILATERAL

$168

1515

SPACE MAINTAINER-FIXED-BILATERAL

$240

1520

SPACE MAINTAINER-REMOVEABLE-UNILATERAL

$201

1525

SPACE MAINTAINER-REMOVEABLE-BILATERAL

$250

RESTORATIVE

2140

AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT

$61

2150

AMALGAM-TWO SURFACES, PRIMARY OR PERMANENT

$81

2160

AMALGAM-THREE SURFACES, PRIMARY OR PERMANENT

$95

2161

AMALGAM-FOUR OR MORE SURFACES, PRIMARY OR PERMANENT

$101

2330

RESIN-BASED COMPOSITE-ONE SURFACE, ANTERIOR

$75

2331

RESIN-BASED COMPOSITE-TWO SURFACES, ANTERIOR

$96

2332

RESIN-BASED COMPOSITE-THREE SURFACES, ANTERIOR

$120

2335

RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, ANTERIOR

$147

2391

RESIN-BASED COMPOSITE-ONE SURFACE, POSTERIOR

$86

2392

RESIN-BASED COMPOSITE-TWO SURFACES, POSTERIOR

$116

2393

RESIN-BASED COMPOSITE-THREE SURFACES, POSTERIOR

$149

2394

RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, POSTERIOR

$179

2750

CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL

$629

2751

CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

$562

2752

CROWN-PORCELAIN FUSED TO NOBLE METAL

$590

2790

CROWN-FULL CAST HIGH NOBLE METAL

$608

2791

CROWN-FULL CAST PREDOMINANTLY BASE METAL

$532

2930

PREFABRICATED STAINLESS STEEL CROWN-PRIMARY

$143

2931

PREFABRICATED STAINLESS STEEL CROWN-PERMANENT

$164

2950

CORE BUILDUP-INCLUDING ANY PINS

$144

2951

PIN RETENTION PER TOOTH IN ADDITION TO RESTORATION

$31

2952

CAST POST AND CORE IN ADDITION TO CROWN

$225

2954

PREFABRICATED POST AND CORE IN ADDITION TO CROWN

$177

ENDODONTICS

3110

PULP CAP DIRECT (EXCLUDING FINAL RESTORATION)

$39

3120

PULP CAP INDIRECT (EXCLUDING FINAL RESTORATION)

$34

3220

THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION)

$92

3310

ROOT CANAL-ANTERIOR (EXCLUDING FINAL RESTORATION)

$354

3320

ROOT CANAL-BICUSPID (EXCLUDING FINAL RESTORATION)

$431

3330

ROOT CANAL-MOLAR (EXCLUDING FINAL RESTORATION)

$542

PERIODONTICS

4210

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

$343

4341

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

$131

4910

PERIODONTAL MAINTENANCE (FOLLOWING ACTIVE THERAPY)

$71

PROSTHODONTICS (REMOVABLE)

5110

COMPLETE DENTURE-MAXILLARY

$810

5120

COMPLETE DENTURE-MANDIBULAR

$810

5130

IMMEDIATE DENTURE-MAXILLARY

$858

5140

IMMEDIATE DENTURE-MANDIBULAR

$858

5211

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

$607

5212

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

$607

5213

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

$874

5214

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

$874

5410

ADJUST COMPLETE DENTURE-MAXILLARY

$45

5411

ADJUST COMPLETE DENTURE-MANDIBULAR

$45

5510

REPAIR BROKEN COMPLETE DENTURE BASE

$97

5520

REPLACE MISSING OR BROKEN TEETH

$87

5630

REPAIR OR REPLACE BROKEN CLASP

$131

5650

ADD TOOTH TO EXISTING PARTIAL DENTURE

$110

5660

ADD CLASP TO EXISTING PARTIAL DENTURE

$145

5730

RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE)

$199

5731

RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE)

$186

5740

RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE)

$178

5741

RELINE MANDIBULAR PARTIAL DENT (CHAIRSIDE)

$178

5750

RELINE COMPLETE MAXILLARY DENTURE (LAB)

$253

5751

RELINE COMPLETE MANDIBULAR DENTURE (LAB)

$253

PROSTHODONTICS (FIXED)

6240

PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL

$607

6241

PONTIC-PORCELAIN FUSED TO PREDOM BASE METAL

$565

6242

PONTIC-PORCELAIN FUSED TO NOBLE METAL

$583

6750

CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL

$628

6751

CROWN-PORCELAIN FUSED TO PREDOM BASE METAL

$566

6752

CROWN-PORCELAIN FUSED TO NOBLE METAL

$586

ORAL SURGERY

7140

EXTRACTION,ERUPTED TOOTH OR EXPOSED ROOT

$75

7220

REMOVAL OF IMPACTED TOOTH-SOFT TISSUE

$164

7230

REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY

$211

7240

REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY

$261

7250

SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS

$156

7310

ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTION PER QUAD

$149

7320

ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTION PER QUAD

$198

7510

INCISION/DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE

$100

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

MISCELLANEOUS SERVICES

9110

PALLIATIVE TREATMENT DENTAL PAIN-MINOR PROCEDURE

$56

9215

LOCAL ANESTHESIA

$26

9230

ANALGESIA

$35

9951

OCCLUSAL ADJUSTMENT LIMITED

$83

9952

OCCLUSAL ADJUSTMENT COMPLETE

$340

Notes:

*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.

*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.

*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.

*Procedures not listed on this schedule will be discounted at 20% off of the General Dentist's normal fee.

*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.

*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.

*Work in progress prior to joining the dental plan must be completed by the dentist who started the work and is subject to no discount.

*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.

*Any procedure involving lab fees will incur additional costs. All applicable lab fees are the responsibility of the member.

*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.