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Plan 501 Schedule
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ADA CODE
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DIAGNOSTIC AND PREVENTIVE SERVICES
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MEMBER PAYS
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0120
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PERIODIC ORAL EVALUATION
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$13.00
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0140
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LIMITED ORAL EVALUATION-PROBLEM
FOCUS
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$15.00
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0150
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COMPREHENSIVE ORAL
EVALUATION-NEW OR ESTABLISHED PATIENT
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$15.00
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0210
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X-RAYS-INTRAORAL-COMPLETE
SERIES (INCLUDING BITEWINGS)
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$38.00
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0220
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X-RAYS-INTRAORAL-PERIAPICAL-1ST
FILM
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$9.00
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0230
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X-RAYS-INTRAORAL-PERIAPICAL-EACH
ADDITIONAL FILM
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$4.00
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0270
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BITEWING X-RAY-SINGLE
FILM
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$9.00
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0272
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BITEWINGS-TWO FILMS
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$12.00
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0273
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BITEWINGS-THREE FILMS
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$16.00
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0274
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BITEWINGS-FOUR FILMS
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$19.00
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0330
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PANORAMIC FILM
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$38.00
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1110
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PROPHYLAXIS-ADULT CLEANING
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$27.00
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1120
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PROPHYLAXIS-CHILD CLEANING
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$20.00
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1201
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TOPICAL APPLICATION
OF FLUORIDE (INCLUDING PROPHYLAXIS)-CHILD
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$25.00
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1351
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SEALANT-PER TOOTH
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$19.00
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1510
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SPACE MAINTAINER-FIXED-UNILATERAL
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$82.00
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1515
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SPACE MAINTAINER-FIXED-BILATERAL
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$120.00
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1520
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SPACE MAINTAINER-REMOVEABLE-UNILATERAL
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$107.00
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1525
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SPACE MAINTAINER-REMOVEABLE-BILATERAL
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$135.00
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RESTORATIVE
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2140
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AMALGAM-ONE SURFACE,
PRIMARY OR PERMANENT
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$38.00
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2150
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AMALGAM-TWO SURFACES,
PRIMARY OR PERMANENT
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$48.00
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2160
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AMALGAM-THREE SURFACES,
PRIMARY OR PERMANENT
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$57.00
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2161
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AMALGAM-FOUR OR MORE
SURFACES, PRIMARY OR PERMANENT
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$69.00
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2330
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RESIN-BASED COMPOSITE-ONE
SURFACE, ANTERIOR
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$48.00
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2331
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RESIN-BASED COMPOSITE-TWO
SURFACES, ANTERIOR
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$58.00
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2332
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RESIN-BASED COMPOSITE-THREE
SURFACES, ANTERIOR
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$73.00
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2335
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RESIN-BASED COMPOSITE-FOUR
OR MORE SURFACES, ANTERIOR
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$92.00
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2391
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RESIN-BASED COMPOSITE-ONE
SURFACE, POSTERIOR
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$60.00
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2392
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RESIN-BASED COMPOSITE-TWO
SURFACES, POSTERIOR
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$89.00
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2393
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RESIN-BASED COMPOSITE-THREE
SURFACES, POSTERIOR
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$112.00
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2394
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RESIN-BASED COMPOSITE-FOUR
OR MORE SURFACES, POSTERIOR
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$130.00
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2750
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CROWN-PORCELAIN FUSED
TO HIGH NOBLE METAL
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$446.00
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2751
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CROWN-PORCELAIN FUSED
TO PREDOMINANTLY BASE METAL
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$404.00
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2752
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CROWN-PORCELAIN FUSED
TO NOBLE METAL
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$422.00
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2790
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CROWN-FULL CAST HIGH
NOBLE METAL
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$439.00
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2791
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CROWN-FULL CAST PREDOMINANTLY
BASE METAL
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$393.00
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2930
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PREFABRICATED STAINLESS
STEEL CROWN-PRIMARY
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$88.00
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2931
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PREFABRICATED STAINLESS
STEEL CROWN-PERMANENT
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$100.00
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2950
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CORE BUILDUP-INCLUDING
ANY PINS
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$88.00
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2951
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PIN RETENTION PER TOOTH
IN ADDITION TO RESTORATION
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$22.00
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2952
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CAST POST AND CORE
IN ADDITION TO CROWN
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$138.00
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2954
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PREFABRICATED POST
AND CORE IN ADDITION TO CROWN
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$108.00
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ENDODONTICS
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3110
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PULP CAP DIRECT (EXCLUDING
FINAL RESTORATION)
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$20.00
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3120
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PULP CAP INDIRECT (EXCLUDING
FINAL RESTORATION)
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$20.00
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3220
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THERAPEUTIC PULPOTOMY
(EXCLUDING FINAL RESTORATION)
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$48.00
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3310
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ROOT CANAL-ANTERIOR
(EXCLUDING FINAL RESTORATION)
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$257.00
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3320
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ROOT CANAL-BICUSPID
(EXCLUDING FINAL RESTORATION)
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$304.00
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3330
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ROOT CANAL-MOLAR (EXCLUDING
FINAL RESTORATION)
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$383.00
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PERIODONTICS
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4210
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GINGIVECTOMY OR GINGIVOPLASTY-FOUR
OR MORE CONTIGUOUS TEETH OR BONDED TEETH SPACES PER QUADRANT
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$256.00
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4341
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PERIODONTAL SCALING
AND ROOT PLANING-FOUR OR MORE CONTIGUOUS TEETH OR BONDED TEETH SPACES
PER QUADRANT
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$89.00
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4910
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PERIODONTAL MAINTENANCE
(FOLLOWING ACTIVE THERAPY)
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$57.00
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PROSTHODONTICS (REMOVABLE)
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5110
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COMPLETE DENTURE-MAXILLARY
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$561.00
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5120
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COMPLETE DENTURE-MANDIBULAR
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$561.00
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5130
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IMMEDIATE DENTURE-MAXILLARY
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$584.00
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5140
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IMMEDIATE DENTURE-MANDIBULAR
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$584.00
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5211
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MAXILLARY PARTIAL DENTURE-RESIN
BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)
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$550.00
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5212
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MANDIBULAR PARTIAL
DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)
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$550.00
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5213
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MAXILLARY PARTIAL DENTURE-CAST
METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL
CLASPS, RESTS OR TEETH)
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$637.00
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5214
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MANDIBULAR PARTIAL
DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY
CONVENTIONAL CLASPS, RESTS AND TEETH)
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$637.00
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5410
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ADJUST COMPLETE DENTURE-MAXILLARY
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$32.00
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5411
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ADJUST COMPLETE DENTURE-MANDIBULAR
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$32.00
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5510
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REPAIR BROKEN COMPLETE
DENTURE BASE
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$50.00
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5520
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REPLACE MISSING OR
BROKEN TEETH
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$48.00
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5630
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REPAIR OR REPLACE BROKEN
CLASP
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$58.00
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5650
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ADD TOOTH TO EXISTING
PARTIAL DENTURE
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$50.00
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5660
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ADD CLASP TO EXISTING
PARTIAL DENTURE
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$64.00
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5730
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RELINE COMPLETE MAXILLARY
DENTURE (CHAIRSIDE)
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$119.00
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5731
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RELINE COMPLETE MANDIBULAR
DENTURE (CHAIRSIDE)
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$119.00
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5740
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RELINE MAXILLARY PARTIAL
DENTURE (CHAIRSIDE)
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$113.00
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5741
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RELINE MANDIBULAR PARTIAL
DENT (CHAIRSIDE)
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$113.00
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5750
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RELINE COMPLETE MAXILLARY
DENTURE (LAB)
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$156.00
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5751
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RELINE COMPLETE MANDIBULAR
DENTURE (LAB)
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$156.00
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PROSTHODONTICS (FIXED)
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6240
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PONTIC-PORCELAIN FUSED
TO HIGH NOBLE METAL
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$388.00
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6241
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PONTIC-PORCELAIN FUSED
TO PREDOM BASE METAL
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$358.00
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6242
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PONTIC-PORCELAIN FUSED
TO NOBLE METAL
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$374.00
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6750
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CROWN-PORCELAIN FUSED
TO HIGH NOBLE METAL
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$427.00
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6751
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CROWN-PORCELAIN FUSED
TO PREDOM BASE METAL
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$385.00
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6752
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CROWN-PORCELAIN FUSED
TO NOBLE METAL
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$400.00
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ORAL SURGERY
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7140
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EXTRACTION,ERUPTED
TOOTH OR EXPOSED ROOT
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$48.00
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7220
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REMOVAL OF IMPACTED
TOOTH-SOFT TISSUE
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$98.00
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7230
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REMOVAL OF IMPACTED
TOOTH-PARTIALLY BONY
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$128.00
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7240
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REMOVAL OF IMPACTED
TOOTH-COMPLETELY BONY
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$185.00
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7250
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SURGICAL REMOVAL OF
RESIDUAL TOOTH ROOTS
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$98.00
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7310
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ALVEOLOPLASTY IN CONJUNCTION
WITH EXTRACTION PER QUAD
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$82.00
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7320
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ALVEOLOPLASTY NOT IN
CONJUNCTION WITH EXTRACTION PER QUAD
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$118.00
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7510
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INCISION/DRAINAGE OF
ABSCESS-INTRAORAL SOFT TISSUE
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$60.00
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ORTHODONTICS
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8070
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COMPLETE ORTHODONTIC
TREATMENT-TRANSITIONAL DENTITION
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20% Discount
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8080
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COMPLETE ORTHODONTIC
TREATMENT-ADOLESCENT DENTITION
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20% Discount
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8090
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COMPLETE ORHTODONTIC
TREATMENT-ADULT DENTITION
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20% Discount
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MISCELLANEOUS SERVICES
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9110
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PALLIATIVE TREATMENT
DENTAL PAIN-MINOR PROCEDURE
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$32.00
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9215
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LOCAL ANESTHESIA
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$11.00
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9230
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ANALGESIA
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$23.00
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9951
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OCCLUSAL ADJUSTMENT
LIMITED
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$44.00
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9952
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OCCLUSAL ADJUSTMENT
COMPLETE
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$177.00
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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 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.
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