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Dental Schedule
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Careington Care 500 Series Schedule - 501 | ||
---|---|---|
Diagnostic Services | Member Pays | |
D0120 | Periodic Oral Evaluation - Established Patient | $16 |
D0140 | Limited Oral Evaluation - Problem Focused | $21 |
D0150 | Comprehensive Oral Evaluation - New or Established Patient | $21 |
D0210 | Intraoral - Complete Series of Radiographic Images | $47 |
D0220 | Intraoral - Periapical First Radiographic Image | $12 |
D0230 | Intraoral - Periapical Each Additional Radiographic Image | $7 |
D0270 | Bitewing - Single Radiographic Image | $12 |
D0272 | Bitewings - Two Radiographic Images | $15 |
D0273 | Bitewings - Three Radiographic Images | $20 |
D0274 | Bitewings - Four Radiographic Images | $24 |
D0330 | Panoramic Radiographic Image | $47 |
Preventative Services | Member Pays | |
D1110 | Prophylaxis - Adult | $34 |
D1120 | Prophylaxis - Child | $25 |
D1351 | Sealant - Per Tooth | $24 |
D1510 | Space Maintainer - Fixed, Unilateral - Per Quadrant | $102 |
D1516 | Space Maintainer - Fixed - Bilateral, Maxillary | 20% Discount |
D1520 | Space Maintainer - Removable - Unilateral - Per Quadrant | $133 |
D1526 | Space Maintainer - Removable - Bilateral, Maxillary | 20% Discount |
Restorative Services | Member Pays | |
D2140 | Amalgam - One Surface, Primary or Permanent | $47 |
D2150 | Amalgam - Two Surfaces, Primary or Permanent | $60 |
D2160 | Amalgam - Three Surfaces, Primary or Permanent | $71 |
D2161 | Amalgam - Four or More Surfaces, Primary or Permanent | $86 |
D2330 | Resin - Based Composite - One Surface, Anterior | $60 |
D2331 | Resin - Based Composite - Two Surfaces, Anterior | $72 |
D2332 | Resin - Based Composite - Three Surfaces, Anterior | $90 |
D2335 | Resin - Based Composite - Four or More Surfaces or Involving Incisal Angle (Anterior) | $116 |
D2391 | Resin - Based Composite - One Surface, Posterior | $75 |
D2392 | Resin - Based Composite - Two Surfaces, Posterior | $111 |
D2393 | Resin - Based Composite - Three Surfaces, Posterior | $141 |
D2394 | Resin - Based Composite - Four or More Surfaces, Posterior | $162 |
D2710 | Crown - Resin-Based Composite (indirect) | $225 |
D2720 | Crown- Resin with High Noble Metal | $474 |
D2750 | Crown - Porcelain Fused to High Noble Metal | $557 |
D2751 | Crown - Porcelain Fused to Predominantly Base Metal | $504 |
D2752 | Crown - Porcelain Fused to Noble Metal | $526 |
D2790 | Crown - Full Cast High Noble Metal | $547 |
D2791 | Crown - Full Cast Predominantly Base Metal | $491 |
D2930 | Prefabricated Stainless Steel Crown - Primary Tooth | $109 |
D2931 | Prefabricated Stainless Steel Crown - Permanent Tooth | $124 |
D2950 | Core Buildup - Including Any Pins When Required | $109 |
D2951 | Pin Retention - Per Tooth in Addition to Restoration | $27 |
D2952 | Post and Core in Addition to Crown, Indirectly Fabricated | $172 |
D2954 | Prefabricated Post and Core in Addition to Crown | $134 |
Endodontic Services | Member Pays | |
D3110 | Pulp Cap - Direct (excluding final restoration) | $25 |
D3120 | Pulp Cap - Indirect (excluding final restoration) | $25 |
D3220 | Therapeutic Pulpotomy (excluding final restoration) - Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament | $60 |
D3310 | Endodontic Therapy, Anterior Tooth (excluding final restoration) | $320 |
D3320 | Endodontic Therapy, Premolar Tooth (excluding final restorations) | $379 |
D3330 | Endodontic Therapy - Molar Tooth (excluding final restorations) | $477 |
Periodontic Services | Member Pays | |
D4210 | Gingivectomy or Gingivoplasty - Four or More Contiguous Teeth or Tooth Bounded Spaces Per Quadrant | $319 |
D4341 | Periodontal Scaling and Root Planing - Four or More Teeth Per Quadrant | $111 |
D4910 | Periodontal Maintenance | $71 |
Prosthodontics (Removeable) Services | Member Pays | |
D5110 | Complete Denture - Maxillary | $701 |
D5120 | Complete Denture - Mandibular | $701 |
D5130 | Immediate Denture - Maxillary | $729 |
D5140 | Immediate Denture - Mandibular | $729 |
D5211 | Maxillary Partial Denture - Resin Base (including retentive/clasping materials, rests, and teeth) | $687 |
D5212 | Mandibular Partial Denture - Resin Base (including retentive/clasping materials, rests, and teeth) | $687 |
D5213 | Maxillary Partial Denture - Cast Metal Framework with Resin Denture Bases (including retentive/clasping materials, rests and teeth) | $795 |
D5214 | Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including retentive/clasping materials, rests and teeth) | $795 |
D5410 | Adjust Complete Denture - Maxillary | $40 |
D5411 | Adjust Complete Denture - Mandibular | $40 |
D5520 | Replace Missing or Broken Teeth - Complete Denture (each tooth) | $60 |
D5611 | Repair Resin Partial Denture Base, Mandibular | 20% Discount |
D5630 | Repair or Replace Broken Retentive/Clasping Materials - Per Tooth | $72 |
D5650 | Add Tooth to Existing Partial Denture | $62 |
D5660 | Add Clasp to Existing Partial Denture - Per Tooth | $80 |
D5730 | Reline Complete Maxillary Denture (direct) | $148 |
D5731 | Reline Complete Mandibular Denture (direct) | $148 |
D5740 | Reline Maxillary Partial Denture (direct) | $142 |
D5741 | Reline Mandibular Partial Denture (direct) | $142 |
D5750 | Reline Complete Maxillary Denture (indirect) | $194 |
D5751 | Reline Complete Mandibular Denture (indirect) | $194 |
Implant Services | Member Pays | |
D6000 through D6199 | 20% Discount | |
Prosthodontics (Fixed) Services | Member Pays | |
D6240 | Pontic - Porcelain Fused to High Noble Metal | $484 |
D6241 | Pontic - Porcelain Fused to Predominantly Base Metal | $446 |
D6242 | Pontic - Porcelain Fused to Noble Metal | $465 |
D6750 | Retainer Crown - Porcelain Fused to High Noble Metal | $533 |
D6751 | Retainer Crown - Porcelain Fused to Predominantly Base Metal | $481 |
D6752 | Retainer Crown - Porcelain Fused to Noble Metal | $499 |
Oral Surgery Services | Member Pays | |
D7140 | Extraction, Erupted Tooth or Exposed Root (elevation and/or forceps removal) | $60 |
D7210 | Extraction, erupted Tooth Requiring Removal of Bone and/or Sectioning of Tooth, and Including Elevation of Mucoperiosteal Flap if Indicated | $153 |
D7220 | Removal of Impacted Tooth - Soft Tissue | $122 |
D7230 | Removal of Impacted Tooth - Partially Bony | $160 |
D7240 | Removal of Impacted Tooth - Completely Bony | $231 |
D7250 | Removal of Residual Tooth Roots (cutting procedure) | $122 |
D7310 | Alveoloplasty in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per Quadrant | $102 |
D7320 | Alveoloplasty not in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per Quadrant | $147 |
D7510 | Incision and Drainage of Abscess - Intraoral Soft Tissue | $75 |
Orthodontic Services | Member Pays | |
D8010 through D8999 | 20% Discount | |
Adjunctive Services | Member Pays | |
D9110 | Palliative (emergency) Treatment of Dental Pain - Minor Procedure | $40 |
D9215 | Local Anesthesia in Conjunction With Operative or Surgical Procedures | $14 |
D9230 | Inhalation of Nitrous Oxide/Analgesia, Anxiolysis | $28 |
D9951 | Occlusal Adjustment - Limited | $56 |
D9952 | Occlusal Adjustment - Complete | $221 |
Careington Care 500 Series Schedule - 502 | ||
---|---|---|
Diagnostic Services | Member Pays | |
D0120 | Periodic Oral Evaluation - Established Patient | $17 |
D0140 | Limited Oral Evaluation - Problem Focused | $24 |
D0150 | Comprehensive Oral Evaluation - New or Established Patient | $28 |
D0210 | Intraoral - Complete Series of Radiographic Images | $55 |
D0220 | Intraoral - Periapical First Radiographic Image | $13 |
D0230 | Intraoral - Periapical Each Additional Radiographic Image | $10 |
D0270 | Bitewing - Single Radiographic Image | $13 |
D0272 | Bitewings - Two Radiographic Images | $16 |
D0273 | Bitewings - Three Radiographic Images | $23 |
D0274 | Bitewings - Four Radiographic Images | $27 |
D0330 | Panoramic Radiographic Image | $55 |
Preventive Services | Member Pays | |
D1110 | Prophylaxis - Adult | $40 |
D1120 | Prophylaxis - Child | $28 |
D1351 | Sealant - Per Tooth | $27 |
D1510 | Space Maintainer - Fixed, Unilateral - Per Quadrant | $116 |
D1516 | Space Maintainer - Fixed - Bilateral, Maxillary | 20% Discount |
D1520 | Space Maintainer - Removable - Unilateral - Per Quadrant | $149 |
D1526 | Space Maintainer - Removable - Bilateral, Maxillary | 20% Discount |
Restorative Services | Member Pays | |
D2140 | Amalgam - One Surface, Primary or Permanent | $55 |
D2150 | Amalgam - Two Surfaces, Primary or Permanent | $68 |
D2160 | Amalgam - Three Surfaces, Primary or Permanent | $82 |
D2161 | Amalgam - Four or More Surfaces, Primary or Permanent | $98 |
D2330 | Resin - Based Composite - One Surface, Anterior | $65 |
D2331 | Resin - Based Composite - Two Surfaces, Anterior | $82 |
D2332 | Resin - Based Composite - Three Surfaces, Anterior | $104 |
D2335 | Resin - Based Composite - Four Or More Surfaces or Involving Incisal Angle (anterior) | $128 |
D2391 | Resin - Based Composite - One Surface, Posterior | $88 |
D2392 | Resin - Based Composite - Two Surfaces, Posterior | $130 |
D2393 | Resin - Based Composite - Three Surfaces, Posterior | $160 |
D2394 | Resin - Based Composite - Four or More Surfaces, Posterior | $182 |
D2710 | Crown - Resin-Based Composite (indirect) | $251 |
D2720 | Crown- Resin with High Noble Metal | $532 |
D2750 | Crown - Porcelain Fused to High Noble Metal | $630 |
D2751 | Crown - Porcelain Fused to Predominantly Base Metal | $571 |
D2752 | Crown - Porcelain Fused to Noble Metal | $594 |
D2790 | Crown - Full Cast High Noble Metal | $620 |
D2791 | Crown - Full Cast Predominantly Base Metal | $578 |
D2930 | Prefabricated Stainless Steel Crown - Primary Tooth | $123 |
D2931 | Prefabricated Stainless Steel Crown - Permanent Tooth | $142 |
D2950 | Core Buildup, Including Any Pins When Required | $123 |
D2951 | Pin Retention - Per Tooth, in Addition to Restoration | $29 |
D2952 | Post and Core in Addition to Crown, Indirectly Fabricated | $194 |
D2954 | Prefabricated Post and Core in Addition to Crown | $152 |
Endodontic Services | Member Pays | |
D3110 | Pulp Cap - Direct (excluding final restoration) | $27 |
D3120 | Pulp Cap - Indirect (excluding final restoration) | $27 |
D3220 | Therapeutic Pulpotomy (excluding final restoration) - Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament | $65 |
D3310 | Endodontic Therapy, Anterior Tooth (excluding final restoration) | $363 |
D3320 | Endodontic Therapy, Premolar Tooth (excluding final restorations) | $429 |
D3330 | Endodontic Therapy, Molar Tooth (excluding final restorations) | $541 |
Periodontic Services | Member Pays | |
D4210 | Gingivectomy or Gingivoplasty - Four or More Contiguous Teeth or Tooth Bounded Spaces Per Quadrant | $368 |
D4341 | Periodontal Scaling and Root Planing - Four or More Teeth Per Quadrant | $122 |
D4910 | Periodontal Maintenance | $75 |
Prosthodontics (Removeable) Services | Member Pays | |
D5110 | Complete Denture - Maxillary | $791 |
D5120 | Complete Denture - Mandibular | $791 |
D5130 | Immediate Denture - Maxillary | $825 |
D5140 | Immediate Denture - Mandibular | $825 |
D5211 | Maxillary Partial Denture - Resin Base (including retentive/clasping materials, rests, and teeth) | $722 |
D5212 | Mandibular Partial Denture - Resin Base (including retentive/clasping materials, rests, and teeth) | $722 |
D5213 | Maxillary Partial Denture - Cast Metal Framework with Resin Denture Bases (including retentive/clasping materials, rests and teeth) | $897 |
D5214 | Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including retentive/clasping materials, rests and teeth) | $897 |
D5410 | Adjust Complete Denture - Maxillary | $41 |
D5411 | Adjust Complete Denture - Mandibular | $41 |
D5520 | Replace Missing or Broken Teeth - Complete Denture (each tooth) | $65 |
D5611 | Repair Resin Partial Denture Base, Mandibular | 20% Discount |
D5630 | Repair or Replace Broken Retentive/Clasping Materials - Per Tooth | $82 |
D5650 | Add Tooth to Existing Partial Denture | $71 |
D5660 | Add Clasp to Existing Partial Denture - Per Tooth | $90 |
D5730 | Reline Complete Maxillary Denture (direct) | $167 |
D5731 | Reline Complete Mandibular Denture (direct) | $167 |
D5740 | Reline Maxillary Partial Denture (direct) | $160 |
D5741 | Reline Mandibular Partial Denture (direct) | $160 |
D5750 | Reline Complete Maxillary Denture (indirect) | $219 |
D5751 | Reline Complete Mandibular Denture (indirect) | $219 |
Implant Services | Member Pays | |
D6000 through D6199 | 20% Discount | |
Prosthodontics (Fixed) Services | Member Pays | |
D6240 | Pontic - Porcelain Fused to High Noble Metal | $543 |
D6241 | Pontic - Porcelain Fused to Predominantly Base Metal | $504 |
D6242 | Pontic - Porcelain Fused to Noble Metal | $526 |
D6750 | Retainer Crown - Porcelain Fused to High Noble Metal | $603 |
D6751 | Retainer Crown - Porcelain Fused to Predominantly Base Metal | $543 |
D6752 | Retainer Crown - Porcelain Fused to Noble Metal | $562 |
Oral Surgery Services | Member Pays | |
D7140 | Extraction, Erupted Tooth or Exposed Root (elevation and/or forceps removal) | $65 |
D7210 | Extraction, erupted Tooth Requiring Removal of Bone and/or Sectioning of Tooth, and Including Elevation of Mucoperiosteal Flap if Indicated | $165 |
D7220 | Removal of Impacted Tooth - Soft Tissue | $137 |
D7230 | Removal of Impacted Tooth - Partially Bony | $180 |
D7240 | Removal of Impacted Tooth - Completely Bony | $252 |
D7250 | Removal of Residual Tooth Roots (cutting procedure) | $138 |
D7310 | Alveoloplasty in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per Quadrant | $116 |
D7320 | Alveoloplasty not in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per Quadrant | $166 |
D7510 | Incision and Drainage of Abscess - Intraoral Soft Tissue | $85 |
Orthodontic Services | Member Pays | |
D8010 through D8999 | 20% Discount | |
Adjunctive Services | Member Pays | |
D9110 | Palliative (emergency) Treatment of Dental Pain - Minor Procedure | $44 |
D9215 | Local Anesthesia in Conjunction With Operative or Surgical Procedures | $16 |
D9230 | Inhalation of Nitrous Oxide/Analgesia, Anxiolysis | $29 |
D9951 | Occlusal Adjustment - Limited | $62 |
D9952 | Occlusal Adjustment - Complete | $249 |
Careington Care 500 Series Schedule - 503 | ||
---|---|---|
Diagnostic Services | Member Pays | |
D0120 | Periodic Oral Evaluation - Established Patient | $19 |
D0140 | Limited Oral Evaluation - Problem Focused | $21 |
D0150 | Comprehensive Oral Evaluation - New or Established Patient | $24 |
D0210 | Intraoral - Complete Series of Radiographic Images | $57 |
D0220 | Intraoral - Periapical First Radiographic Image | $13 |
D0230 | Intraoral - Periapical Each Additional Radiographic Image | $9 |
D0270 | Bitewing - Single Radiographic Image | $13 |
D0272 | Bitewings - Two Radiographic Images | $17 |
D0273 | Bitewings - Three Radiographic Images | $24 |
D0274 | Bitewings - Four Radiographic Images | $28 |
D0330 | Panoramic Radiographic Image | $57 |
Preventative Services | Member Pays | |
D1110 | Prophylaxis - Adult | $41 |
D1120 | Prophylaxis - Child | $34 |
D1351 | Sealant - Per Tooth | $28 |
D1510 | Space Maintainer - Fixed - Unilateral - Per Quadrant | $122 |
D1516 | Space Maintainer - Fixed - Bilateral, Maxillary | 20% Discount |
D1520 | Space Maintainer - Removable - Unilateral - Per Quadrant | $160 |
D1526 | Space Maintainer - Removable - Bilateral, Maxillary | 20% Discount |
Restorative Services | Member Pays | |
D2140 | Amalgam - One Surface, Primary or Permanent | $57 |
D2150 | Amalgam - Two Surfaces, Primary or Permanent | $72 |
D2160 | Amalgam - Three Surfaces, Primary or Permanent | $85 |
D2161 | Amalgam - Four or More Surfaces, Primary or Permanent | $104 |
D2330 | Resin - Based Composite - One Surface, Anterior | $72 |
D2331 | Resin - Based Composite - Two Surfaces, Anterior | $86 |
D2332 | Resin - Based Composite - Three Surfaces, Anterior | $109 |
D2335 | Resin - Based Composite - Four or More Surfaces or Involving Incisal Angle (anterior) | $137 |
D2391 | Resin - Based Composite - One Surface, Posterior | $90 |
D2392 | Resin - Based Composite - Two Surfaces, Posterior | $130 |
D2393 | Resin - Based Composite - Three Surfaces, Posterior | $164 |
D2394 | Resin - Based Composite - Four or More Surfaces, Posterior | $189 |
D2710 | Crown - Resin-Based Composite (indirect) | $268 |
D2720 | Crown- Resin with High Noble Metal | $569 |
D2750 | Crown - Porcelain Fused to High Noble Metal | $674 |
D2751 | Crown - Porcelain Fused to Predominantly Base Metal | $613 |
D2752 | Crown - Porcelain Fused to Noble Metal | $657 |
D2790 | Crown - Full Cast High Noble Metal | $659 |
D2791 | Crown - Full Cast Predominantly Base Metal | $613 |
D2930 | Prefabricated Stainless Steel Crown - Primary Tooth | $132 |
D2931 | Prefabricated Stainless Steel Crown - Permanent Tooth | $149 |
D2950 | Core Buildup - Including Any Pins When Required | $132 |
D2951 | Pin Retention - Per Tooth in Addition to Restoration | $32 |
D2952 | Post and Core in Addition to Crown, Indirectly Fabricated | $207 |
D2954 | Prefabricated Post and Core in Addition to Crown | $161 |
Endodontic Services | Member Pays | |
D3110 | Pulp Cap - Direct (excluding final restoration) | $29 |
D3120 | Pulp Cap - Indirect (excluding final restoration) | $29 |
D3220 | Therapeutic Pulpotomy (excluding final restoration) - Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament | $72 |
D3310 | Endodontic Therapy - Anterior Tooth (excluding final restoration) | $384 |
D3320 | Endodontic Therapy - Premolar Tooth (excluding final restorations) | $457 |
D3330 | Endodontic Thearpy - Molar Tooth (excluding final restorations) | $573 |
Periodontic Services | Member Pays | |
D4210 | Gingivectomy or Gingivoplasty - Four or More Contiguous Teeth or Tooth Bounded Spaces Per Quadrant | $383 |
D4341 | Periodontal Scaling and Root Planing - Four or More Teeth Per Quadrant | $136 |
D4910 | Periodontal Maintenance | $82 |
Prosthodontics (Removable) Services | Member Pays | |
D5110 | Complete Denture - Maxillary | $826 |
D5120 | Complete Denture - Mandibular | $826 |
D5130 | Immediate Denture - Maxillary | $858 |
D5140 | Immediate Denture - Mandibular | $858 |
D5211 | Maxillary Partial Denture - Resin Base (including retentive/clasping materials, rests, and teeth) | $807 |
D5212 | Mandibular Partial Denture - Resin Base (including retentive/clasping materials, rests, and teeth) | $807 |
D5213 | Maxillary Partial Denture - Cast Metal Framework with Resin Denture Bases (including retentive/clasping materials, rests and teeth) | $937 |
D5214 | Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including retentive/clasping materials, rests and teeth) | $937 |
D5410 | Adjust Complete Denture - Maxillary | $47 |
D5411 | Adjust Complete Denture - Mandibular | $47 |
D5520 | Replace Missing or Broken Teeth - Complete Denture (each tooth) | $72 |
D5611 | Repair Resin Partial Denture Base, Mandibular | 20% Discount |
D5630 | Repair or Replace Broken Retentive/Clasping Materials - Per Tooth | $86 |
D5650 | Add Tooth to Existing Partial Denture | $75 |
D5660 | Add Clasp to Existing Partial Denture - Per Tooth | $95 |
D5730 | Reline Complete Maxillary Denture (direct) | $179 |
D5731 | Reline Complete Mandibular Denture (direct) | $179 |
D5740 | Reline Maxillary Partial Denture (direct) | $168 |
D5741 | Reline Mandibular Partial Dent (direct) | $168 |
D5750 | Reline Complete Maxillary Denture (indirect) | $232 |
D5751 | Reline Complete Mandibular Denture (indirect) | $232 |
Implant Services | Member Pays | |
D6000 through D6199 | 20% Discount | |
Prosthodontics (Fixed) Services | Member Pays | |
D6240 | Pontic - Porcelain Fused to High Noble Metal | $578 |
D6241 | Pontic - Porcelain Fused to Predominantly Base Metal | $534 |
D6242 | Pontic - Porcelain Fused to Noble Metal | $558 |
D6750 | Retainer Crown - Porcelain Fused to High Noble Metal | $632 |
D6751 | Retainer Crown - Porcelain Fused to Predominantly Base Metal | $576 |
D6752 | Retainer Crown - Porcelain Fused to Noble Metal | $600 |
Oral Surgery Services | Member Pays | |
D7140 | Extraction, Erupted Tooth or Exposed Root (elevation and/or forceps removal) | $72 |
D7210 | Erupted Tooth Requiring Removal of Bone and/or Sectioning of Tooth, and Including Elevation of Mucoperiosteal Flap if Indicated | $174 |
D7220 | Removal of Impacted Tooth - Soft Tissue | $147 |
D7230 | Removal of Impacted Tooth - Partially Bony | $191 |
D7240 | Removal of Impacted Tooth - Completely Bony | $268 |
D7250 | Removal of Residual Tooth Roots (cutting procedure) | $138 |
D7310 | Alveoloplasty in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per Quadrant | $122 |
D7320 | Alveoloplasty not in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per Quadrant | $178 |
D7510 | Incision and Drainage of Abscess - Intraoral Soft Tissue | $90 |
Orthodontic Services | Member Pays | |
D8010 through D8999 | 20% Discount | |
Adjunctive Services | Member Pays | |
D9110 | Palliative (emergency) Treatment of Dental Pain - Minor Procedure | $47 |
D9215 | Local Anesthesia in Conjunction With Operative or Surgical Procedures | $17 |
D9230 | Inhalation of Nitrous Oxide/Analgesia, Anxiolysis | $32 |
D9951 | Occlusal Adjustment - Limited | $64 |
D9952 | Occlusal Adjustment - Complete | $264 |
Careington Care 500 Series Schedule - 504 | ||
---|---|---|
Diagnostic Services | Member Pays | |
D0120 | Periodic Oral Evaluation - Established Patient | $20 |
D0140 | Limited Oral Evaluation - Problem Focused | $25 |
D0150 | Comprehensive Oral Evaluation - New or Established Patient | $25 |
D0210 | Intraoral - Complete Series of Radiographic Images | $62 |
D0220 | Intraoral - Periapical First Radiographic Image | $14 |
D0230 | Intraoral - Periapical Each Additional Radiographic Image | $9 |
D0270 | Bitewing - Single Radiographic Image | $14 |
D0272 | Bitewings - Two Radiographic Images | $19 |
D0273 | Bitewings - Three Radiographic Images | $25 |
D0274 | Bitewings - Four Radiographic Images | $32 |
D0330 | Panoramic Radiographic Image | $62 |
Preventative Services | Member Pays | |
D1110 | Prophylaxis - Adult | $45 |
D1120 | Prophylaxis - Child | $39 |
D1351 | Sealant - Per Tooth | $29 |
D1510 | Space Maintainer - Fixed, Unilateral - Per Quadrant | $134 |
D1516 | Space Maintainer - Fixed - Bilateral, Maxillary | 20% Discount |
D1520 | Space Maintainer - Removable - Unilateral - Per Quadrant | $178 |
D1526 | Space Maintainer - Removable - Bilateral, Maxillary | 20% Discount |
Restorative Services | Member Pays | |
D2140 | Amalgam - One Surface, Primary or Permanent | $62 |
D2150 | Amalgam - Two Surfaces, Primary or Permanent | $80 |
D2160 | Amalgam - Three Surfaces, Primary or Permanent | $94 |
D2161 | Amalgam - Four or More Surfaces, Primary or Permanent | $116 |
D2330 | Resin - Based Composite - One Surface, Anterior | $80 |
D2331 | Resin - Based Composite - Two Surfaces, Anterior | $95 |
D2332 | Resin - Based Composite - Three Surfaces Anterior | $121 |
D2335 | Resin - Based Composite - Four Or More Surfaces or Involving Incisal Angle (anterior) | $152 |
D2391 | Resin - Based Composite - One Surface, Posterior | $101 |
D2392 | Resin - Based Composite - Two Surfaces, Posterior | $146 |
D2393 | Resin - Based Composite - Three Surfaces, Posterior | $187 |
D2394 | Resin - Based Composite - Four or More Surfaces, Posterior | $216 |
D2710 | Crown - Resin-Based Composite (indirect) | $282 |
D2720 | Crown- Resin with High Noble Metal | $598 |
D2750 | Crown - Porcelain Fused to High Noble Metal | $701 |
D2751 | Crown - Porcelain Fused to Predominantly Base Metal | $638 |
D2752 | Crown - Porcelain Fused to Noble Metal | $680 |
D2790 | Crown - Full Cast High Noble Metal | $687 |
D2791 | Crown - Full Cast Predominantly Base Metal | $646 |
D2930 | Prefabricated Stainless Steel Crown - Primary Tooth | $146 |
D2931 | Prefabricated Stainless Steel Crown - Permanent Tooth | $166 |
D2950 | Core Buildup - Including Any Pins When Required | $146 |
D2951 | Pin Retention - Per Tooth, in Addition to Restoration | $33 |
D2952 | Post and Core in Addition to Crown, Indirectly Fabricated | $229 |
D2954 | Prefabricated Post and Core in Addition to Crown | $179 |
Endodontic Services | Member Pays | |
D3110 | Pulp Cap - Direct (excluding final restoration) | $33 |
D3120 | Pulp Cap - Indirect (excluding final restoration) | $33 |
D3220 | Therapeutic Pulpotomy (excluding final restoration) - Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament | $80 |
D3310 | Endodontic Therapy - Anterior Tooth (excluding final restoration) | $399 |
D3320 | Endodontic Therapy - Premolar Tooth (excluding final restoration) | $480 |
D3330 | Endodontic Thearpy - Molar Tooth (excluding final restoration) | $607 |
Periodontic Services | Member Pays | |
D4210 | Gingivectomy or Gingivoplasty - Four or More Contiguous Teeth or Tooth Bounded Spaces Per Quadrant | $422 |
D4341 | Periodontal Scaling and Root Planing - Four or More Teeth Per Quadrant | $138 |
D4910 | Periodontal Maintenance | $88 |
Prosthodontics (Removable) Services | Member Pays | |
D5110 | Complete Denture - Maxillary | $884 |
D5120 | Complete Denture - Mandibular | $884 |
D5130 | Immediate Denture - Maxillary | $952 |
D5140 | Immediate Denture - Mandibular | $952 |
D5211 | Maxillary Partial Denture - Resin Base (including retentive/clasping materials, rests, and teeth) | $865 |
D5212 | Mandibular Partial Denture - Resin Base (including retentive/clasping materials, rests, and teeth) | $865 |
D5213 | Maxillary Partial Denture - Cast Metal Framework with Resin Denture Bases (including retentive/clasping materials, rests and teeth) | $1,007 |
D5214 | Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including retentive/clasping materials, rests and teeth) | $1,007 |
D5410 | Adjust Complete Denture - Maxillary | $48 |
D5411 | Adjust Complete Denture - Mandibular | $48 |
D5520 | Replace Missing or Broken Teeth - Complete Denture (each tooth) | $80 |
D5611 | Repair Resin Partial Denture Base, Mandibular | 20% Discount |
D5630 | Repair or Replace Broken Retentive/Clasping Materials - Per Tooth | $95 |
D5650 | Add Tooth to Existing Partial Denture | $83 |
D5660 | Add Clasp to Existing Partial Denture - Per Tooth | $106 |
D5730 | Reline Complete Maxillary Denture (direct) | $196 |
D5731 | Reline Complete Mandibular Denture (direct) | $196 |
D5740 | Reline Maxillary Partial Denture (direct) | $187 |
D5741 | Reline Mandibular Partial Denture (direct) | $187 |
D5750 | Reline Complete Maxillary Denture (indirect) | $258 |
D5751 | Reline Complete Mandibular Denture (indirect) | $258 |
Implant Services | Member Pays | |
D6000 through D6199 | 20% Discount | |
Prosthodontics (Fixed) Services | Member Pays | |
D6240 | Pontic - Porcelain Fused to High Noble Metal | $633 |
D6241 | Pontic - Porcelain Fused to Predominantly Base Metal | $584 |
D6242 | Pontic - Porcelain Fused to Noble Metal | $607 |
D6750 | Retainer Crown - Porcelain Fused to High Noble Metal | $661 |
D6751 | Retainer Crown - Porcelain Fused to Predominantly Base Metal | $613 |
D6752 | Retainer Crown - Porcelain Fused to Noble Metal | $637 |
Oral Surgery Services | Member Pays | |
D7140 | Extraction, Erupted Tooth or Exposed Root (elevation and/or forceps removal) | $80 |
D7210 | Extraction, erupted Tooth Requiring Removal of Bone and/or Sectioning of Tooth, and Including Elevation of Mucoperiosteal Flap if Indicated | $185 |
D7220 | Removal of Impacted Tooth - Soft Tissue | $164 |
D7230 | Removal of Impacted Tooth - Partially Bony | $211 |
D7240 | Removal of Impacted Tooth - Completely Bony | $276 |
D7250 | Removal of Residual Tooth Roots (cutting procedure) | $147 |
D7310 | Alveoloplasty in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per Quadrant | $134 |
D7320 | Alveoloplasty not in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per Quadrant | $195 |
D7510 | Incision and Drainage of Abscess - Intraoral Soft Tissue | $101 |
Orthodontic Services | Member Pays | |
D8010 through D8999 | 20% Discount | |
Adjunctive Services | Member Pays | |
D9110 | Palliative (emergency) Treatment of Dental Pain - Minor Procedure | $50 |
D9215 | Local Anesthesia in Conjunction With Operative or Surgical Procedures | $19 |
D9230 | Inhalation of Nitrous Oxide/Anxiolysis, Analgesia | $34 |
D9951 | Occlusal Adjustment - Limited | $74 |
D9952 | Occlusal Adjustment - Complete | $293 |
Careington Care 500 Series Schedule - 505 | ||
---|---|---|
Diagnostic Services | Member Pays | |
D0120 | Periodic Oral Evaluation - Established Patient | $21 |
D0140 | Limited Oral Evaluation - Problem Focused | $27 |
D0150 | Comprehensive Oral Evaluation - New or Established Patient | $27 |
D0210 | Intraoral - Complete Series of Radiographic Images | $64 |
D0220 | Intraoral - Periapical First Radiographic Image | $15 |
D0230 | Intraoral - Periapical Each Additional Radiographic Image | $9 |
D0270 | Bitewing - Single Radiographic Image | $16 |
D0272 | Bitewings - Two Radiographic Images | $20 |
D0273 | Bitewings - Three Radiographic Images | $26 |
D0274 | Bitewings - Four Radiographic Images | $33 |
D0330 | Panoramic Radiographic Image | $64 |
Preventative Services | Member Pays | |
D1110 | Prophylaxis - Adult | $48 |
D1120 | Prophylaxis - Child | $40 |
D1351 | Sealant - Per Tooth | $32 |
D1510 | Space Maintainer - Fixed, Unilateral - Per Quadrant | $143 |
D1516 | Space Maintainer - Fixed - Bilateral, Maxillary | 20% Discount |
D1520 | Space Maintainer - Removable - Unilateral - Per Quadrant | $186 |
D1526 | Space Maintainer - Removable - Bilateral, Maxillary | 20% Discount |
Restorative Services | Member Pays | |
D2140 | Amalgam - One Surface, Primary or Permanent | $64 |
D2150 | Amalgam - Two Surfaces, Primary or Permanent | $83 |
D2160 | Amalgam - Three Surfaces, Primary or Permanent | $98 |
D2161 | Amalgam - Four or More Surfaces, Primary or Permanent | $121 |
D2330 | Resin - Based Composite - One Surface, Anterior | $83 |
D2331 | Resin - Based Composite - Two Surfaces, Anterior | $101 |
D2332 | Resin - Based Composite - Three Surfaces, Anterior | $126 |
D2335 | Resin - Based Composite - Four or More Surfaces or Involving Incisal Angle (anterior) | $160 |
D2391 | Resin - Based Composite - One Surface, Posterior | $109 |
D2392 | Resin - Based Composite - Two Surfaces, Posterior | $157 |
D2393 | Resin - Based Composite - Three Surfaces, Posterior | $208 |
D2394 | Resin - Based Composite - Four or More Surfaces, Posterior | $240 |
D2710 | Crown - Resin-Based Composite (indirect) | $305 |
D2720 | Crown- Resin with High Noble Metal | $645 |
D2750 | Crown - Porcelain Fused to High Noble Metal | $749 |
D2751 | Crown - Porcelain Fused to Predominantly Base Metal | $675 |
D2752 | Crown - Porcelain Fused to Noble Metal | $713 |
D2790 | Crown - Full Cast High Noble Metal | $722 |
D2791 | Crown - Full Cast Predominantly Base Metal | $687 |
D2930 | Prefabricated Stainless Steel Crown - Primary Tooth | $153 |
D2931 | Prefabricated Stainless Steel Crown - Permanent Tooth | $175 |
D2950 | Core Buildup, Including Any Pins When Required | $153 |
D2951 | Pin Retention - Per Tooth, in Addition to Restoration | $35 |
D2952 | Post and Core in Addition to Crown, Indirectly Fabricated | $241 |
D2954 | Prefabricated Post and Core in Addition to Crown | $187 |
Endodontic Services | Member Pays | |
D3110 | Pulp Cap - Direct (excluding final restoration) | $34 |
D3120 | Pulp Cap - Indirect (excluding final restoration) | $34 |
D3220 | Therapeutic Pulpotomy (excluding final restoration) - Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament | $83 |
D3310 | Endodontic Therapy, Anterior Tooth (excluding final restoration) | $450 |
D3320 | Endodontic Therapy, Premolar Tooth (excluding final restorations) | $532 |
D3330 | Endodontic Therapy, Molar Tooth (excluding final restorations) | $667 |
Periodontic Services | Member Pays | |
D4210 | Gingivectomy or Gingivoplasty - Four or More Contiguous Teeth or Tooth Bounded Spaces Per Quadrant | $450 |
D4341 | Periodontal Scaling and Root Planing - Four or More Teeth Per Quadrant | $149 |
D4910 | Periodontal Maintenance | $95 |
Prosthodontics (Removable) Services | Member Pays | |
D5110 | Complete Denture - Maxillary | $972 |
D5120 | Complete Denture - Mandibular | $972 |
D5130 | Immediate Denture - Maxillary | $1,033 |
D5140 | Immediate Denture - Mandibular | $1,033 |
D5211 | Maxillary Partial Denture - Resin Base (including retentive/clasping materials, rests, and teeth) | $954 |
D5212 | Mandibular Partial Denture - Resin Base (including retentive/clasping materials, rests, and teeth) | $954 |
D5213 | Maxillary Partial Denture - Cast Metal Framework with Resin Denture Bases (including retentive/clasping materials, rests and teeth) | $1,086 |
D5214 | Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including retentive/clasping materials, rests and teeth) | $1,086 |
D5410 | Adjust Complete Denture - Maxillary | $50 |
D5411 | Adjust Complete Denture - Mandibular | $50 |
D5520 | Replace Missing or Broken Teeth - Complete Denture (each tooth) | $83 |
D5611 | Repair Resin Partial Denture Base, Mandibular | 20% Discount |
D5630 | Repair or Replace Broken Retentive/Clasping Materials - Per Tooth | $101 |
D5650 | Add Tooth to Existing Partial Denture | $87 |
D5660 | Add Clasp to Existing Partial Denture - Per Tooth | $111 |
D5730 | Reline Complete Maxillary Denture (direct) | $208 |
D5731 | Reline Complete Mandibular Denture (direct) | $208 |
D5740 | Reline Maxillary Partial Denture (direct) | $196 |
D5741 | Reline Mandibular Partial Denture (direct) | $196 |
D5750 | Reline Complete Maxillary Denture (indirect) | $271 |
D5751 | Reline Complete Mandibular Denture (indirect) | $271 |
Implant Services | Member Pays | |
D6000 through D6199 | 20% Discount | |
Prosthodontics (Fixed) Services | Member Pays | |
D6240 | Pontic - Porcelain Fused to High Noble Metal | $734 |
D6241 | Pontic - Porcelain Fused to Predominantly Base Metal | $615 |
D6242 | Pontic - Porcelain Fused to Noble Metal | $665 |
D6750 | Retainer Crown - Porcelain Fused to High Noble Metal | $701 |
D6751 | Retainer Crown - Porcelain Fused to Predominantly Base Metal | $651 |
D6752 | Retainer Crown - Porcelain Fused to Noble Metal | $666 |
Oral Surgery Services | Member Pays | |
D7140 | Extraction, Erupted Tooth or Exposed Root (elevation and/or forceps removal) | $83 |
D7210 | Extraction, erupted Tooth Requiring Removal of Bone and/or Sectioning of Tooth, and Including Elevation of Mucoperiosteal Flap if Indicated | $191 |
D7220 | Removal of Impacted Tooth - Soft Tissue | $170 |
D7230 | Removal of Impacted Tooth - Partially Bony | $223 |
D7240 | Removal of Impacted Tooth - Completely Bony | $298 |
D7250 | Removal of Residual Tooth Roots (cutting procedure) | $157 |
D7310 | Alveoloplasty in Conjunction with Extraction - Four or More Teeth or Tooth Spaces, Per Quadrant | $143 |
D7320 | Alveoloplasty not in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per Quadrant | $207 |
D7510 | Incision and Drainage of Abscess - Intraoral Soft Tissue | $105 |
Orthodontic Services | Member Pays | |
D8010 through D8999 | 20% Discount | |
Adjunctive Services | Member Pays | |
D9110 | Palliative (emergency) Treatment of Dental Pain - Minor Procedure | $56 |
D9215 | Local Anesthesia in Conjunction With Operative or Surgical Procedures | $20 |
D9230 | Inhalation of Nitrous Oxide/Analgesia, Anxiolysis | $34 |
D9951 | Occlusal Adjustment - Limited | $76 |
D9952 | Occlusal Adjustment - Complete | $308 |
Careington Care 500 Series Schedule - 506 | ||
---|---|---|
Diagnostic Services | Member Pays | |
D0120 | Periodic Oral Evaluation - Established Patient | $25 |
D0140 | Limited Oral Evaluation - Problem Focused | $29 |
D0150 | Comprehensive Oral Evaluation - New or Established Patient | $36 |
D0210 | Intraoral - Complete Series of Radiographic Images | $75 |
D0220 | Intraoral - Periapical First Radiographic Image | $17 |
D0230 | Intraoral - Periapical Each Additional Radiographic Image | $11 |
D0270 | Bitewing - Single Radiographic Image | $17 |
D0272 | Bitewings - Two Radiographic Images | $21 |
D0273 | Bitewings - Three Radiographic Images | $27 |
D0274 | Bitewings - Four Radiographic Images | $33 |
D0330 | Panoramic Radiographic Image | $75 |
Preventative Services | Member Pays | |
D1110 | Prophylaxis - Adult | $56 |
D1120 | Prophylaxis - Child | $45 |
D1351 | Sealant - Per Tooth | $39 |
D1510 | Space Maintainer - Fixed, Unilateral - Per Quadrant | $164 |
D1516 | Space Maintainer - Fixed - Bilateral, Maxillary | 20% Discount |
D1520 | Space Maintainer - Removable - Unilateral - Per Quadrant | $211 |
D1526 | Space Maintainer - Removable - Bilateral, Maxillary | 20% Discount |
Restorative Services | Member Pays | |
D2140 | Amalgam - One Surface, Primary or Permanent | $75 |
D2150 | Amalgam - Two Surfaces, Primary or Permanent | $95 |
D2160 | Amalgam - Three Surfaces, Primary or Permanent | $112 |
D2161 | Amalgam - Four or More Surfaces, Primary or Permanent | $137 |
D2330 | Resin - Based Composite - One Surface, Anterior | $95 |
D2331 | Resin - Based Composite - Two Surfaces, Anterior | $117 |
D2332 | Resin - Based Composite - Three Surfaces, Anterior | $146 |
D2335 | Resin - Based Composite - Four or More Surfaces or Involving Incisal Angle (anterior) | $183 |
D2391 | Resin - Based Composite - One Surface, Posterior | $122 |
D2392 | Resin - Based Composite - Two Surfaces, Posterior | $179 |
D2393 | Resin - Based Composite - Three Surfaces, Posterior | $226 |
D2394 | Resin - Based Composite - Four or More Surfaces, Posterior | $258 |
D2710 | Crown - Resin-Based Composite (indirect) | $335 |
D2720 | Crown- Resin with High Noble Metal | $710 |
D2750 | Crown - Porcelain Fused to High Noble Metal | $836 |
D2751 | Crown - Porcelain Fused to Predominantly Base Metal | $815 |
D2752 | Crown - Porcelain Fused to Noble Metal | $827 |
D2790 | Crown - Full Cast High Noble Metal | $855 |
D2791 | Crown - Full Cast Predominantly Base Metal | $810 |
D2930 | Prefabricated Stainless Steel Crown - Primary Tooth | $167 |
D2931 | Prefabricated Stainless Steel Crown - Permanent Tooth | $187 |
D2950 | Core Buildup - Including Any Pins When Required | $164 |
D2951 | Pin Retention - Per Tooth, in Addition to Restoration | $41 |
D2952 | Post and Core in Addition to Crown, Indirectly Fabricated | $270 |
D2954 | Prefabricated Post and Core in Addition to Crown | $205 |
Endodontic Services | Member Pays | |
D3110 | Pulp Cap - Direct (excluding final restoration) | $41 |
D3120 | Pulp Cap - Indirect (excluding final restoration) | $39 |
D3220 | Therapeutic Pulpotomy (excluding final restoration) - Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament | $95 |
D3310 | Endodontic Therapy - Anterior Tooth (excluding final restoration) | $513 |
D3320 | Endodontic Therapy - Premolar Tooth (excluding final restorations) | $607 |
D3330 | Endodontic Thearpy - Molar Tooth (excluding final restorations) | $763 |
Periodontic Services | Member Pays | |
D4210 | Gingivectomy or Gingivoplasty - Four or More Contiguous Teeth or Tooth Bounded Spaces Per Quadrant | $529 |
D4341 | Periodontal Scaling and Root Planing - Four or More Teeth Per Quadrant | $172 |
D4910 | Periodontal Maintenance | $107 |
Prosthodontics (Removable) Services | Member Pays | |
D5110 | Complete Denture - Maxillary | $1,107 |
D5120 | Complete Denture - Mandibular | $1,107 |
D5130 | Immediate Denture - Maxillary | $1,166 |
D5140 | Immediate Denture - Mandibular | $1,166 |
D5211 | Maxillary Partial Denture - Resin Base (including retentive/clasping materials, rests, and teeth) | $1,089 |
D5212 | Mandibular Partial Denture - Resin Base (including retentive/clasping materials, rests, and teeth) | $1,089 |
D5213 | Maxillary Partial Denture - Cast Metal Framework with Resin Denture Bases (including retentive/clasping materials, rests and teeth) | $1,245 |
D5214 | Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including retentive/clasping materials, rests and teeth) | $1,245 |
D5410 | Adjust Complete Denture - Maxillary | $59 |
D5411 | Adjust Complete Denture - Mandibular | $59 |
D5520 | Replace Missing or Broken Teeth - Complete Denture (each tooth) | $95 |
D5611 | Repair Resin Partial Denture Base, Mandibular | 20% Discount |
D5630 | Repair or Replace Broken Retentive/Clasping Materials - Per Tooth | $117 |
D5650 | Add Tooth to Existing Partial Denture | $101 |
D5660 | Add Clasp to Existing Partial Denture - Per Tooth | $128 |
D5730 | Reline Complete Maxillary Denture (direct) | $231 |
D5731 | Reline Complete Mandibular Denture (direct) | $231 |
D5740 | Reline Maxillary Partial Denture (direct) | $217 |
D5741 | Reline Mandibular Partial Dent (direct) | $217 |
D5750 | Reline Complete Maxillary Denture (indirect) | $299 |
D5751 | Reline Complete Mandibular Denture (indirect) | $299 |
Implant Services | Member Pays | |
D6000 through D6199 | 20% Discount | |
Prosthodontics (Fixed) Services | Member Pays | |
D6240 | Pontic - Porcelain Fused to High Noble Metal | $766 |
D6241 | Pontic - Porcelain Fused to Predominantly Base Metal | $707 |
D6242 | Pontic - Porcelain Fused to Noble Metal | $729 |
D6750 | Retainer Crown - Porcelain Fused to High Noble Metal | $815 |
D6751 | Retainer Crown - Porcelain Fused to Predominantly Base Metal | $768 |
D6752 | Retainer Crown - Porcelain Fused to Noble Metal | $798 |
Oral Surgery Services | Member Pays | |
D7140 | Extraction, Erupted Tooth or Exposed Root (elevation and/or forceps removal) | $95 |
D7210 | Extraction, Erupted Tooth Requiring Removal of Bone and/or Sectioning of Tooth, and Including Elevation of Mucoperiosteal Flap if Indicated | $199 |
D7220 | Removal of Impacted Tooth - Soft Tissue | $195 |
D7230 | Removal of Impacted Tooth - Partially Bony | $254 |
D7240 | Removal of Impacted Tooth - Completely Bony | $334 |
D7250 | Removal of Residual Tooth Roots (cutting procedure) | $183 |
D7310 | Alveoloplasty in Conjunction with Extraction - Four or More Teeth or Tooth Spaces, Per Quadrant | $164 |
D7320 | Alveoloplasty not in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per Quadrant | $235 |
D7510 | Incision and Drainage of Abscess - Intraoral Soft Tissue | $121 |
Orthodontic Services | Member Pays | |
D8010 through D8999 | 20% Discount | |
Adjunctive Services | Member Pays | |
D9110 | Palliative (emergency) Treatment of Dental Pain - Minor Procedure | $62 |
D9215 | Local Anesthesia in Conjunction With Operative or Surgical Procedures | $25 |
D9230 | Inhalation of Nitrous Oxide/Analgesia, Anxiolysis | $41 |
D9951 | Occlusal Adjustment - Limited | $87 |
D9952 | Occlusal Adjustment - Complete | $353 |
Careington Care 500 Series Schedule - 507 | ||
---|---|---|
Diagnostic Services | Member Pays | |
D0120 | Periodic Oral Evaluation - Established Patient | $26 |
D0140 | Limited Oral Evaluation - Problem Focused | $39 |
D0150 | Comprehensive Oral Evaluation - New or Established Patient | $44 |
D0210 | Intraoral - Complete Series of Radiographic Images | $75 |
D0220 | Intraoral - Periapical First Radiographic Image | $15 |
D0230 | Intraoral - Periapical Each Additional Radiographic Image | $13 |
D0270 | Bitewing - Single Radiographic Image | $14 |
D0272 | Bitewings - Two Radiographic Images | $20 |
D0273 | Bitewings - Three Radiographic Images | $25 |
D0274 | Bitewings - Four Radiographic Images | $29 |
D0330 | Panoramic Radiographic Image | $63 |
Preventative Services | Member Pays | |
D1110 | Prophylaxis - Adult | $49 |
D1120 | Prophylaxis - Child | $39 |
D1351 | Sealant - Per Tooth | $29 |
D1510 | Space Maintainer - Fixed, Unilateral - Per Quadrant | $187 |
D1516 | Space Maintainer - Fixed - Bilateral, Maxillary | 20% Discount |
D1520 | Space Maintainer - Removable - Unilateral - Per Quadrant | $223 |
D1526 | Space Maintainer - Removable - Bilateral, Maxillary | 20% Discount |
Restorative Services | Member Pays | |
D2140 | Amalgam - One Surface, Primary or Permanent | $62 |
D2150 | Amalgam - Two Surfaces, Primary or Permanent | $83 |
D2160 | Amalgam - Three Surfaces, Primary or Permanent | $100 |
D2161 | Amalgam - Four or More Surfaces, Primary or Permanent | $122 |
D2330 | Resin - Based Composite - One Surface, Anterior | $77 |
D2331 | Resin - Based Composite - Two Surfaces, Anterior | $98 |
D2332 | Resin - Based Composite - Three Surfaces, Anterior | $126 |
D2335 | Resin - Based Composite - Four or More Surfaces or Involving Incisal Angle (anterior) | $157 |
D2391 | Resin - Based Composite - One Surface, Posterior | $87 |
D2392 | Resin - Based Composite - Two Surfaces, Posterior | $122 |
D2393 | Resin - Based Composite - Three Surfaces, Posterior | $157 |
D2394 | Resin - Based Composite - Four or More Surfaces, Posterior | $185 |
D2710 | Crown - Resin-Based Composite (indirect) | $267 |
D2720 | Crown- Resin with High Noble Metal | $568 |
D2750 | Crown - Porcelain Fused to High Noble Metal | $667 |
D2751 | Crown - Porcelain Fused to Predominantly Base Metal | $600 |
D2752 | Crown - Porcelain Fused to Noble Metal | $625 |
D2790 | Crown - Full Cast High Noble Metal | $646 |
D2791 | Crown - Full Cast Predominantly Base Metal | $564 |
D2930 | Prefabricated Stainless Steel Crown - Primary Tooth | $150 |
D2931 | Prefabricated Stainless Steel Crown - Permanent Tooth | $174 |
D2950 | Core Buildup - Including Any Pins When Required | $152 |
D2951 | Pin Retention - Per Tooth, in Addition to Restoration | $33 |
D2952 | Post and Core in Addition to Crown, Indirectly Fabricated | $238 |
D2954 | Prefabricated Post and Core in Addition to Crown | $187 |
Endodontic Services | Member Pays | |
D3110 | Pulp Cap - Direct (excluding final restoration) | $40 |
D3120 | Pulp Cap - Indirect (excluding final restoration) | $40 |
D3220 | Therapeutic Pulpotomy (excluding final restoration) - Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament | $95 |
D3310 | Endodontic Therapy, Anterior Tooth (excluding final restoration) | $380 |
D3320 | Endodontic Therapy, Premolar Tooth (excluding final restoration) | $457 |
D3330 | Endodontic Therapy - Molar Tooth (excluding final restoration) | $576 |
Periodontic Services | Member Pays | |
D4210 | Gingivectomy or Gingivoplasty - Four or More Contiguous Teeth or Tooth Bounded Spaces Per Quadrant | $360 |
D4341 | Periodontal Scaling and Root Planing - Four or More Teeth Per Quadrant | $133 |
D4910 | Periodontal Maintenance | $77 |
Prosthodontics (Removable) Services | Member Pays | |
D5110 | Complete Denture - Maxillary | $859 |
D5120 | Complete Denture - Mandibular | $859 |
D5130 | Immediate Denture - Maxillary | $906 |
D5140 | Immediate Denture - Mandibular | $911 |
D5211 | Maxillary Partial Denture - Resin Base (including retentive/clasping materials, rests, and teeth) | $645 |
D5212 | Mandibular Partial Denture - Resin Base (including retentive/clasping materials, rests, and teeth) | $645 |
D5213 | Maxillary Partial Denture - Cast Metal Framework with Resin Denture Bases (including retentive/clasping materials, rests and teeth) | $924 |
D5214 | Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including retentive/clasping materials, rests and teeth) | $929 |
D5410 | Adjust Complete Denture - Maxillary | $46 |
D5411 | Adjust Complete Denture - Mandibular | $46 |
D5520 | Replace Missing or Broken Teeth - Complete Denture (each tooth) | $94 |
D5611 | Repair Resin Partial Denture Base, Mandibular | 20% Discount |
D5630 | Repair or Replace Broken Retentive/Clasping Materials - Per Tooth | $133 |
D5650 | Add Tooth to Existing Partial Denture | $116 |
D5660 | Add Clasp to Existing Partial Denture - Per Tooth | $141 |
D5730 | Reline Complete Maxillary Denture (direct) | $195 |
D5731 | Reline Complete Mandibular Denture (direct) | $195 |
D5740 | Reline Maxillary Partial Denture (direct) | $182 |
D5741 | Reline Mandibular Partial Denture (direct) | $182 |
D5750 | Reline Complete Maxillary Denture (indirect) | $263 |
D5751 | Reline Complete Mandibular Denture (indirect) | $259 |
Implant Services | Member Pays | |
D6000 through D6199 | 20% Discount | |
Prosthodontics (Fixed) Services | Member Pays | |
D6240 | Pontic - Porcelain Fused to High Noble Metal | $645 |
D6241 | Pontic - Porcelain Fused to Predominantly Base Metal | $602 |
D6242 | Pontic - Porcelain Fused to Noble Metal | $619 |
D6750 | Retainer Crown - Porcelain Fused to High Noble Metal | $666 |
D6751 | Retainer Crown - Porcelain Fused to Predominantly Base Metal | $602 |
D6752 | Retainer Crown - Porcelain Fused to Noble Metal | $622 |
Oral Surgery Services | Member Pays | |
D7140 | Extraction, Erupted Tooth or Exposed Root (elevation and/or forceps removal) | $80 |
D7210 | Extraction, erupted Tooth Requiring Removal of Bone and/or Sectioning of Tooth, and Including Elevation of Mucoperiosteal Flap if Indicated | $199 |
D7220 | Removal of Impacted Tooth - Soft Tissue | $178 |
D7230 | Removal of Impacted Tooth - Partially Bony | $225 |
D7240 | Removal of Impacted Tooth - Completely Bony | $277 |
D7250 | Removal of Residual Tooth Roots (cutting procedure) | $164 |
D7310 | Alveoloplasty in Conjunction with Extraction - Four or More Teeth or Tooth Spaces, Per Quadrant | $161 |
D7320 | Alveoloplasty not in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per Quadrant | $226 |
D7510 | Incision and Drainage of Abscess - Intraoral Soft Tissue | $106 |
Orthodontic Services | Member Pays | |
D8010 through D8999 | 20% Discount | |
Adjunctive Services | Member Pays | |
D9110 | Palliative (emergency) Treatment of Dental Pain - Minor Procedure | $58 |
D9215 | Local Anesthesia in Conjunction With Operative or Surgical Procedures | $25 |
D9230 | Inhalation of Nitrous Oxide/Analgesia, Anxiolysis | $34 |
D9951 | Occlusal Adjustment - Limited | $88 |
D9952 | Occlusal Adjustment - Complete | $360 |
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