Careington Dental
Dental Schedule
Dental schedule by state
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Schedule of Services
- 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. Fee schedules are subject to change without prior notification to members.
- Dental procedure codes not listed on this schedule will be discounted at 20% off the General Dentist's normal fee 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.
- Discount plans are not insurance
| 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 | $102 |
| D1516 | Space Maintainer - Fixed - Bilateral, Maxillary | 20% Discount |
| D1520 | Space Maintainer - Removable - Unilateral | $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 Bonded 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 any conventional clasps, rests and teeth) | $795 |
| D5214 | Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, 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 (chairside) | $148 |
| D5731 | Reline Complete Mandibular Denture (chairside) | $148 |
| D5740 | Reline Maxillary Partial Denture (chairside) | $142 |
| D5741 | Reline Mandibular Partial Denture (chairside) | $142 |
| D5750 | Reline Complete Maxillary Denture (laboratory) | $194 |
| D5751 | Reline Complete Mandibular Denture (laboratory) | $194 |
| Implant Services | Member Pays | |
| D6000 through D6096 | 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 forcepts removal) | $60 |
| D7210 | 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 | |
| D8070 | Comprehensive Orthodontic Treatment of the Transitional Dentition | 20% Discount |
| D8080 | Comprehensive Orthodontic Treatment of the Adolescent Dentition | 20% Discount |
| D8090 | Comprehensive Orthodontic Treatment of the Adult Dentition | 20% Discount |
| Other Services | Member Pays | |
| D9110 | Palliative (emergency) Treatment Dental Pain - Minor Procedure | $40 |
| D9215 | Local Anesthesia in Conjunction With Operative or Surgical Procedures | $14 |
| D9230 | Inhalation of Nitrous Oxide/Anxiolysis, Analgesia | $28 |
| D9951 | Occlusal Adjustment - Limited | $56 |
| D9952 | Occlusal Adjustment - Complete | $221 |
Exclusions and Limitations
- If the General Dentist's normal fee for any dental procedure is less than the fee listed on this schedule, the dentist will charge 20% off of their normal fee for that dental procedure.
- Any procedure involving lab and OSHA fees will incur additional costs. All applicable lab and OSHA fees are the full responsibility of the member and are subject to no discount.
- Fees subject to change.
- 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 Corporation, Attn. Provider Relations, PO Box 2568, Frisco, Texas 75034. Please call 800-290-0523 if you have any further questions.
- 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.
- 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.
Schedule of Services
- 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. Fee schedules are subject to change without prior notification to members.
- Dental procedure codes not listed on this schedule will be discounted at 20% off the General Dentist's normal fee 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.
- Discount plans are not insurance
| 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 | $116 |
| D1516 | Space Maintainer - Fixed - Bilateral, Maxillary | 20% Discount |
| D1520 | Space Maintainer - Removable - Unilateral | $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 Bonded 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 any conventional clasps, rests and teeth) | $897 |
| D5214 | Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, 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 (chairside) | $167 |
| D5731 | Reline Complete Mandibular Denture (chairside) | $167 |
| D5740 | Reline Maxillary Partial Denture (chairside) | $160 |
| D5741 | Reline Mandibular Partial Denture (chairside) | $160 |
| D5750 | Reline Complete Maxillary Denture (laboratory) | $219 |
| D5751 | Reline Complete Mandibular Denture (laboratory) | $219 |
| Implant Services | Member Pays | |
| D6000 through D6096 | 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 forcepts removal) | $65 |
| D7210 | 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 Extraction - 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 | |
| D8070 | Comprehensive Orthodontic Treatment of the Transitional Dentition | 20% Discount |
| D8080 | Comprehensive Orthodontic Treatment of the Adolescent Dentition | 20% Discount |
| D8090 | Comprehensive Orthodontic Treatment of the Adult Dentition | 20% Discount |
| Other 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/Anxiolysis, Analgesia | $29 |
| D9951 | Occlusal Adjustment - Limited | $62 |
| D9952 | Occlusal Adjustment - Complete | $249 |
Exclusions and Limitations
- If the General Dentist's normal fee for any dental procedure is less than the fee listed on this schedule, the dentist will charge 20% off of their normal fee for that dental procedure.
- Any procedure involving lab and OSHA fees will incur additional costs. All applicable lab and OSHA fees are the full responsibility of the member and are subject to no discount.
- Fees subject to change.
- 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 Corporation, Attn. Provider Relations, PO Box 2568, Frisco, Texas 75034. Please call 800-290-0523 if you have any further questions.
- 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.
- 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.
Schedule of Services
- 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. Fee schedules are subject to change without prior notification to members.
- Dental procedure codes not listed on this schedule will be discounted at 20% off the General Dentist's normal fee 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.
- Discount plans are not insurance
| 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 | $122 |
| D1516 | Space Maintainer - Fixed - Bilateral, Maxillary | 20% Discount |
| D1520 | Space Maintainer - Removable - Unilateral | $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 Bonded 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 any conventional clasps, rests and teeth) | $937 |
| D5214 | Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, 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 (chairside) | $179 |
| D5731 | Reline Complete Mandibular Denture (chairside) | $179 |
| D5740 | Reline Maxillary Partial Denture (chairside) | $168 |
| D5741 | Reline Mandibular Partial Dent (chairside) | $168 |
| D5750 | Reline Complete Maxillary Denture (laboratory) | $232 |
| D5751 | Reline Complete Mandibular Denture (laboratory) | $232 |
| Implant Services | Member Pays | |
| D6000 through D6096 | 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 forcepts 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 Extraction - 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 | |
| D8070 | Comprehensive Orthodontic Treatment of the Transitional Dentition | 20% Discount |
| D8080 | Comprehensive Orthodontic Treatment of the Adolescent Dentition | 20% Discount |
| D8090 | Comprehensive Orthodontic Treatment of the Adult Dentition | 20% Discount |
| Other Services | Member Pays | |
| D9110 | Palliative (emergency) Treatment Dental Pain - Minor Procedure | $47 |
| D9215 | Local Anesthesia in Conjunction With Operative or Surgical Procedures | $17 |
| D9230 | Inhalation of Nitrous Oxide/Anxiolysis, Analgesia | $32 |
| D9951 | Occlusal Adjustment - Limited | $64 |
| D9952 | Occlusal Adjustment - Complete | $264 |
Exclusions and Limitations
- If the General Dentist's normal fee for any dental procedure is less than the fee listed on this schedule, the dentist will charge 20% off of their normal fee for that dental procedure.
- Any procedure involving lab and OSHA fees will incur additional costs. All applicable lab and OSHA fees are the full responsibility of the member and are subject to no discount.
- Fees subject to change.
- 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 Corporation, Attn. Provider Relations, PO Box 2568, Frisco, Texas 75034. Please call 800-290-0523 if you have any further questions.
- 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.
- 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.
Schedule of Services
- 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. Fee schedules are subject to change without prior notification to members.
- Dental procedure codes not listed on this schedule will be discounted at 20% off the General Dentist's normal fee 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.
- Discount plans are not insurance
| 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 | $134 |
| D1516 | Space Maintainer - Fixed - Bilateral, Maxillary | 20% Discount |
| D1520 | Space Maintainer - Removable - Unilateral | $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 or | $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 restorations) | $480 |
| D3330 | Endodontic Thearpy - Molar Tooth (excluding final restorations) | $607 |
| Periodontic Services | Member Pays | |
| D4210 | Gingivectomy or Gingivoplasty - Four or More Contiguous Teeth or Tooth Bonded 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 any conventional clasps, rests and teeth) | $1,007 |
| D5214 | Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, 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 (chairside) | $196 |
| D5731 | Reline Complete Mandibular Denture (chairside) | $196 |
| D5740 | Reline Maxillary Partial Denture (chairside) | $187 |
| D5741 | Reline Mandibular Partial Dent (chairside) | $187 |
| D5750 | Reline Complete Maxillary Denture (laboratory) | $258 |
| D5751 | Reline Complete Mandibular Denture (laboratory) | $258 |
| Implant Services | Member Pays | |
| D6000 through D6096 | 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 forcepts removal) | $80 |
| D7210 | 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 Extraction - 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 | |
| D8070 | Comprehensive Orthodontic Treatment of the Transitional Dentition | 20% Discount |
| D8080 | Comprehensive Orthodontic Treatment of the Adolescent Dentition | 20% Discount |
| D8090 | Comprehensive Orthodontic Treatment of the Adult Dentition | 20% Discount |
| Other Services | Member Pays | |
| D9110 | Palliative (emergency) Treatment 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 |
Exclusions and Limitations
- If the General Dentist's normal fee for any dental procedure is less than the fee listed on this schedule, the dentist will charge 20% off of their normal fee for that dental procedure.
- Any procedure involving lab and OSHA fees will incur additional costs. All applicable lab and OSHA fees are the full responsibility of the member and are subject to no discount.
- Fees subject to change.
- 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 Corporation, Attn. Provider Relations, PO Box 2568, Frisco, Texas 75034. Please call 800-290-0523 if you have any further questions.
- 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.
- 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.
Schedule of Services
- 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. Fee schedules are subject to change without prior notification to members.
- Dental procedure codes not listed on this schedule will be discounted at 20% off the General Dentist's normal fee 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.
- Discount plans are not insurance
| 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 | $143 |
| D1516 | Space Maintainer - Fixed - Bilateral, Maxillary | 20% Discount |
| D1520 | Space Maintainer - Removable - Unilateral | $171 |
| 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 Bonded 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 any conventional clasps, rests and teeth) | $1,086 |
| D5214 | Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, 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 (chairside) | $208 |
| D5731 | Reline Complete Mandibular Denture (chairside) | $208 |
| D5740 | Reline Maxillary Partial Denture (chairside) | $196 |
| D5741 | Reline Mandibular Partial Denture (chairside) | $196 |
| D5750 | Reline Complete Maxillary Denture (laboratory) | $271 |
| D5751 | Reline Complete Mandibular Denture (laboratory) | $271 |
| Implant Services | Member Pays | |
| D6000 through D6096 | 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 forcepts removal) | $83 |
| D7210 | 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 | |
| D8070 | Comprehensive Orthodontic Treatment of the Transitional Dentition | 20% Discount |
| D8080 | Comprehensive Orthodontic Treatment of the Adolescent Dentition | 20% Discount |
| D8090 | Comprehensive Orthodontic Treatment of the Adult Dentition | 20% Discount |
| Other Services | Member Pays | |
| D9110 | Palliative (emergency) Treatment Dental Pain - Minor Procedure | $56 |
| D9215 | Local Anesthesia in Conjunction With Operative or Surgical Procedures | $20 |
| D9230 | Inhalation of Nitrous Oxide/Anxiolysis, Analgesia | $34 |
| D9951 | Occlusal Adjustment - Limited | $76 |
| D9952 | Occlusal Adjustment - Complete | $308 |
Exclusions and Limitations
- If the General Dentist's normal fee for any dental procedure is less than the fee listed on this schedule, the dentist will charge 20% off of their normal fee for that dental procedure.
- Any procedure involving lab and OSHA fees will incur additional costs. All applicable lab and OSHA fees are the full responsibility of the member and are subject to no discount.
- Fees subject to change.
- 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 Corporation, Attn. Provider Relations, PO Box 2568, Frisco, Texas 75034. Please call 800-290-0523 if you have any further questions.
- 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.
- 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.
Schedule of Services
- 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. Fee schedules are subject to change without prior notification to members.
- Dental procedure codes not listed on this schedule will be discounted at 20% off the General Dentist's normal fee 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.
- Discount plans are not insurance
| 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 | $164 |
| D1516 | Space Maintainer - Fixed - Bilateral, Maxillary | 20% Discount |
| D1520 | Space Maintainer - Removable - Unilateral | $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 Bonded 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 any conventional clasps, rests and teeth) | $1,245 |
| D5214 | Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, 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 (chairside) | $231 |
| D5731 | Reline Complete Mandibular Denture (chairside) | $231 |
| D5740 | Reline Maxillary Partial Denture (chairside) | $217 |
| D5741 | Reline Mandibular Partial Dent (chairside) | $217 |
| D5750 | Reline Complete Maxillary Denture (laboratory) | $299 |
| D5751 | Reline Complete Mandibular Denture (laboratory) | $299 |
| Implant Services | Member Pays | |
| D6000 through D6096 | 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 forcepts removal) | $95 |
| D7210 | 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 | |
| D8070 | Comprehensive Orthodontic Treatment of the Transitional Dentition | 20% Discount |
| D8080 | Comprehensive Orthodontic Treatment of the Adolescent Dentition | 20% Discount |
| D8090 | Comprehensive Orthodontic Treatment of the Adult Dentition | 20% Discount |
| Other Services | Member Pays | |
| D9110 | Palliative (emergency) Treatment Dental Pain - Minor Procedure | $62 |
| D9215 | Local Anesthesia in Conjunction With Operative or Surgical Procedures | $25 |
| D9230 | Inhalation of Nitrous Oxide/Anxiolysis, Analgesia | $41 |
| D9951 | Occlusal Adjustment - Limited | $87 |
| D9952 | Occlusal Adjustment - Complete | $353 |
Exclusions and Limitations
- If the General Dentist's normal fee for any dental procedure is less than the fee listed on this schedule, the dentist will charge 20% off of their normal fee for that dental procedure.
- Any procedure involving lab and OSHA fees will incur additional costs. All applicable lab and OSHA fees are the full responsibility of the member and are subject to no discount.
- Fees subject to change.
- 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 Corporation, Attn. Provider Relations, PO Box 2568, Frisco, Texas 75034. Please call 800-290-0523 if you have any further questions.
- 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.
- 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.
Schedule of Services
- 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. Fee schedules are subject to change without prior notification to members.
- Dental procedure codes not listed on this schedule will be discounted at 20% off the General Dentist's normal fee 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.
- Discount plans are not insurance
| 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 | $187 |
| D1516 | Space Maintainer - Fixed - Bilateral, Maxillary | 20% Discount |
| D1520 | Space Maintainer - Removable - Unilateral | $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 Bonded 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 any conventional clasps, rests and teeth) | $924 |
| D5214 | Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, 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 (chairside) | $195 |
| D5731 | Reline Complete Mandibular Denture (chairside) | $195 |
| D5740 | Reline Maxillary Partial Denture (chairside) | $182 |
| D5741 | Reline Mandibular Partial Denture (chairside) | $182 |
| D5750 | Reline Complete Maxillary Denture (laboratory) | $263 |
| D5751 | Reline Complete Mandibular Denture (laboratory) | $259 |
| Implant Services | Member Pays | |
| D6000 through D6096 | 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 forcepts removal) | $80 |
| D7210 | 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 | |
| D8070 | Comprehensive Orthodontic Treatment of the Transitional Dentition | 20% Discount |
| D8080 | Comprehensive Orthodontic Treatment of the Adolescent Dentition | 20% Discount |
| D8090 | Comprehensive Orthodontic Treatment of the Adult Dentition | 20% Discount |
| Other Services | Member Pays | |
| D9110 | Palliative (emergency) Treatment Dental Pain - Minor Procedure | $58 |
| D9215 | Local Anesthesia in Conjunction With Operative or Surgical Procedures | $25 |
| D9230 | Inhalation of Nitrous Oxide/Anxiolysis, Analgesia | $34 |
| D9951 | Occlusal Adjustment - Limited | $88 |
| D9952 | Occlusal Adjustment - Complete | $360 |
Exclusions and Limitations
- If the General Dentist's normal fee for any dental procedure is less than the fee listed on this schedule, the dentist will charge 20% off of their normal fee for that dental procedure.
- Any procedure involving lab and OSHA fees will incur additional costs. All applicable lab and OSHA fees are the full responsibility of the member and are subject to no discount.
- Fees subject to change.
- 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 Corporation, Attn. Provider Relations, PO Box 2568, Frisco, Texas 75034. Please call 800-290-0523 if you have any further questions.
- 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.
- 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.
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