ADA
CODE

DIAGNOSTIC

MEMBER
PAYS

0120

PERIODIC ORAL EVALUATION

$20

0140

LIMITED ORAL EVALUATION-PROBLEM FOCUSED

$24

0150

COMPREHENSIVE ORAL EVALUATION-NEW OR ESTABLISHED PATIENT

$24

0210

INTRAORAL-COMPLETE SERIES INCLUDING BITEWINGS

$60

0220

INTRAORAL-PERIAPICAL-FIRST FILM

$14

0230

INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM

$7

0270

BITEWING-SINGLE FILM

$14

0272

BITEWINGS-TWO FILMS

$17

0273

BITEWINGS-THREE FILMS

$22

0274

BITEWINGS-FOUR FILMS

$26

0330

PANORAMIC FILM

$60

PREVENTIVE

1110

PROPHYLAXIS-ADULT

$44

1120

PROPHYLAXIS-CHILD

$36

1351

SEALANT-PER TOOTH

$31

1510

SPACE MAINTAINER-FIXED-UNILATERAL

$131

1515

SPACE MAINTAINER-FIXED-BILATERAL

$193

1520

SPACE MAINTAINER-REMOVABLE-UNILATERAL

$170

1525

SPACE MAINTAINER-REMOVABLE-BILATERAL

$217

RESTORATIVE

2140

AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT

$60

2150

AMALGAM-TWO SURFACES, PRIMARY OR PERMANENT

$76

2160

AMALGAM-THREE SURFACES, PRIMARY OR PERMANENT

$90

2161

AMALGAM-FOUR OR MORE SURFACES, PRIMARY OR PERMANENT

$110

2330

RESIN-BASED COMPOSITE-ONE SURFACE, ANTERIOR

$76

2331

RESIN-BASED COMPOSITE-TWO SURFACES, ANTERIOR

$93

2332

RESIN-BASED COMPOSITE-THREE SURFACES, ANTERIOR

$117

2335

RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE, ANTERIOR

$147

2391

RESIN-BASED COMPOSITE-ONE SURFACE, POSTERIOR

$98

2392

RESIN-BASED COMPOSITE-TWO SURFACES, POSTERIOR

$143

2393

RESIN-BASED COMPOSITE-THREE SURFACES, POSTERIOR

$181

2394

RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, POSTERIOR

$207

2750

CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL

$670

2751

CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

$654

2752

CROWN-PORCELAIN FUSED TO NOBLE METAL

$663

2790

CROWN-FULL CAST HIGH NOBLE METAL

$685

2791

CROWN-FULL CAST PREDOMINANTLY BASE METAL

$649

2930

PREFABRICATED STAINLESS STEEL CROWN-PRIMARY

$134

2931

PREFABRICATED STAINLESS STEEL CROWN-PERMANENT

$150

2950

CORE BUILD-UP, INCLUDING ANY PINS

$131

2951

PIN RETENTION/TOOTH, IN ADDITION TO RESTORATION

$33

2952

CAST POST AND CORE IN ADDITION TO CROWN

$217

2954

PREFABRICATED POST AND CORE IN ADDITION TO CROWN

$164

ENDODONTICS

3110

PULP CAP-DIRECT (EXCLUDING FINAL RESTORATION)

$33

3120

PULP CAP-INDIRECT (EXCLUDING FINAL RESTORATION)

$31

3220

THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION)

$76

3310

ROOT CANAL-ANTERIOR (EXCLUDING FINAL RESTORATION)

$411

3320

ROOT CANAL-BICUSPID (EXCLUDING FINAL RESTORATION)

$487

3330

ROOT CANAL-MOLAR (EXCLUDING FINAL RESTORATION)

$611

PERIODONTICS

4210

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

$424

4341

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

$138

4910

PERIODONTAL MAINTENANCE

$86

PROSTHODONTICS (REMOVABLE)

5110

COMPLETE DENTURE-MAXILLARY

$888

5120

COMPLETE DENTURE-MANDIBULAR

$888

5130

IMMEDIATE DENTURE-MAXILLARY

$935

5140

IMMEDIATE DENTURE-MANDIBULAR

$935

5211

MAXILLARY PARTIAL DENTURE-RESIN BASE (CLASP/RESTS)

$873

5212

MANDIBULAR PARTIAL DENTURE-RESIN BASE (CLASP/RESTS)

$873

5213

MAXILLARY PARTIAL DENTURE-METAL FRAME WITH RESIN BASE

$997

5214

MANDIBULAR PARTIAL DENTURE-METAL FRAME WITH RESIN BASE

$997

5410

ADJUST COMPLETE DENTURE-MAXILLARY

$47

5411

ADJUST COMPLETE DENTURE-MANDIBULAR

$47

5510

REPAIR BROKEN COMPLETE DENTURE BASE

$81

5520

REPLACE MISSING OR BROKEN TEETH-COMPLETE DENTURE (EACH TOOTH)

$76

5630

REPAIR OR REPLACE BROKEN CLASP, PARTIAL DENTURE

$93

5650

ADD TOOTH TO EXISTING PARTIAL DENTURE

$81

5660

ADD CLASP TO EXISTING PARTIAL DENTURE

$102

5730

RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE)

$185

5731

RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE)

$185

5740

RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE)

$174

5741

RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE)

$174

5750

RELINE COMPLETE MAXILLARY DENTURE (LABORATORY)

$240

5751

RELINE COMPETE MANDIBULAR DENTURE (LABORATORY)

$240

PROSTHODONTICS (FIXED)

6240

PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL

$614

6241

PONTIC-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

$567

6242

PONTIC-PORCELAIN FUSED TO NOBLE METAL

$586

6750

CROWN-RETAINER-PORCELAIN FUSED TO HIGH NOBLE METAL

$654

6751

CROWN-RETAINER-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

$616

6752

CROWN-RETAINER-PORCELAIN FUSED TO NOBLE METAL

$640

ORAL SURGERY

7140

EXTRACTION-ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPTS REMOVAL)

$76

7220

REMOVAL OF IMPACTED TOOTH-SOFT TISSUE

$157

7230

REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY

$204

7240

REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY

$267

7250

SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE)

$147

7310

ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS-PER QUADRANT

$131

7320

ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS-PER QUADRANT

$189

7510

INCISION AND DRAINAGE ABSCESS-INTRAORAL SOFT TISSUE

$97

ORTHODONTICS

ADJUNCTIVE SERVICES

9110

PALLIATIVE (EMERGENCY) TREATMENT-DENTAL PAIN-MINOR PROCEDURE

$50

9215

LOCAL ANESTHESIA

$20

9230

ANALGESIA

$33

9951

OCCLUSAL ADJUSTMENT-LIMITED

$70

9952

OCCLUSAL ADJUSTMENT-COMPLETE

$283

*This schedule applies to services provided by a participating CAREINGTON General Dentist. The purpose of this schedule is to establish the fee that a General Dentist will charge for each procedure. Member is responsible for all charges at the time of service. Participating Specialists (Board Certified or Advanced Degree) do not charge according to a fee schedule. Participating Specialists will give up to a 20% discount off of their normal fees. Fee schedules are subject to change without prior notification to members.

*It is the Member’s responsibility to verify that the dentist is a participating Provider before seeking any treatment. Any dental procedures performed by a non-participating dentist are not discounted and are charged at the dentist's normal fees.

*The dollar amount specified adjacent to each procedure may not be the only cost incurred for a given treatment - many treatments may require more than one dental procedure. Please consult your CAREINGTON provider for a detailed treatment plan prior to beginning any work.

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

*Implants and some whitening procedures will not be discounted by all participating CAREINGTON providers. Implants and some whitening procedures will only be discounted if the participating CAREINGTON provider has agreed to discount these procedures as part of their contract. These services will be offered, when applicable, at a 15% discount off of the provider's normal fee.

*If the General Dentist's normal fee for any procedure is less than the fee listed on this schedule, the dentist will charge 20% off of their normal fee for that procedure.

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

*CAREINGTON can not guarantee the continued participation of any dentist. If the dentist leaves the plan, you will need to select another participating CAREINGTON provider. Not all types of dentists may be available in your area.

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

*While all participating CAREINGTON providers are professionally licensed in the state in which they practice, CAREINGTON does not guarantee the quality of service of the providers. Any quality of care concerns involving any participating CAREINGTON provider should be directed in writing to: CAREINGTON International, Attn. Provider Relations, PO Box 2568, Frisco, Texas 75034.