Plan 501 Full Schedule

ADA
CODE

DIAGNOSTIC

MEMBER
PAYS

0120

PERIODIC ORAL EVALUATION

$15

0140

LIMITED ORAL EVALUATION-PROBLEM FOCUSED

$19

0150

COMPREHENSIVE ORAL EVALUATION-NEW OR ESTABLISHED PATIENT

$19

0210

INTRAORAL-COMPLETE SERIES INCLUDING BITEWINGS

$43

0220

INTRAORAL-PERIAPICAL-FIRST FILM

$11

0230

INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM

$6

0270

BITEWING-SINGLE FILM

$11

0272

BITEWINGS-TWO FILMS

$14

0273

BITEWINGS-THREE FILMS

$18

0274

BITEWINGS-FOUR FILMS

$22

0330

PANORAMIC FILM

$43

PREVENTIVE

1110

ADULT CLEANING (PROPHYLAXIS)

$31

1120

CHILD CLEANING (PROPHYLAXIS)

$23

1351

SEALANT-PER TOOTH

$22

1510

SPACE MAINTAINER-FIXED-UNILATERAL

$87

1515

SPACE MAINTAINER-FIXED-BILATERAL

 

$137

1520

SPACE MAINTAINER-REMOVABLE-UNILATERAL

$122

1525

SPACE MAINTAINER-REMOVABLE-BILATERAL

$154

RESTORATIVE

2140

AMALGAM FILLING-ONE SURFACE, PRIMARY OR PERMANENT

$43

2150

AMALGAM FILLING-TWO SURFACES, PRIMARY OR PERMANENT

$55

2160

AMALGAM FILLING-THREE SURFACES, PRIMARY OR PERMANENT

$65

2161

AMALGAM FILLING-FOUR OR MORE SURFACES, PRIMARY OR PERMANENT

$79

2330

RESIN-BASED COMPOSITE FILLING-ONE SURFACE, ANTERIOR

$55

2331

RESIN-BASED COMPOSITE FILLING-TWO SURFACES, ANTERIOR

$66

2332

RESIN-BASED COMPOSITE FILLING-THREE SURFACES, ANTERIOR

$83

2335

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

$106

2391

RESIN-BASED COMPOSITE FILLING-ONE SURFACE, POSTERIOR

$69

2392

RESIN-BASED COMPOSITE FILLING-TWO SURFACES, POSTERIOR

$102

2393

RESIN-BASED COMPOSITE FILLING-THREE SURFACES, POSTERIOR

$129

2394

RESIN-BASED COMPOSITE FILLING-FOUR OR MORE SURFACES, POSTERIOR

$149

2710

CROWN-RESIN BASED COMPOSITE (INDIRECT)

$206

2720

CROWN-RESIN WITH HIGH NOBLE METAL

$435

2750

CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL

$511

2751

CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

$462

2752

CROWN-PORCELAIN FUSED TO NOBLE METAL

$483

2790

CROWN-FULL CAST HIGH NOBLE METAL

$502

2791

CROWN-FULL CAST PREDOMINANTLY BASE METAL

$450

2930

PREFABRICATED STAINLESS STEEL CROWN-PRIMARY

$100

2931

PREFABRICATED STAINLESS STEEL CROWN-PERMANENT

$114

2950

CORE BUILD-UP, INCLUDING ANY PINS

$100

2951

PIN RETENTION/TOOTH, IN ADDITION TO RESTORATION

$25

2952

CAST POST AND CORE IN ADDITION TO CROWN

$158

2954

PREFABRICATED POST AND CORE IN ADDITION TO CROWN

$123

ENDODONTICS

3110

PULP CAP-DIRECT (EXCLUDING FINAL RESTORATION)

$23

3120

PULP CAP-INDIRECT (EXCLUDING FINAL RESTORATION)

$23

3220

THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION)

$55

3310

ROOT CANAL-ANTERIOR (EXCLUDING FINAL RESTORATION)

$294

3320

ROOT CANAL-BICUSPID (EXCLUDING FINAL RESTORATION)

$348

3330

ROOT CANAL-MOLAR (EXCLUDING FINAL RESTORATION)

$438

PERIODONTICS

4210

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

$293

4341

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

$102

4910

PERIODONTAL MAINTENANCE

$65

PROSTHODONTICS (REMOVABLE)

5110

COMPLETE DENTURE-MAXILLARY

$643

5120

COMPLETE DENTURE-MANDIBULAR

$643

5130

IMMEDIATE DENTURE-MAXILLARY

$669

5140

IMMEDIATE DENTURE-MANDIBULAR

$669

5211

MAXILLARY PARTIAL DENTURE-RESIN BASE (CLASP/RESTS)

$630

5212

MANDIBULAR PARTIAL DENTURE-RESIN BASE (CLASP/RESTS)

$630

5213

MAXILLARY PARTIAL DENTURE-METAL FRAME WITH RESIN BASE

$729

5214

MANDIBULAR PARTIAL DENTURE-METAL FRAME WITH RESIN BASE

$729

5410

ADJUST COMPLETE DENTURE-MAXILLARY

$37

5411

ADJUST COMPLETE DENTURE-MANDIBULAR

$37

5510

REPAIR BROKEN COMPLETE DENTURE BASE

$57

5520

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

$55

5630

REPAIR OR REPLACE BROKEN CLASP, PARTIAL DENTURE

$66

5650

ADD TOOTH TO EXISTING PARTIAL DENTURE

$57

5660

ADD CLASP TO EXISTING PARTIAL DENTURE

$73

5730

RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE)

 

$136

5731

RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE)

 

$136

5740

RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE)

 

$130

5741

RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE)

 

$130

5750

RELINE COMPLETE MAXILLARY DENTURE (LABORATORY)

$178

5751

RELINE COMPETE MANDIBULAR DENTURE (LABORATORY)

$178

IMPLANTS (6000-6096): 20% Discount

PROSTHODONTICS (FIXED)

6240

PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL

$444

6241

PONTIC-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

$409

6242

PONTIC-PORCELAIN FUSED TO NOBLE METAL

$427

6750

CROWN-RETAINER-PORCELAIN FUSED TO HIGH NOBLE METAL

$489

6751

CROWN-RETAINER-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

$441

6752

CROWN-RETAINER-PORCELAIN FUSED TO NOBLE METAL

$458

ORAL SURGERY

7140

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

$55

7210

SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING ELEVATION OF MUCOPERIOSTEAL

 

$140

7220

REMOVAL OF IMPACTED TOOTH-SOFT TISSUE

$112

7230

REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY

$147

7240

REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY

$212

7250

SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE)

$112

7310

ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS-PER QUADRANT

$94

7320

ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS-PER QUADRANT

 

$135

7510

INCISION AND DRAINAGE ABSCESS-INTRAORAL SOFT TISSUE

$69

ORTHODONTICS

8070

COMPLETE ORTHODONTIC TREATMENT-TRANSITIONAL DENTITION

20% Discount

8080

COMPLETE ORTHODONTIC TREATMENT-ADOLESCENT DENTITION

20% Discount

8090

COMPLETE ORHTODONTIC TREATMENT-ADULT DENTITION

20% Discount

ADJUNCTIVE SERVICES

9110

PALLIATIVE (EMERGENCY) TREATMENT-DENTAL PAIN-MINOR PROCEDURE

$37

9215

LOCAL ANESTHESIA

$13

9230

ANALGESIA

$26

9951

OCCLUSAL ADJUSTMENT-LIMITED

$51

9952

OCCLUSAL ADJUSTMENT-COMPLETE

$203

*This schedule applies to services provided by a participating CareingtonGeneral 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.

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

*Any procedure involving lab fees will incur additional costs. All applicable lab fees are the responsibility of the member and are subject to no discount.

*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.

Careington 501 Fee Schedule

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Instructions For Use: To determine what you pay at the dentists, find the ADA (American Dental Association) code number or service number on your dental estimate and match the 4 digit number in the left column.  Once the discount is applied, what you pay the dentist can be seen in the right column.  If you do not have the ADA codes, call your dental office and ask for them!  CLICK HERE to download and print out this fee schedule in PDF format. If your ADA code is NOT listed in the fee schedule, then your discount will be 20%.*  Call us at 1-855-568-6447 with any questions.                               

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