To determine what you pay at the dentist, 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.  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.

Plan 503 Full Schedule

ADA CODE

DIAGNOSTIC

MEMBER PAYS

0120

PERIODIC ORAL EVALUATION

$17

0140

LIMITED ORAL EVALUATION-PROBLEM FOCUSED

$19

0150

COMPREHENSIVE ORAL EVALUATION-NEW OR ESTABLISHED PATIENT

$22

0210

INTRAORAL-COMPLETE SERIES INCLUDING BITEWINGS

$52

0220

INTRAORAL-PERIAPICAL-FIRST FILM

$12

0230

INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM

$8

0270

BITEWING-SINGLE FILM

$12

0272

BITEWINGS-TWO FILMS

$16

0273

BITEWINGS-THREE FILMS

$22

0274

BITEWINGS-FOUR FILMS

$26

0330

PANORAMIC FILM

$52

PREVENTIVE

1110

ADULT CLEANING (PROPHYLAXIS)

$38

1120

CHILD CLEANING (PROPHYLAXIS)

$31

1351

SEALANT-PER TOOTH

$26

1510

SPACE MAINTAINER-FIXED-UNILATERAL

$112

1515

SPACE MAINTAINER-FIXED-BILATERAL

$165

1520

SPACE MAINTAINER-REMOVABLE-UNILATERAL

$147

1525

SPACE MAINTAINER-REMOVABLE-BILATERAL

$188

RESTORATIVE

2140

AMALGAM FILLING-ONE SURFACE, PRIMARY OR PERMANENT

$52

2150

AMALGAM FILLING-TWO SURFACES, PRIMARY OR PERMANENT

$66

2160

AMALGAM FILLING-THREE SURFACES, PRIMARY OR PERMANENT

$78

2161

AMALGAM FILLING-FOUR OR MORE SURFACES, PRIMARY OR PERMANENT

$95

2330

RESIN-BASED COMPOSITE FILLING-ONE SURFACE, ANTERIOR

$66

2331

RESIN-BASED COMPOSITE FILLING-TWO SURFACES, ANTERIOR

$79

2332

RESIN-BASED COMPOSITE FILLING-THREE SURFACES, ANTERIOR

$100

2335

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

$126

2391

RESIN-BASED COMPOSITE FILLING-ONE SURFACE, POSTERIOR

$83

2392

RESIN-BASED COMPOSITE FILLING-TWO SURFACES, POSTERIOR

$119

2393

RESIN-BASED COMPOSITE FILLING-THREE SURFACES, POSTERIOR

$150

2394

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

$173

2710

CROWN-RESIN BASED COMPOSITE (INDIRECT)

$246

2720

CROWN-RESIN WITH HIGH NOBLE METAL

$522

2750

CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL

$618

2751

CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

$562

2752

CROWN-PORCELAIN FUSED TO NOBLE METAL

$603

2790

CROWN-FULL CAST HIGH NOBLE METAL

$603

2791

CROWN-FULL CAST PREDOMINANTLY BASE METAL

$562

2930

PREFABRICATED STAINLESS STEEL CROWN-PRIMARY

$121

2931

PREFABRICATED STAINLESS STEEL CROWN-PERMANENT

$137

2950

CORE BUILD-UP, INCLUDING ANY PINS

$121

2951

PIN RETENTION/TOOTH, IN ADDITION TO RESTORATION

$29

2952

CAST POST AND CORE IN ADDITION TO CROWN

$190

2954

PREFABRICATED POST AND CORE IN ADDITION TO CROWN

$148

ENDODONTICS

3110

PULP CAP-DIRECT (EXCLUDING FINAL RESTORATION)

$27

3120

PULP CAP-INDIRECT (EXCLUDING FINAL RESTORATION)

$27

3220

THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION)

$66

3310

ROOT CANAL-ANTERIOR (EXCLUDING FINAL RESTORATION)

$352

3320

ROOT CANAL-BICUSPID (EXCLUDING FINAL RESTORATION)

$419

3330

ROOT CANAL-MOLAR (EXCLUDING FINAL RESTORATION)

$526

PERIODONTICS

4210

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

$351

4341

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

$125

4910

PERIODONTAL MAINTENANCE

$75

PROSTHODONTICS (REMOVABLE)

5110

COMPLETE DENTURE-MAXILLARY

$758

5120

COMPLETE DENTURE-MANDIBULAR

$758

5130

IMMEDIATE DENTURE-MAXILLARY

$787

5140

IMMEDIATE DENTURE-MANDIBULAR

$787

5211

MAXILLARY PARTIAL DENTURE-RESIN BASE (CLASP/RESTS)

$740

5212

MANDIBULAR PARTIAL DENTURE-RESIN BASE (CLASP/RESTS)

$740

5213

MAXILLARY PARTIAL DENTURE-METAL FRAME WITH RESIN BASE

$860

5214

MANDIBULAR PARTIAL DENTURE-METAL FRAME WITH RESIN BASE

$860

5410

ADJUST COMPLETE DENTURE-MAXILLARY

$43

5411

ADJUST COMPLETE DENTURE-MANDIBULAR

$43

5510

REPAIR BROKEN COMPLETE DENTURE BASE

$69

5520

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

$66

5630

REPAIR OR REPLACE BROKEN CLASP, PARTIAL DENTURE

$79

5650

ADD TOOTH TO EXISTING PARTIAL DENTURE

$69

5660

ADD CLASP TO EXISTING PARTIAL DENTURE

$87

5730

RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE)

$164

5731

RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE)

$164

5740

RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE)

$154

5741

RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE)

$154

5750

RELINE COMPLETE MAXILLARY DENTURE (LABORATORY)

$213

5751

RELINE COMPETE MANDIBULAR DENTURE (LABORATORY)

$213

IMPLANTS (ADA #6000-6096): 20% Discount

PROSTHODONTICS (FIXED)

6240

PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL

$530

6241

PONTIC-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

$490

6242

PONTIC-PORCELAIN FUSED TO NOBLE METAL

$512

6750

CROWN-RETAINER-PORCELAIN FUSED TO HIGH NOBLE METAL

$580

6751

CROWN-RETAINER-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

$528

6752

CROWN-RETAINER-PORCELAIN FUSED TO NOBLE METAL

$550

ORAL SURGERY

7140

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

$66

7210

SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING ELEVATION OF MUCOPERIOSTEAL

$160

7220

REMOVAL OF IMPACTED TOOTH-SOFT TISSUE

$135

7230

REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY

$175

7240

REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY

$246

7250

SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE)

$127

7310

ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS-PER QUADRANT

$112

7320

ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS-PER QUADRANT

$163

7510

INCISION AND DRAINAGE ABSCESS-INTRAORAL SOFT TISSUE

$83

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

$43

9215

LOCAL ANESTHESIA

$16

9230

ANALGESIA

$29

9951

OCCLUSAL ADJUSTMENT-LIMITED

$59

9952

OCCLUSAL ADJUSTMENT-COMPLETE

$242

*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.

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

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503 Fee Schedule

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