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Careington - Plan 501 Schedule |
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ADA | MEMBER | |
0120 | PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT | $14 |
0140 | LIMITED ORAL EVALUATION - PROBLEM FOCUS | $18 |
0150 | COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED PATIENT | $18 |
0210 | X - RAYS - INTRAORAL - COMPLETE SERIES (INCLUDING BITEWINGS) | $40 |
0220 | X - RAYS - INTRAORAL - PERIAPICAL - 1ST FILM | $10 |
0230 | X - RAYS - INTRAORAL - PERIAPICAL - EACH ADDITIONAL FILM | $6 |
0270 | BITEWING - SINGLE FILM | $10 |
0272 | BITEWINGS - TWO FILMS | $13 |
0273 | BITEWINGS - THREE FILMS | $17 |
0274 | BITEWINGS - FOUR FILMS | $20 |
0330 | PANORAMIC FILM | $40 |
1110 | PROPHYLAXIS - ADULT CLEANING | $29 |
1120 | PROPHYLAXIS - CHILD CLEANING | $21 |
1351 | SEALANT - PER TOOTH | $20 |
1510 | SPACE MAINTAINER - FIXED - UNILATERAL | $87 |
1515 | SPACE MAINTAINER - FIXED - BILATERAL | $127 |
1520 | SPACE MAINTAINER - REMOVEABLE - UNILATERAL | $113 |
1525 | SPACE MAINTAINER - REMOVEABLE - BILATERAL | $143 |
2140 | AMALGAM - ONE SURFACE, PRIMARY OR PERMANENT | $40 |
2150 | AMALGAM - TWO SURFACES, PRIMARY OR PERMANENT | $51 |
2160 | AMALGAM - THREE SURFACES, PRIMARY OR PERMANENT | $60 |
2161 | AMALGAM - FOUR OR MORE SURFACES, PRIMARY OR PERMANENT | $73 |
2330 | RESIN - BASED COMPOSITE - ONE SURFACE, ANTERIOR | $51 |
2331 | RESIN - BASED COMPOSITE - TWO SURFACES, ANTERIOR | $61 |
2332 | RESIN - BASED COMPOSITE - THREE SURFACES, ANTERIOR | $77 |
2335 | RESIN - BASED COMPOSITE - FOUR OR MORE SURFACES, ANTERIOR | $98 |
2391 | RESIN - BASED COMPOSITE - ONE SURFACE, POSTERIOR | $64 |
2392 | RESIN - BASED COMPOSITE - TWO SURFACES, POSTERIOR | $94 |
2393 | RESIN - BASED COMPOSITE - THREE SURFACES, POSTERIOR | $119 |
2394 | RESIN - BASED COMPOSITE - FOUR OR MORE SURFACES, POSTERIOR | $138 |
2710 | CROWN - RESIN-BASED COMPOSITE (INDIRECT) | $191 |
2720 | CROWN- RESIN WITH HIGH NOBLE METAL | $403 |
2750 | CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL | $473 |
2751 | CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL | $428 |
2752 | CROWN - PORCELAIN FUSED TO NOBLE METAL | $447 |
2790 | CROWN - FULL CAST HIGH NOBLE METAL | $465 |
2791 | CROWN - FULL CAST PREDOMINANTLY BASE METAL | $417 |
2930 | PREFABRICATED STAINLESS STEEL CROWN - PRIMARY | $93 |
2931 | PREFABRICATED STAINLESS STEEL CROWN - PERMANENT | $106 |
2950 | CORE BUILDUP - INCLUDING ANY PINS | $93 |
2951 | PIN RETENTION PER TOOTH IN ADDITION TO RESTORATION | $23 |
2952 | POST AND CORE IN ADDITION TO CROWN, INDIRECTLY FABRICATED | $146 |
2954 | PREFABRICATED POST AND CORE IN ADDITION TO CROWN | $114 |
3110 | PULP CAP DIRECT (EXCLUDING FINAL RESTORATION) | $21 |
3120 | PULP CAP INDIRECT (EXCLUDING FINAL RESTORATION) | $21 |
3220 | THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) | $51 |
3310 | ROOT CANAL - ANTERIOR (EXCLUDING FINAL RESTORATION) | $272 |
3320 | ROOT CANAL - BICUSPID (EXCLUDING FINAL RESTORATION) | $322 |
3330 | ROOT CANAL - MOLAR (EXCLUDING FINAL RESTORATION) | $406 |
4210 | GINGIVECTOMY OR GINGIVOPLASTY - FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUADRANT | $271 |
4341 | PERIODONTAL SCALING AND ROOT PLANING - FOUR OR MORE TEETH PER QUADRANT | $94 |
4910 | PERIODONTAL MAINTENANCE | $60 |
5110 | COMPLETE DENTURE - MAXILLARY | $595 |
5120 | COMPLETE DENTURE - MANDIBULAR | $595 |
5130 | IMMEDIATE DENTURE - MAXILLARY | $619 |
5140 | IMMEDIATE DENTURE - MANDIBULAR | $619 |
5211 | MAXILLARY PARTIAL DENTURE - RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) | $583 |
5212 | MANDIBULAR PARTIAL DENTURE - RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) | $583 |
5213 | MAXILLARY PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) | $675 |
5214 | MANDIBULAR PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) | $675 |
5410 | ADJUST COMPLETE DENTURE - MAXILLARY | $34 |
5411 | ADJUST COMPLETE DENTURE - MANDIBULAR | $34 |
5510 | REPAIR BROKEN COMPLETE DENTURE BASE | $53 |
5520 | REPLACE MISSING OR BROKEN TEETH | $51 |
5630 | REPAIR OR REPLACE BROKEN CLASP | $61 |
5650 | ADD TOOTH TO EXISTING PARTIAL DENTURE | $53 |
5660 | ADD CLASP TO EXISTING PARTIAL DENTURE | $68 |
5730 | RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) | $126 |
5731 | RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) | $126 |
5740 | RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) | $120 |
5741 | RELINE MANDIBULAR PARTIAL DENT (CHAIRSIDE) | $120 |
5750 | RELINE COMPLETE MAXILLARY DENTURE (LAB) | $165 |
5751 | RELINE COMPLETE MANDIBULAR DENTURE (LAB) | $165 |
6040 | SURGICAL PLACEMENT: EPOSTEAL IMPLANT | 20% Discount |
6050 | SURGICAL PLACEMENT: TRANSOSTEAL IMPLANT | 20% Discount |
6065 | IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWN | 20% Discount |
6066 | IMPLANT SUPPORTED PORCELAIN FUSED TO METAL CROWN (TITANIUM, TITANIUM ALLOY, HIGH NOBLE METAL) | 20% Discount |
6067 | IMPLANT SUPPORTED METAL CROWN (TITANIUM, TITANIUM ALLOY, HIGH NOBLE METAL) | 20% Discount |
6240 | PONTIC - PORCELAIN FUSED TO HIGH NOBLE METAL | $411 |
6241 | PONTIC - PORCELAIN FUSED TO PREDOM BASE METAL | $379 |
6242 | PONTIC - PORCELAIN FUSED TO NOBLE METAL | $395 |
6750 | CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL | $453 |
6751 | CROWN - PORCELAIN FUSED TO PREDOM BASE METAL | $408 |
6752 | CROWN - PORCELAIN FUSED TO NOBLE METAL | $424 |
7140 | EXTRACTION,ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPTS | $51 |
7210 | SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING ELEVATION OF MUCOPERIOSTEAL | $130 |
7220 | REMOVAL OF IMPACTED TOOTH - SOFT TISSUE | $104 |
7230 | REMOVAL OF IMPACTED TOOTH - PARTIALLY BONY | $136 |
7240 | REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY | $196 |
7250 | SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS | $104 |
7310 | ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTION PER QUAD | $87 |
7320 | ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTION PER QUAD | $125 |
7510 | INCISION/DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE | $64 |
8070 | COMPLETE ORTHODONTIC TREATMENT - TRANSITIONAL DENTITION | 20% Discount |
8080 | COMPLETE ORTHODONTIC TREATMENT - ADOLESCENT DENTITION | 20% Discount |
8090 | COMPLETE ORHTODONTIC TREATMENT - ADULT DENTITION | 20% Discount |
9110 | PALLIATIVE TREATMENT DENTAL PAIN - MINOR PROCEDURE | $34 |
9215 | LOCAL ANESTHESIA | $12 |
9230 | ANALGESIA | $24 |
9951 | OCCLUSAL ADJUSTMENT LIMITED | $47 |
9952 | OCCLUSAL ADJUSTMENT COMPLETE | $188 |
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*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. 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. 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 full 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. Please call 800-372-7615 if you have any further questions. |
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