CAREINGTON Schedule 501

Plan 501 Schedule
ADA CODE	DIAGNOSTIC AND PREVENTIVE SERVICES	MEMBER PAYS
0120	PERIODIC ORAL EVALUATION	$13.00
0140	LIMITED ORAL EVALUATION-PROBLEM FOCUS	$15.00
0150	COMPREHENSIVE ORAL EVALUATION-NEW OR ESTABLISHED PATIENT	$15.00
0210	X-RAYS-INTRAORAL-COMPLETE SERIES (INCLUDING BITEWINGS)	$38.00
0220	X-RAYS-INTRAORAL-PERIAPICAL-1ST FILM	$9.00
0230	X-RAYS-INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM	$4.00
0270	BITEWING X-RAY-SINGLE FILM	$9.00
0272	BITEWINGS-TWO FILMS	$12.00
0273	BITEWINGS-THREE FILMS	$16.00
0274	BITEWINGS-FOUR FILMS	$19.00
0330	PANORAMIC FILM	$38.00
1110	PROPHYLAXIS-ADULT CLEANING	$27.00
1120	PROPHYLAXIS-CHILD CLEANING	$20.00
1201	TOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHYLAXIS)-CHILD	$25.00
1351	SEALANT-PER TOOTH	$19.00
1510	SPACE MAINTAINER-FIXED-UNILATERAL	$82.00
1515	SPACE MAINTAINER-FIXED-BILATERAL	$120.00
1520	SPACE MAINTAINER-REMOVEABLE-UNILATERAL	$107.00
1525	SPACE MAINTAINER-REMOVEABLE-BILATERAL	$135.00
RESTORATIVE
2140	AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT	$38.00
2150	AMALGAM-TWO SURFACES, PRIMARY OR PERMANENT	$48.00
2160	AMALGAM-THREE SURFACES, PRIMARY OR PERMANENT	$57.00
2161	AMALGAM-FOUR OR MORE SURFACES, PRIMARY OR PERMANENT	$69.00
2330	RESIN-BASED COMPOSITE-ONE SURFACE, ANTERIOR	$48.00
2331	RESIN-BASED COMPOSITE-TWO SURFACES, ANTERIOR	$58.00
2332	RESIN-BASED COMPOSITE-THREE SURFACES, ANTERIOR	$73.00
2335	RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, ANTERIOR	$92.00
2391	RESIN-BASED COMPOSITE-ONE SURFACE, POSTERIOR	$60.00
2392	RESIN-BASED COMPOSITE-TWO SURFACES, POSTERIOR	$89.00
2393	RESIN-BASED COMPOSITE-THREE SURFACES, POSTERIOR	$112.00
2394	RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, POSTERIOR	$130.00
2750	CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL	$446.00
2751	CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL	$404.00
2752	CROWN-PORCELAIN FUSED TO NOBLE METAL	$422.00
2790	CROWN-FULL CAST HIGH NOBLE METAL	$439.00
2791	CROWN-FULL CAST PREDOMINANTLY BASE METAL	$393.00
2930	PREFABRICATED STAINLESS STEEL CROWN-PRIMARY	$88.00
2931	PREFABRICATED STAINLESS STEEL CROWN-PERMANENT	$100.00
2950	CORE BUILDUP-INCLUDING ANY PINS	$88.00
2951	PIN RETENTION PER TOOTH IN ADDITION TO RESTORATION	$22.00
2952	CAST POST AND CORE IN ADDITION TO CROWN	$138.00
2954	PREFABRICATED POST AND CORE IN ADDITION TO CROWN	$108.00
ENDODONTICS
3110	PULP CAP DIRECT (EXCLUDING FINAL RESTORATION)	$20.00
3120	PULP CAP INDIRECT (EXCLUDING FINAL RESTORATION)	$20.00
3220	THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION)	$48.00
3310	ROOT CANAL-ANTERIOR (EXCLUDING FINAL RESTORATION)	$257.00
3320	ROOT CANAL-BICUSPID (EXCLUDING FINAL RESTORATION)	$304.00
3330	ROOT CANAL-MOLAR (EXCLUDING FINAL RESTORATION)	$383.00
PERIODONTICS
4210	GINGIVECTOMY OR GINGIVOPLASTY-FOUR OR MORE CONTIGUOUS TEETH OR BONDED TEETH SPACES PER QUADRANT	$256.00
4341	PERIODONTAL SCALING AND ROOT PLANING-FOUR OR MORE CONTIGUOUS TEETH OR BONDED TEETH SPACES PER QUADRANT	$89.00
4910	PERIODONTAL MAINTENANCE (FOLLOWING ACTIVE THERAPY)	$57.00
PROSTHODONTICS (REMOVABLE)
5110	COMPLETE DENTURE-MAXILLARY	$561.00
5120	COMPLETE DENTURE-MANDIBULAR	$561.00
5130	IMMEDIATE DENTURE-MAXILLARY	$584.00
5140	IMMEDIATE DENTURE-MANDIBULAR	$584.00
5211	MAXILLARY PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)	$550.00
5212	MANDIBULAR PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)	$550.00
5213	MAXILLARY PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS OR TEETH)	$637.00
5214	MANDIBULAR PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)	$637.00
5410	ADJUST COMPLETE DENTURE-MAXILLARY	$32.00
5411	ADJUST COMPLETE DENTURE-MANDIBULAR	$32.00
5510	REPAIR BROKEN COMPLETE DENTURE BASE	$50.00
5520	REPLACE MISSING OR BROKEN TEETH	$48.00
5630	REPAIR OR REPLACE BROKEN CLASP	$58.00
5650	ADD TOOTH TO EXISTING PARTIAL DENTURE	$50.00
5660	ADD CLASP TO EXISTING PARTIAL DENTURE	$64.00
5730	RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE)	$119.00
5731	RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE)	$119.00
5740	RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE)	$113.00
5741	RELINE MANDIBULAR PARTIAL DENT (CHAIRSIDE)	$113.00
5750	RELINE COMPLETE MAXILLARY DENTURE (LAB)	$156.00
5751	RELINE COMPLETE MANDIBULAR DENTURE (LAB)	$156.00
PROSTHODONTICS (FIXED)
6240	PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL	$388.00
6241	PONTIC-PORCELAIN FUSED TO PREDOM BASE METAL	$358.00
6242	PONTIC-PORCELAIN FUSED TO NOBLE METAL	$374.00
6750	CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL	$427.00
6751	CROWN-PORCELAIN FUSED TO PREDOM BASE METAL	$385.00
6752	CROWN-PORCELAIN FUSED TO NOBLE METAL	$400.00
ORAL SURGERY
7140	EXTRACTION,ERUPTED TOOTH OR EXPOSED ROOT	$48.00
7220	REMOVAL OF IMPACTED TOOTH-SOFT TISSUE	$98.00
7230	REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY	$128.00
7240	REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY	$185.00
7250	SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS	$98.00
7310	ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTION PER QUAD	$82.00
7320	ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTION PER QUAD	$118.00
7510	INCISION/DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE	$60.00
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
MISCELLANEOUS SERVICES
9110	PALLIATIVE TREATMENT DENTAL PAIN-MINOR PROCEDURE	$32.00
9215	LOCAL ANESTHESIA	$11.00
9230	ANALGESIA	$23.00
9951	OCCLUSAL ADJUSTMENT LIMITED	$44.00
9952	OCCLUSAL ADJUSTMENT COMPLETE	$177.00
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 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 joining 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.