Schedule of Benefits 507

ADA CODE	DIAGNOSTIC AND PREVENTIVE SERVICES	MEMBER PAYS
0120	PERIODIC ORAL EVALUATION	$19.00
0140	LIMITED ORAL EVALUATION--PROBLEM FOCUS	$28.00
0150	COMPREHENSIVE ORAL EVALUATION	$32.00
0210	INTRAORAL--COMPLETE SERIES (INC. BITEWINGS)	$55.00
0220	INTRAORAL--PERIAPICAL--1ST FILM	$11.00
0230	INTRAORAL PERIAPICAL--EACH ADDITIONAL FILM	$8.00
0270	BITEWING--SINGLE FILM	$10.00
0272	BITEWINGS--TWO FILMS	$15.00
0274	BITEWINGS--FOUR FILMS	$22.00
0330	PANORAMIC FILM	$47.00
1110	PROPHY-ADULT (CLEANING)	$37.00
1120	PROPHY-CHILD (CLEANING)	$28.00
1201	TOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHY)-CHILD	$38.00
1351	SEALANT-PER TOOTH	$22.00
1510	SPACE MAINTAINER-FIXED-UNILATERAL	$138.00
1515	SPACE MAINTAINER-FIXED-BILATERAL	$196.00
1520	SPACE MAINTAINER-REMOVEABLE-UNILATERAL	$164.00
1525	SPACE MAINTAINER-REMOVEABLE-BILATERAL	$205.00
RESTORATIVE
2110	AMALGAM-ONE SURFACE PRIMARY	$43.00
2120	AMALGAM-TWO SURFACE PRIMARY	$54.00
2130	AMALGAM-THREE SURFACE PRIMARY	$65.00
2131	AMALGAM-FOUR OR MORE-PRIMARY	$78.00
2140	AMALGAM-ONE SURFACE PERMANENT	$46.00
2150	AMALGAM-TWO SURFACE PERMANENT	$61.00
2160	AMALGAM-THREE SURFACE PERMANENT	$73.00
2161	AMALGAM-FOUR OR MORE PERMANENT	$90.00
2330	RESIN-ONE SURFACE ANTERIOR	$57.00
2331	RESIN-TWO SURFACE ANTERIOR	$72.00
2332	RESIN-THREE SURFACE ANTERIOR	$93.00
2335	RESIN-FOUR OR MORE SURFACES	$115.00
2385	RESIN-ONE SURF-POSTERIOR-PERMANENT	$64.00
2386	RESIN-TWO SURF-POSTERIOR-PERMANENT	$90.00
2387	RESIN-THREE OR MORE-POSTERIOR PERMANENT	$115.00
	CROWNS
2750	CROWN-PORCELAIN FUSED HIGH NOBLE METAL	$491.00
2751	CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL	$440.00
2752	CROWN-PORCELAIN FUSED TO NOBLE METAL	$460.00
2790	CROWN-FULL CAST HIGH NOBLE METAL	$475.00
2791	CROWN-FULL CAST-PREDOMINANTLY BASE METAL	$415.00
2930	PREFAB STAINLESS STEEL CROWN- PRIMARY	$111.00
2931	PREFAB STAINLESS STEEL CROWN- PERMANENT	$128.00
2950	CORE BUILDUP-INCLUDING ANY PINS	$112.00
2951	PIN RETENTION/TOOTH IN ADDITION TO RESTORATION	$24.00
2952	CAST POST AND CORE IN ADDITION TO CROWN	$175.00
2954	PREFAB POST AND CORE IN ADDITION TO CROWN	$138.00
3110	PULP CAP DIRECT (EXCL FNL REST)	$29.00
3120	PULP CAP INDIRECT (EXCL FNL REST)	$29.00
3220	THERAPEUTIC PULPOTOMY (EXCL FNL REST)	$70.00
3310	ROOT CANAL--ANTERIOR (EXCL FNL REST)	$280.00
3320	ROOT CANAL--BICUSPID (EXCL FNL REST)	$336.00
3330	ROOT CANAL--MOLAR (EXCL FNL REST)	$423.00
	PERIODONTICS
4210	GINGIVECTOMY OR GINGIVOPLASTY/QUAD	$265.00
4341	PERIO SCALING AND ROOT PLANING/QUAD	$98.00
4910	PERIO MAINTENANCE	$57.00
	PROSTHODONTICS
5110	COMPLETE DENTURE-MAXILLARY	$632.00
5120	COMPLETE DENTURE-MANDIBULAR	$632.00
5130	IMMEDIATE DENTURE-MAXILLARY	$665.00
5140	IMMEDIATE DENTURE-MANDIBULAR	$670.00
5211	MAXILLARY PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)	$474.00
5212	MANDIBULAR PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)	$474.00
5213	MAXILLARY PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES(INCLUDING ANY CONVENTIONAL CLASPS, RESTS OR TEETH)	$680.00
5214	MAXILLARY PARTIAL DENT-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES(INCLUDING ANY CONVENTIONAL CLASPS, RESTS OR TEETH)	$683.00
5410	ADJUST COMPLETE DENTURE-MAXILLARY	$34.00
5411	ADJUST COMPLETE DENTURE-MANDIBULAR	$34.00
5510	REPAIR BROKEN COMPLETE DENTURE BASE	$76.00
5520	REPLACE MISSING/BROKEN TEETH	$69.00
5630	REPAIR OR REPLACE BROKEN CLASP	$98.00
5650	ADD TOOTH TO EXISTING PARTIAL DENTURE	$84.00
5660	ADD CLASP TO EXISTING PARTIAL DENTURE	$103.00
5730	RELINE COMPLETE MAX DENTURE (CHAIRSIDE)	$144.00
5731	RELINE COMPLETE MAND DENTURE (CHAIRSIDE)	$144.00
5740	RELINE MAX PARTIAL DENTURE (CHAIRSIDE)	$134.00
5741	RELINE MAND PARTIAL DENT (CHAIRSIDE)	$134.00
5750	RELINE COMPLETE MAX DENTURE (LAB)	$193.00
5761	RELINE COMPLETE MAND DENTURE (LAB)	$191.00
	FIXED PROSTHETICS
6240	PONTIC PORCELAIN FUSED TO HIGH NOBLE METAL	$474.00
6241	PONTIC-PORCELAIN FUSED TO PREDOM BASE METAL	$442.00
6242	PONTIC PORCELAIN FUSED TO NOBLE METAL	$457.00
6750	CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL	$490.00
6751	CROWN PORCELAIN FUSED TO PREDOM BASE METAL	$442.00
6752	CROWN-PORCELAIN FUSED TO NOBLE METAL	$458.00
	ORAL SURGERY
7110	SINGLE TOOTH EXTRACTION	$59.00
7120	EACH ADDITIONAL TOOTH	$55.00
7130	ROOT REMOVAL-EXPOSED ROOTS	$75.00
7220	REMOVAL OF IMPACTED TOOTH-SOFT TISSUE	$130.00
7230	REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY	$165.00
7240	REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY	$204.00
7250	SURG REMOVAL OF RESIDUAL TOOTH ROOTS	$120.00
7310	ALVEOLOPLASTY IN CONJUNCT W/ EXTRACTIONS/QUAD	$118.00
7320	ALVEOLOPLASTY NOT IN CONJUNCTION W/ EXT/QUAD	$166.00
7510	INCISION/DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE	$78.00
	ORTHODONTICS
8070	COMP ORTHO TREATMENT--TRANSITIONAL DENTITION	20% discount
8080	COMP ORTHO TREATMENT--ADOLESCENT DENTITION	20% discount
8090	COMP ORHTO TREATMENT--ADULT DENTITION	20% discount
	MISCELLANEOUS SERVICES
9110	PALLIATIVE TREATMENT DENT PAIN-MINOR PROCEDURE	$42.00
9215	LOCAL ANESTHESIA	$18.00
9230	ANALGESIA	$25.00
9951	OCCLUSAL ADJUSTMENT LIMITED	$65.00
9952	OCCLUSAL ADJUSTMENT COMPLETE	$265.00
* 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 the fee schedule. Participating Specialists will give up to a 20% discount off 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 with 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 as part of their contract. These services will be offered, when applicable, at a 15% discount off 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 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 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.