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Dental Fee Schedule - 508

This Careington dental plan fee schedule provides for discount dental work by in-network providers in the following states:
Washington.

Anesthesia	Extractions	Add Prescription Plan - $1/month Compare All Plans
Braces	Fillings
Cleaning	Lab Fees
Crowns	Root Canals
Deep Cleaning - Scaling	Oral Evaluation
Dentures - Fixed	Orthodontics
Dentures - Removable	X-Rays

DIAGNOSTIC (Exams, X-Rays)
ADA code	Procedure	Typical Fee	You Pay	Savings
0120	periodic oral evaluation - established patient	$54	$24	55% off
0140	limited oral evaluation - problem focused	$81	$36	55% off
0150	comprehensive oral evaluation - new or established patient	$95	$40	57% off
0210	intraoral - complete series (including bitewings)	$139	$70	49% off
0220	intraoral - periapical first film	$30	$13	56% off
0230	intraoral - periapical each additional film	$26	$10	61% off
0270	bitewing - single film	$30	$13	56% off
0272	bitewings - two films	$48	$21	56% off
0273	bitewings - three films	$60	$25	58% off
0274	bitewings - four films	$70	$30	57% off
0330	panoramic film	$117	$61	47% off

PREVENTIVE (Cleanings, etc.)
ADA code	Procedure	Typical Fee	You Pay	Savings
1110	prophylaxis - adult	$97	$49	49% off
1120	prophylaxis - child	$71	$34	52% off
1351	sealant - per tooth	$59	$28	52% off
1510	space maintainer - fixed - unilateral	$338	$178	47% off
1515	space maintainer - fixed - bilateral	$456	$254	44% off
1520	space maintainer - removable - unilateral	$414	$213	48% off
1525	space maintainer - removable - bilateral	$520	$265	49% off

RESTORATIVE (Fillings)
ADA code	Procedure	Typical Fee	You Pay	Savings
2140	amalgam - one surface, primary or permanent	$150	$66	56% off
2150	amalgam - two surfaces, primary or permanent	$191	$87	54% off
2160	amalgam - three surfaces, primary or permanent	$236	$103	56% off
2161	amalgam - four or more surfaces, primary or permanent	$276	$109	60% off
2330	resin-based composite - one surface, anterior	$174	$80	54% off
2331	resin-based composite - two surfaces, anterior	$215	$102	52% off
2332	resin-based composite - three surfaces, anterior	$269	$127	52% off
2335	resin-based composite - four or more surfaces or involving incisal angle (anterior)	$334	$156	53% off
2391	resin-based composite - one surface, posterior	$193	$91	52% off
2392	resin-based composite - two surfaces, posterior	$250	$123	50% off
2393	resin-based composite - three surfaces, posterior	$310	$158	49% off
2394	resin-based composite - four or more surfaces, posterior	$369	$190	48% off

RESTORATIVE (Crowns)
ADA code	Procedure	Typical Fee	You Pay	Savings
2710	crown - resin-based composite (indirect)	$1032	$261	74% off
2720	crown - resin with high noble metal	$1134	$554	51% off
2750	crown - porcelain fused to high noble metal	$1194	$667	44% off
2751	crown - porcelain fused to predominantly base metal	$1100	$596	45% off
2752	crown - porcelain fused to noble metal	$1125	$625	44% off
2790	crown - full cast high noble metal	$1200	$644	46% off
2791	crown - full cast predominantly base metal	$1061	$564	46% off
2930	prefabricated stainless steel crown - primary tooth	$285	$152	46% off
2931	prefabricated stainless steel crown - permanent tooth	$347	$174	49% off
2950	core buildup, including any pins	$285	$153	46% off
2951	pin retention - per tooth, in addition to restoration	$79	$33	58% off
2952	post and core in addition to crown, indirectly fabricated	$446	$239	46% off
2954	prefabricated post and core in addition to crown	$356	$188	47% off

ENDODONTICS (Root Canals, etc.)
ADA code	Procedure	Typical Fee	You Pay	Savings
3110	pulp cap - direct (excluding final restoration)	$88	$41	53% off
3120	pulp cap - indirect (excluding final restoration)	$90	$36	60% off
3220	therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament	$211	$98	53% off
3310	endodontic therapy, anterior tooth (excluding final restoration)	$774	$375	51% off
3320	endodontic therapy, bicuspid tooth (excluding final restoration)	$893	$457	48% off
3330	endodontic therapy, molar (excluding final restoration)	$1082	$575	46% off

PERIODONTICS (Scaling / Deep Cleaning / Root Planing, etc.)
ADA code	Procedure	Typical Fee	You Pay	Savings
4210	gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant	$675	$364	46% off
4341	periodontal scaling and root planing - four or more teeth per quadrant	$275	$139	49% off
4910	periodontal maintenance	$148	$75	49% off

PROSTHODONTICS (Dentures - Removable, Partials, etc.)
ADA code	Procedure	Typical Fee	You Pay	Savings
5110	complete denture - maxillary	$1825	$842	53% off
5120	complete denture - mandibular	$1825	$842	53% off
5130	immediate denture - maxillary	$1950	$892	54% off
5140	immediate denture - mandibular	$1951	$892	54% off
5211	maxillary partial denture - resin base (including any conventional clasps, rests and teeth)	$1447	$631	56% off
5212	mandibular partial denture - resin base (including any conventional clasps, rests and teeth)	$1450	$631	56% off
5213	maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)	$1898	$909	52% off
5214	mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)	$1900	$909	52% off
5410	adjust complete denture - maxillary	$95	$48	49% off
5411	adjust complete denture - mandibular	$95	$48	49% off
5510	repair broken complete denture base	$225	$103	54% off
5520	replace missing or broken teeth - complete denture (each tooth)	$200	$92	54% off
5630	repair or replace broken clasp	$280	$139	50% off
5650	add tooth to existing partial denture	$237	$117	50% off
5660	add clasp to existing partial denture	$289	$154	46% off
5730	reline complete maxillary denture (chairside)	$398	$211	46% off
5731	reline complete mandibular denture (chairside)	$395	$197	50% off
5740	reline maxillary partial denture (chairside)	$390	$189	51% off
5741	reline mandibular partial denture (chairside)	$395	$189	52% off
5750	reline complete maxillary denture (laboratory)	$509	$268	47% off
5751	reline complete mandibular denture (laboratory)	$509	$268	47% off

PROSTHODONTICS - FIXED (Bridges, Dentures, etc.)
ADA code	Procedure	Typical Fee	You Pay	Savings
6040	surgical placement: eposteal implant	$8682	20% Discount	$1736 off
6050	surgical placement: transosteal implant	$6003	20% Discount	$1200 off
6065	implant supported porcelain/ceramic crown	$1662	20% Discount	$332 off
6066	implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)	$1665	20% Discount	$333 off
6067	implant supported metal crown (titanium, titanium alloy, high noble metal)	$1687	20% Discount	$337 off
6240	pontic - porcelain fused to high noble metal	$1190	$643	45% off
6241	pontic - porcelain fused to predominantly base metal	$1100	$599	45% off
6242	pontic - porcelain fused to noble metal	$1129	$619	45% off
6750	crown - porcelain fused to high noble metal	$1195	$666	44% off
6751	crown - porcelain fused to predominantly base metal	$1082	$600	44% off
6752	crown - porcelain fused to noble metal	$1118	$621	44% off

ORAL SURGERY (Tooth Extractions, etc.)
ADA code	Procedure	Typical Fee	You Pay	Savings
7140	extraction, erupted tooth or exposed root (elevation and/or forceps removal)	$185	$80	56% off
7210	surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated	$294	$143	51% off
7220	removal of impacted tooth - soft tissue	$333	$174	47% off
7230	removal of impacted tooth - partially bony	$422	$224	46% off
7240	removal of impacted tooth - completely bony	$515	$277	46% off
7250	surgical removal of residual tooth roots (cutting procedure)	$333	$165	50% off
7310	alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant	$325	$158	51% off
7320	alveoloplasty not in conjunction with extractions -four or more teeth or tooth spaces, per quadrant	$475	$210	55% off
7510	incision and drainage of abscess - intraoral soft tissue	$250	$106	57% off

ORTHODONTICS (Braces - Children and Adults, etc.)
ADA code	Procedure	Typical Fee	You Pay	Savings
8070	comprehensive orthodontic treatment of the transitional dentition	$5478	20% Discount	$1095 off
8080	comprehensive orthodontic treatment of the adolescent dentition	$5534	20% Discount	$1106 off
8090	comprehensive orthodontic treatment of the adult dentition	$5561	20% Discount	$1112 off

ADJUNCTIVE SERVICES (Anesthesia, Analgesia, etc.)
ADA code	Procedure	Typical Fee	You Pay	Savings
9110	palliative (emergency) treatment of dental pain - minor procedure	$138	$59	57% off
9215	local anesthesia in conjunction with operative or surgical procedures	$70	$28	60% off
9230	inhalation of nitrous oxide / anxiolysis, analgesia	$85	$37	56% off
9951	occlusal adjustment - limited	$200	$88	56% off
9952	occlusal adjustment - complete	$747	$360	51% off

DISCLAIMERS
* Typical fees based on the 80th percentile of the National Dental Advisory Service Comprehensive Fee Report for 2009 General Information 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. [back to top of schedule] Lab Fees 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. [back to top of schedule] Providers 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 1-855-329-6303 if you have any further questions. [back to top of schedule]