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Dental Fee Schedule - 501

This Careington dental plan fee schedule provides for discount dental work by in-network providers in the following states:
Alabama, Florida, Georgia, Illinois, Kansas, Kentucky, Louisiana, Minnesota, Missouri, Mississippi, Nebraska, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, Virginia.

Anesthesia	Extractions	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	$65	$16	75% off
0140	Limited Oral Evaluation - Problem Focused	$96	$21	78% off
0150	Comprehensive Oral Evaluation - New or Established Patient	$112	$21	81% off
0210	Intraoral - Complete Series of Radiographic Images	$163	$47	71% off
0220	Intraoral - Periapical - First Radiographic Image	$37	$12	67% off
0230	Intraoral - Periapical - Each Additional Radiographic Image	$31	$7	77% off
0270	Bitewing - Single Radiographic Image	$36	$12	66% off
0272	Bitewings - Two Radiographic Images	$57	$15	73% off
0273	Bitewings - Three Radiographic Images	$68	$20	70% off
0274	Bitewings - Four Radiographic Images	$81	$24	70% off
0330	Panoramic Radiographic Image	$140	$47	66% off

PREVENTIVE (Cleanings, etc.)
ADA code	Procedure	Typical Fee	You Pay	Savings
1110	Prophylaxis - Adult Cleaning	$114	$34	70% off
1120	Prophylaxis - Child Cleaning	$85	$25	70% off
1351	Sealant - Per Tooth	$70	$24	65% off
1510	Space Maintainer - Fixed - Unilateral	$381	$102	73% off
1520	Space Maintainer - Removable - Unilateral	$463	$133	71% off

RESTORATIVE (Fillings)
ADA code	Procedure	Typical Fee	You Pay	Savings
2140	Amalgam - One Surface, Primary or Permanent	$182	$47	74% off
2150	Amalgam - Two Surfaces, Primary or Permanent	$229	$60	73% off
2160	Amalgam - Three Surfaces, Primary or Permanent	$279	$71	74% off
2161	Amalgam - Four or More Surfaces, Primary or Permanent	$330	$86	73% off
2330	Resin - Based Composite - One Surface, Anterior	$208	$60	71% off
2331	Resin - Based Composite - Two Surfaces, Anterior	$252	$72	71% off
2332	Resin - Based Composite - Three Surfaces, Anterior	$309	$90	70% off
2335	Resin - Based Composite - Four or More Surfaces, Anterior	$386	$116	69% off
2391	Resin - Based Composite - One Surface, Posterior	$228	$75	67% off
2392	Resin - Based Composite - Two Surfaces, Posterior	$288	$111	61% off
2393	Resin - Based Composite - Three Surfaces, Posterior	$356	$141	60% off
2394	Resin - Based Composite - Four or More Surfaces, Posterior	$418	$162	61% off

RESTORATIVE (Crowns)
ADA code	Procedure	Typical Fee	You Pay	Savings
2710	Crown - Resin-Based Composite (indirect)	$1180	$225	80% off
2720	Crown- Resin With High Noble Metal	$1289	$474	63% off
2750	Crown - Porcelain Fused to High Noble Metal	$1389	$557	59% off
2751	Crown - Porcelain Fused to Predominantly Base Metal	$1295	$504	61% off
2752	Crown - Porcelain Fused to Noble Metal	$1324	$526	60% off
2790	Crown - Full Cast High Noble Metal	$1412	$547	61% off
2791	Crown - Full Cast Predominantly Base Metal	$1284	$491	61% off
2930	Prefabricated Stainless Steel Crown - Primary Tooth	$329	$109	66% off
2931	Prefabricated Stainless Steel Crown - Permanent Tooth	$397	$124	68% off
2950	Core Buildup - Including Any Pins	$329	$109	66% off
2951	Pin Retention Per Tooth in Addition to Restoration	$96	$27	71% off
2952	Post and Core in Addition to Crown, Indirectly Fabricated	$514	$172	66% off
2954	Prefabricated Post and Core in Addition to Crown	$408	$134	67% off

ENDODONTICS (Root Canals, etc.)
ADA code	Procedure	Typical Fee	You Pay	Savings
3110	Pulp Cap Direct (excluding final restoration)	$105	$25	76% off
3120	Pulp Cap Indirect (excluding final restoration)	$105	$25	76% off
3220	Therapeutic Pulpotomy (excluding final restoration)	$253	$60	76% off
3310	Endodontic Therapy - Anterior Tooth (excluding final restoration)	$925	$320	65% off
3320	Endodontic Therapy - Bicuspid Tooth (excluding final restoration)	$1048	$379	63% off
3330	Endodontic Therapy - Molar (excluding final restoration)	$1290	$477	63% 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 Bonded Spaces Per Quadrant	$782	$319	59% off
4341	Periodontal Scaling and Root Planing - Four or More Teeth Per Quadrant	$316	$111	64% off
4910	Periodontal Maintenance	$169	$71	57% off

PROSTHODONTICS (Dentures - Removable, Partials, etc.)
ADA code	Procedure	Typical Fee	You Pay	Savings
5110	Complete Denture - Maxillary	$2154	$701	67% off
5120	Complete Denture - Mandibular	$2175	$701	67% off
5130	Immediate Denture - Maxillary	$2300	$729	68% off
5140	Immediate Denture - Mandibular	$2323	$729	68% off
5211	Maxillary Partial Denture - Resin Base (including any conventional clasps, rests and teeth)	$1719	$687	60% off
5212	Mandibular Partial Denture - Resin Base (including any conventional clasps, rests and teeth)	$1714	$687	59% off
5213	Maxillary Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, rests and teeth)	$2222	$795	64% off
5214	Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, rests and teeth)	$2225	$795	64% off
5410	Adjust Complete Denture - Maxillary	$114	$40	64% off
5411	Adjust Complete Denture - Mandibular	$112	$40	64% off
5520	Replace Missing or Broken Teeth - Complete Denture (each tooth)	$250	$60	76% off
5630	Repair or Replace Broken Clasp	$333	$72	78% off
5650	Add Tooth to Existing Partial Denture	$285	$62	78% off
5660	Add Clasp to Existing Partial Denture	$333	$80	75% off
5730	Reline Complete Maxillary Denture (chairside)	$475	$148	68% off
5731	Reline Complete Mandibular Denture (chairside)	$468	$148	68% off
5740	Reline Maxillary Partial Denture (chairside)	$463	$142	69% off
5741	Reline Mandibular Partial Dent (chairside)	$469	$142	69% off
5750	Reline Complete Maxillary Denture (lab)	$584	$194	66% off
5751	Reline Complete Mandibular Denture (lab)	$584	$194	66% off

PROSTHODONTICS - FIXED (Bridges, Dentures, etc.)
ADA code	Procedure	Typical Fee	You Pay	Savings
6040	Surgical Placement: Eposteal Implant	$8655	20% Discount	$1731 off
6050	Surgical Placement: Transosteal Implant	$6332	20% Discount	$1266 off
6065	Implant Supported Porcelain/Ceramic Crown	$1799	20% Discount	$359 off
6066	Implant Supported Porcelain Fused To Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1808	20% Discount	$361 off
6067	Implant Supported Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1879	20% Discount	$375 off
6240	Pontic - Porcelain Fused to High Noble Metal	$1379	$484	64% off
6241	Pontic - Porcelain Fused to Predominantly Base Metal	$1300	$446	65% off
6242	Pontic - Porcelain Fused to Noble Metal	$1335	$465	65% off
6750	Crown - Porcelain Fused to High Noble Metal	$1396	$533	61% off
6751	Crown - Porcelain Fused to Predominantly Base Metal	$1291	$481	62% off
6752	Crown - Porcelain Fused to Noble Metal	$1318	$499	62% off

ORAL SURGERY (Tooth Extractions, etc.)
ADA code	Procedure	Typical Fee	You Pay	Savings
7140	Extraction, Erupted Tooth or Exposed Root (elevation and/or forcepts removal)	$236	$60	74% off
7210	Surgical Removal of Erupted Tooth Requiring Removal of Bone and/or Sectioning of Tooth, and Including Elevation of Mucoperiosteal Flap if Indicated	$355	$153	56% off
7220	Removal of Impacted Tooth - Soft Tissue	$390	$122	68% off
7230	Removal of Impacted Tooth - Partially Bony	$488	$160	67% off
7240	Removal of Impacted Tooth - Completely Bony	$599	$231	61% off
7250	Surgical Removal of Residual Tooth Roots (cutting procedure)	$384	$122	68% off
7310	Alveoloplasty in Conjunction with Extraction - Four or More Teeth or Tooth Spaces, Per Quadrant	$388	$102	73% off
7320	Alveoloplasty not in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per Quadrant	$580	$147	74% off
7510	Incision and Drainage of Abscess - Intraoral Soft Tissue	$305	$75	75% off

ORTHODONTICS (Braces - Children and Adults, etc.)
ADA code	Procedure	Typical Fee	You Pay	Savings
8070	Comprehensive Orthodontic Treatment of the Transitional Dentition	$5979	20% Discount	$1195 off
8080	Comprehensive Orthodontic Treatment of the Adolescent Dentition	$6090	20% Discount	$1218 off
8090	Comprehensive Orthodontic Treatment of the Adult Dentition	$6020	20% Discount	$1204 off

ADJUNCTIVE SERVICES (Anesthesia, Analgesia, etc.)
ADA code	Procedure	Typical Fee	You Pay	Savings
9110	Palliative (emergency) Treatment Dental Pain - Minor Procedure	$165	$40	75% off
9215	Local Anesthesia in Conjunction With Operative or Surgical Procedures	$77	$14	81% off
9230	Inhalation of Nitrous Oxide/Anxiolysis, Analgesia	$100	$28	72% off
9951	Occlusal Adjustment Limited	$236	$56	76% off
9952	Occlusal Adjustment Complete	$850	$221	74% off

DISCLAIMERS
* Typical fees based on the 80th percentile of the National Dental Advisory Service Comprehensive Fee Report for 2017 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]