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Dental Fee Schedule - 504

This Careington dental plan fee schedule provides for discount dental work by in-network providers in the following states:
District of Columbia, Iowa, North Carolina, New York, South Carolina, Virgin Islands.





back to topDIAGNOSTIC (Exams, X-Rays)
ADA code Procedure Typical Fee You Pay Savings
0120 Periodic Oral Evaluation - Established Patient $65 $20 69% off
0140 Limited Oral Evaluation - Problem Focused $96 $25 73% off
0150 Comprehensive Oral Evaluation - New or Established Patient $112 $25 77% off
0210 Intraoral - Complete Series of Radiographic Images $163 $62 61% off
0220 Intraoral - Periapical - First Radiographic Image $37 $14 62% off
0230 Intraoral - Periapical - Each Additional Radiographic Image $31 $9 70% off
0270 Bitewing - Single Radiographic Image $36 $14 61% off
0272 Bitewings - Two Radiographic Images $57 $19 66% off
0273 Bitewings - Three Radiographic Images $68 $25 63% off
0274 Bitewings - Four Radiographic Images $81 $32 60% off
0330 Panoramic Radiographic Image $140 $62 55% off
 
back to topPREVENTIVE (Cleanings, etc.)
ADA code Procedure Typical Fee You Pay Savings
1110 Prophylaxis - Adult Cleaning $114 $45 60% off
1120 Prophylaxis - Child Cleaning $85 $39 54% off
1351 Sealant - Per Tooth $70 $29 58% off
1510 Space Maintainer - Fixed - Unilateral $381 $134 64% off
1520 Space Maintainer - Removable - Unilateral $463 $178 61% off
 
back to topRESTORATIVE (Fillings)
ADA code Procedure Typical Fee You Pay Savings
2140 Amalgam - One Surface, Primary or Permanent $182 $62 65% off
2150 Amalgam - Two Surfaces, Primary or Permanent $229 $80 65% off
2160 Amalgam - Three Surfaces, Primary or Permanent $279 $94 66% off
2161 Amalgam - Four or More Surfaces, Primary or Permanent $330 $116 64% off
2330 Resin - Based Composite - One Surface, Anterior $208 $80 61% off
2331 Resin - Based Composite - Two Surfaces, Anterior $252 $95 62% off
2332 Resin - Based Composite - Three Surfaces, Anterior $309 $121 60% off
2335 Resin - Based Composite - Four or More Surfaces, Anterior $386 $152 60% off
2391 Resin - Based Composite - One Surface, Posterior $228 $101 55% off
2392 Resin - Based Composite - Two Surfaces, Posterior $288 $146 49% off
2393 Resin - Based Composite - Three Surfaces, Posterior $356 $187 47% off
2394 Resin - Based Composite - Four or More Surfaces, Posterior $418 $216 48% off
 
back to topRESTORATIVE (Crowns)
ADA code Procedure Typical Fee You Pay Savings
2710 Crown - Resin-Based Composite (indirect) $1180 $282 76% off
2720 Crown- Resin With High Noble Metal $1289 $598 53% off
2750 Crown - Porcelain Fused to High Noble Metal $1389 $701 49% off
2751 Crown - Porcelain Fused to Predominantly Base Metal $1295 $638 50% off
2752 Crown - Porcelain Fused to Noble Metal $1324 $680 48% off
2790 Crown - Full Cast High Noble Metal $1412 $687 51% off
2791 Crown - Full Cast Predominantly Base Metal $1284 $646 49% off
2930 Prefabricated Stainless Steel Crown - Primary Tooth $329 $146 55% off
2931 Prefabricated Stainless Steel Crown - Permanent Tooth $397 $166 58% off
2950 Core Buildup - Including Any Pins $329 $146 55% off
2951 Pin Retention Per Tooth in Addition to Restoration $96 $33 65% off
2952 Post and Core in Addition to Crown, Indirectly Fabricated $514 $229 55% off
2954 Prefabricated Post and Core in Addition to Crown $408 $179 56% off
 
back to topENDODONTICS (Root Canals, etc.)
ADA code Procedure Typical Fee You Pay Savings
3110 Pulp Cap Direct (excluding final restoration) $105 $33 68% off
3120 Pulp Cap Indirect (excluding final restoration) $105 $33 68% off
3220 Therapeutic Pulpotomy (excluding final restoration) $253 $80 68% off
3310 Endodontic Therapy - Anterior Tooth (excluding final restoration) $925 $399 56% off
3320 Endodontic Therapy - Bicuspid Tooth (excluding final restoration) $1048 $480 54% off
3330 Endodontic Therapy - Molar (excluding final restoration) $1290 $607 52% off
 
back to topPERIODONTICS (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 $422 46% off
4341 Periodontal Scaling and Root Planing - Four or More Teeth Per Quadrant $316 $138 56% off
4910 Periodontal Maintenance $169 $88 47% off
 
back to topPROSTHODONTICS (Dentures - Removable, Partials, etc.)
ADA code Procedure Typical Fee You Pay Savings
5110 Complete Denture - Maxillary $2154 $884 58% off
5120 Complete Denture - Mandibular $2175 $884 59% off
5130 Immediate Denture - Maxillary $2300 $952 58% off
5140 Immediate Denture - Mandibular $2323 $952 59% off
5211 Maxillary Partial Denture - Resin Base (including any conventional clasps, rests and teeth) $1719 $865 49% off
5212 Mandibular Partial Denture - Resin Base (including any conventional clasps, rests and teeth) $1714 $865 49% off
5213 Maxillary Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, rests and teeth) $2222 $1007 54% off
5214 Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, rests and teeth) $2225 $1007 54% off
5410 Adjust Complete Denture - Maxillary $114 $48 57% off
5411 Adjust Complete Denture - Mandibular $112 $48 57% off
5520 Replace Missing or Broken Teeth - Complete Denture (each tooth) $250 $80 68% off
5630 Repair or Replace Broken Clasp $333 $95 71% off
5650 Add Tooth to Existing Partial Denture $285 $83 70% off
5660 Add Clasp to Existing Partial Denture $333 $106 68% off
5730 Reline Complete Maxillary Denture (chairside) $475 $196 58% off
5731 Reline Complete Mandibular Denture (chairside) $468 $196 58% off
5740 Reline Maxillary Partial Denture (chairside) $463 $187 59% off
5741 Reline Mandibular Partial Dent (chairside) $469 $187 60% off
5750 Reline Complete Maxillary Denture (lab) $584 $258 55% off
5751 Reline Complete Mandibular Denture (lab) $584 $258 55% off
 
back to topPROSTHODONTICS - 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 $633 54% off
6241 Pontic - Porcelain Fused to Predominantly Base Metal $1300 $584 55% off
6242 Pontic - Porcelain Fused to Noble Metal $1335 $607 54% off
6750 Crown - Porcelain Fused to High Noble Metal $1396 $661 52% off
6751 Crown - Porcelain Fused to Predominantly Base Metal $1291 $613 52% off
6752 Crown - Porcelain Fused to Noble Metal $1318 $637 51% off
 
back to topORAL 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 $80 66% 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 $185 47% off
7220 Removal of Impacted Tooth - Soft Tissue $390 $164 57% off
7230 Removal of Impacted Tooth - Partially Bony $488 $211 56% off
7240 Removal of Impacted Tooth - Completely Bony $599 $276 53% off
7250 Surgical Removal of Residual Tooth Roots (cutting procedure) $384 $147 61% off
7310 Alveoloplasty in Conjunction with Extraction - Four or More Teeth or Tooth Spaces, Per Quadrant $388 $134 65% off
7320 Alveoloplasty not in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per Quadrant $580 $195 66% off
7510 Incision and Drainage of Abscess - Intraoral Soft Tissue $305 $101 66% off
 
back to topORTHODONTICS (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
 
back to topADJUNCTIVE SERVICES (Anesthesia, Analgesia, etc.)
ADA code Procedure Typical Fee You Pay Savings
9110 Palliative (emergency) Treatment Dental Pain - Minor Procedure $165 $50 69% off
9215 Local Anesthesia in Conjunction With Operative or Surgical Procedures $77 $19 75% off
9230 Inhalation of Nitrous Oxide/Anxiolysis, Analgesia $100 $34 66% off
9951 Occlusal Adjustment Limited $236 $74 68% off
9952 Occlusal Adjustment Complete $850 $293 65% 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.
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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.
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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.
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