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Dental Plans
Individual (1) $7.95
Couple (2) $11.95
Family Rate $15.95
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Network Dental Schedule of Benefits
Preferred Plan 503
| ADA Codes | DIAGNOSTIC AND PREVENTIVE SERVICES | Member Pays |
|
0120 0140 0150 0210 0220 0230 0270 0272 0274 0330 1110 1120 1201 1351 1510 1515 1520 1525 |
PERIODIC ORAL EVALUATION LIMITED ORAL EVALUATION-PROBLEM FOCUS COMPREHENSIVE ORAL EVALUATION X-RAYS-INTRAORAL-COMPLETE SERIES (INCLUDING BITEWINGS) X-RAYS-INTRAORAL-PERIAPICAL-1ST FILM X-RAYS-INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM BITEWING X-RAY-SINGLE FILM BITEWINGS-TWO FILMS BITEWINGS-FOUR FILMS PANORAMIC FILM PROPHY-ADULT CLEANING PROPHY-CHILD CLEANING TOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHY)-CHILD SEALANT-PER TOOTH SPACE MAINTAINER-FIXED-UNILATERAL SPACE MAINTAINER-FIXED-BILATERAL SPACE MAINTAINER-REMOVEABLE-UNILATERAL SPACE MAINTAINER-REMOVEABLE-BILATERAL |
$14.00 $16.00 $16.00 $41.00 $9.00 $5.00 $9.00 $13.00 $21.00 $41.00 $30.00 $25.00 $35.00 $21.00 $90.00 $132.00 $117.00 $150.00 |
|
2110 2120 2130 2131 2140 2150 2160 2161 2330 2331 2332 2335 2385 2386 2387 |
RESTORATIVE (FILLINGS) AMALGAM-ONE SURFACE PRIMARY AMALGAM-TWO SURFACES PRIMARY AMALGAM-THREE SURFACES PRIMARY AMALGAM-FOUR OR MORE SURFACES PRIMARY AMALGAM-ONE SURFACE PERMANENT AMALGAM-TWO SURFACES PERMANENT AMALGAM-THREE SURFACES PERMANENT AMALGAM-FOUR OR MORE SURFACES PERMANENT RESIN-ONE SURFACE ANTERIOR RESIN-TWO SURFACES ANTERIOR RESIN-THREE SURFACES ANTERIOR RESIN-FOUR OR MORE SURFACES RESIN-ONE SURFACE POSTERIOR PERMANENT RESIN-TWO SURFACES POSTERIOR PERMANENT RESIN-THREE OR MORE SURFACES POSTERIOR PERMANENT |
$36.00 $47.00 $56.00 $67.00 $41.00 $53.00 $62.00 $76.00 $53.00 $63.00 $81.00 $101.00 $69.00 $99.00 $125.00 |
|
2750 2751 2752 2790 2791 2930 2931 2950 2951 2952 2954 3110 3120 3220 3310 3320 3330 |
CROWNS CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL CROWN-PORCELAIN FUSED TO NOBLE METAL CROWN-FULL CAST HIGH NOBLE METAL CROWN-FULL CAST PREDOMINANTLY BASE METAL PREFABRICATED STAINLESS STEEL CROWN-PRIMARY PREFABRICATED STAINLESS STEEL CROWN-PERMANENT CORE BUILDUP-INCLUDING ANY PINS PIN RETENTION PER TOOTH IN ADDITION TO RESTORATION CAST POST AND CORE IN ADDITION TO CROWN PREFABRICATED POST AND CORE IN ADDITION TO CROWN PULP CAP DIRECT (EXCLUDING FINAL RESTORATION) PULP CAP INDIRECT (EXCLUDING FINAL RESTORATION) THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) ROOT CANAL-ANTERIOR (EXCLUDING FINAL RESTORATION) ROOT CANAL-BICUSPID (EXCLUDING FINAL RESTORATION) ROOT CANAL-MOLAR (EXCLUDING FINAL RESTORATION) |
$495.00 $450.00 $483.00 $484.00 $450.00 $97.00 $110.00 $97.00 $23.00 $152.00 $118.00 $22.00 $22.00 $53.00 $283.00 $336.00 $421.00 |
|
4210 4341 4910 |
PERIODONTICS GINGIVECTOMY OR GINGIVOPLASTY PER QUADRANT PERIODONTAL SCALING AND ROOT PLANING PER QUADRANT PERIODONTAL MAINTENANCE (FOLLOWING ACTIVE THERAPY) |
$282.00 $100.00 $60.00 |
|
5110 5120 5130 5140 5211 5212 5213 5214 5410 5411 5510 5520 5630 5650 5660 5730 5731 5740 5741 5750 5761 |
PROSTHODONTICS COMPLETE DENTURE-MAXILLARY COMPLETE DENTURE-MANDIBULAR IMMEDIATE DENTURE-MAXILLARY IMMEDIATE DENTURE-MANDIBULAR MAXILLARY PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) MANDIBULAR PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) MAXILLARY PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS OR TEETH) MANDIBULAR PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS, AND TEETH) ADJUST COMPLETE DENTURE-MAXILLARY ADJUST COMPLETE DENTURE-MANDIBULAR REPAIR BROKEN COMPLETE DENTURE BASE REPLACE MISSING OR BROKEN TEETH REPAIR OR REPLACE BROKEN CLASP ADD TOOTH TO EXISTING PARTIAL DENTURE ADD CLASP TO EXISTING PARTIAL DENTURE RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) RELINE MANDIBULAR PARTIAL DENT (CHAIRSIDE) RELINE COMPLETE MAXILLARY DENTURE (LAB) RELINE COMPLETE MANDIBULAR DENTURE (LAB) |
$619.00 $619.00 $643.00 $643.00 $605.00 $605.00 $702.00 $702.00 $35.00 $35.00 $55.00 $53.00 $63.00 $55.00 $70.00 $131.00 $131.00 $124.00 $124.00 $171.00 $171.00 |
|
6240 6241 6242 6750 6751 6752 |
FIXED PROSTHETICS PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL PONTIC-PORCELAIN FUSED TO PREDOM BASE METAL PONTIC-PORCELAIN FUSED TO NOBLE METAL CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL CROWN-PORCELAIN FUSED TO PREDOM BASE METAL CROWN-PORCELAIN FUSED TO NOBLE METAL |
$425.00 $393.00 $412.00 $465.00 $423.00 $440.00 |
|
7110 7120 7130 7220 7230 7240 7250 7310 7320 7510 |
ORAL SURGERY SINGLE TOOTH EXTRACTION EACH ADDITIONAL TOOTH ROOT REMOVAL-EXPOSED ROOTS REMOVAL OF IMPACTED TOOTH-SOFT TISSUE REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTION PER QUAD ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTION PER QUAD INCISION/DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE |
$53.00 $49.00 $64.00 $108.00 $140.00 $197.00 $102.00 $90.00 $130.00 $67.00 |
|
8070 8080 8090 |
ORTHODONTICS COMPLETE ORTHODONTIC TREATMENT-TRANSITIONAL DENTITION COMPLETE ORTHODONTIC TREATMENT-ADOLESCENT DENTITION COMPLETE ORHTODONTIC TREATMENT-ADULT DENTITION |
20% Discount 20% Discount 20% Discount |
|
9110 9215 9230 9951 9952 |
MISCELLANEOUS SERVICES PALLIATIVE TREATMENT DENTAL PAIN-MINOR PROCEDURE LOCAL ANESTHESIA ANALGESIA OCCLUSAL ADJUSTMENT LIMITED OCCLUSAL ADJUSTMENT COMPLETE |
$35.00 $13.00 $23.00 $48.00 $194.00 |
|
*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. Please call 800-290-0523 for assistance. *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 enrollment on 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. Please call 800-290-0523 if you have any further questions.
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