Plan 504 Schedule of Benefits

ADA
CODE

DIAGNOSTIC AND PREVENTIVE SERVICES

MEMBER
PAYS

0120

PERIODIC ORAL EVALUATION

$15.00

0140

LIMITED ORAL EVALUATION-PROBLEM FOCUS

$18.00

0150

COMPREHENSIVE ORAL EVALUATION

$18.00

0210

X-RAYS-INTRAORAL-COMPLETE SERIES (INCLUDING BITEWINGS)

$46.00

0220

X-RAYS-INTRAORAL-PERIAPICAL-1ST FILM

$10.00

0230

X-RAYS-INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM

$5.00

0270

BITEWING X-RAY-SINGLE FILM

$10.00

0272

BITEWINGS-TWO FILMS

$14.00

0274

BITEWINGS-FOUR FILMS

$23.00

0330

PANORAMIC FILM

$46.00

1110

PROPHY-ADULT CLEANING

$33.00

1120

PROPHY-CHILD CLEANING

$28.00

1201

TOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHY)-CHILD

$37.00

1351

SEALANT-PER TOOTH

$22.00

1510

SPACE MAINTAINER-FIXED-UNILATERAL

$99.00

1515

SPACE MAINTAINER-FIXED-BILATERAL

$147.00

1520

SPACE MAINTAINER-REMOVEABLE-UNILATERAL

$130.00

1525

SPACE MAINTAINER-REMOVEABLE-BILATERAL

$166.00

RESTORATIVE (FILLINGS)

2110

AMALGAM-ONE SURFACE PRIMARY

$40.00

2120

AMALGAM-TWO SURFACES PRIMARY

$52.00

2130

AMALGAM-THREE SURFACES PRIMARY

$63.00

2131

AMALGAM-FOUR OR MORE SURFACES PRIMARY

$74.00

2140

AMALGAM-ONE SURFACE PERMANENT

$46.00

2150

AMALGAM-TWO SURFACES PERMANENT

$59.00

2160

AMALGAM-THREE SURFACES PERMANENT

$69.00

2161

AMALGAM-FOUR OR MORE SURFACES PERMANENT

$84.00

2330

RESIN-ONE SURFACE ANTERIOR

$59.00

2331

RESIN-TWO SURFACES ANTERIOR

$70.00

2332

RESIN-THREE SURFACES ANTERIOR

$89.00

2335

RESIN-FOUR OR MORE SURFACES

$112.00

2385

RESIN-ONE SURFACE POSTERIOR PERMANENT

$74.00

2386

RESIN-TWO SURFACES POSTERIOR PERMANENT

$107.00

2387

RESIN-THREE OR MORE SURFACES POSTERIOR PERMANENT

$138.00

CROWNS

2750

CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL

$515.00

2751

CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

$469.00

2752

CROWN-PORCELAIN FUSED TO NOBLE METAL

$500.00

2790

CROWN-FULL CAST HIGH NOBLE METAL

$505.00

2791

CROWN-FULL CAST PREDOMINANTLY BASE METAL

$475.00

2930

PREFABRICATED STAINLESS STEEL CROWN-PRIMARY

$107.00

2931

PREFABRICATED STAINLESS STEEL CROWN-PERMANENT

$122.00

2950

CORE BUILDUP-INCLUDING ANY PINS

$107.00

2951

PIN RETENTION PER TOOTH IN ADDITION TO RESTORATION

$24.00

2952

CAST POST AND CORE IN ADDITION TO CROWN

$168.00

2954

PREFABRICATED POST AND CORE IN ADDITION TO CROWN

$131.00

3110

PULP CAP DIRECT (EXCLUDING FINAL RESTORATION)

$24.00

3120

PULP CAP INDIRECT (EXCLUDING FINAL RESTORATION)

$24.00

3220

THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION)

$59.00

3310

ROOT CANAL-ANTERIOR (EXCLUDING FINAL RESTORATION)

$294.00

3320

ROOT CANAL-BICUSPID (EXCLUDING FINAL RESTORATION)

$352.00

3330

ROOT CANAL-MOLAR (EXCLUDING FINAL RESTORATION)

$447.00

PERIODONTICS

4210

GINGIVECTOMY OR GINGIVOPLASTY PER QUADRANT

$310.00

4341

PERIODONTAL SCALING AND ROOT PLANING PER QUADRANT

$102.00

4910

PERIODONTAL MAINTENANCE (FOLLOWING ACTIVE THERAPY)

$65.00

PROSTHODONTICS

5110

COMPLETE DENTURE-MAXILLARY

$662.00

5120

COMPLETE DENTURE-MANDIBULAR

$662.00

5130

IMMEDIATE DENTURE-MAXILLARY

$713.00

5140

IMMEDIATE DENTURE-MANDIBULAR

$713.00

5211

MAXILLARY PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)

$649.00

5212

MANDIBULAR PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)

$649.00

5213

MAXILLARY PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS OR TEETH)

$755.00

5214

MANDIBULAR PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS, AND TEETH)

$755.00

PROSTHODONTICS

5410

ADJUST COMPLETE DENTURE-MAXILLARY

$36.00

5411

ADJUST COMPLETE DENTURE-MANDIBULAR

$36.00

5510

REPAIR BROKEN COMPLETE DENTURE BASE

$61.00

5520

REPLACE MISSING OR BROKEN TEETH

$59.00

5630

REPAIR OR REPLACE BROKEN CLASP

$70.00

5650

ADD TOOTH TO EXISTING PARTIAL DENTURE

$61.00

5660

ADD CLASP TO EXISTING PARTIAL DENTURE

$78.00

5730

RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE)

$145.00

5731

RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE)

$145.00

5740

RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE)

$138.00

5741

RELINE MANDIBULAR PARTIAL DENT (CHAIRSIDE)

$138.00

5750

RELINE COMPLETE MAXILLARY DENTURE (LAB)

$190.00

5761

RELINE COMPLETE MANDIBULAR DENTURE (LAB)

$190.00

FIXED PROSTHETICS

6240

PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL

$466.00

6241

PONTIC-PORCELAIN FUSED TO PREDOM BASE METAL

$429.00

6242

PONTIC-PORCELAIN FUSED TO NOBLE METAL

$449.00

6750

CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL

$485.00

6751

CROWN-PORCELAIN FUSED TO PREDOM BASE METAL

$450.00

6752

CROWN-PORCELAIN FUSED TO NOBLE METAL

$468.00

ORAL SURGERY

7110

SINGLE TOOTH EXTRACTION

$59.00

7120

EACH ADDITIONAL TOOTH

$55.00

7130

ROOT REMOVAL-EXPOSED ROOTS

$72.00

7220

REMOVAL OF IMPACTED TOOTH-SOFT TISSUE

$120.00

7230

REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY

$156.00

7240

REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY

$203.00

7250

SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS

$108.00

7310

ALVEOLOPLASTY IN CONJUNCT W/ EXTRACTIONS/QUAD

$99.00

7320

ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTION PER QUAD

$144.00

7510

INCISION/DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE

$74.00

ORTHODONTICS

8070

COMPLETE ORTHODONTIC TREATMENT-TRANSITIONAL DENTITION

20% Discount

8080

COMPLETE ORTHODONTIC TREATMENT-ADOLESCENT DENTITION

20% Discount

8090

COMPLETE ORHTODONTIC TREATMENT-ADULT DENTITION

20% Discount

MISCELLANEOUS SERVICES

9110

PALLIATIVE TREATMENT DENTAL PAIN-MINOR PROCEDURE

$38.00

9215

LOCAL ANESTHESIA

$14.00

9230

ANALGESIA

$25.00

9951

OCCLUSAL ADJUSTMENT LIMITED

$54.00

9952

OCCLUSAL ADJUSTMENT COMPLETE

$216.00

*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.

*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