Instructions For Use: To determine what you pay at the dentist, find the ADA (American Dental Association) code number or service number on your dental estimate and match the 4 digit number in the left column.  Once the discount is applied, what you pay the dentist can be seen in the right column.  If you do not have the ADA codes, call your dental office and ask for them! BEST FOR PRINTING: CLICK HERE to download and print out this fee schedule in PDF format. If your ADA code is NOT listed in the fee schedule, then your discount will be 20%.*

Careington 506 Fee Schedule

Plan 506 Schedule

ADA
CODE

DIAGNOSTIC (Exams, X-Rays)

MEMBER
PAYS

0120

PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT

$23

0140

LIMITED ORAL EVALUATION - PROBLEM FOCUS

$27

0150

COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED PATIENT

$33

0210

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

$69

0220

X - RAYS - INTRAORAL - PERIAPICAL - 1ST FILM

$16

0230

X - RAYS - INTRAORAL - PERIAPICAL - EACH ADDITIONAL FILM

$10

0270

BITEWING - SINGLE FILM

$16

0272

BITEWINGS - TWO FILMS

$19

0273

BITEWINGS - THREE FILMS

$25

0274

BITEWINGS - FOUR FILMS

$30

0330

PANORAMIC FILM

$69

PREVENTIVE (Cleanings, etc.)

1110

PROPHYLAXIS - ADULT CLEANING

$51

1120

PROPHYLAXIS - CHILD CLEANING

$41

1351

SEALANT - PER TOOTH

$36

1510

SPACE MAINTAINER - FIXED - UNILATERAL

$150

1515

SPACE MAINTAINER - FIXED - BILATERAL

$221

1520

SPACE MAINTAINER - REMOVEABLE - UNILATERAL

$194

1525

SPACE MAINTAINER - REMOVEABLE - BILATERAL

$248

RESTORATIVE (Fillings)

2140

AMALGAM - ONE SURFACE, PRIMARY OR PERMANENT

$69

2150

AMALGAM - TWO SURFACES, PRIMARY OR PERMANENT

$87

2160

AMALGAM - THREE SURFACES, PRIMARY OR PERMANENT

$103

2161

AMALGAM - FOUR OR MORE SURFACES, PRIMARY OR PERMANENT

$126

2330

RESIN - BASED COMPOSITE - ONE SURFACE, ANTERIOR

$87

2331

RESIN - BASED COMPOSITE - TWO SURFACES, ANTERIOR

$107

2332

RESIN - BASED COMPOSITE - THREE SURFACES, ANTERIOR

$134

2335

RESIN - BASED COMPOSITE - FOUR OR MORE SURFACES, ANTERIOR

$168

2391

RESIN - BASED COMPOSITE - ONE SURFACE, POSTERIOR

$112

2392

RESIN - BASED COMPOSITE - TWO SURFACES, POSTERIOR

$164

2393

RESIN - BASED COMPOSITE - THREE SURFACES, POSTERIOR

$207

2394

RESIN - BASED COMPOSITE - FOUR OR MORE SURFACES, POSTERIOR

$237

RESTORATIVE (Crowns)

2710

CROWN - RESIN-BASED COMPOSITE (INDIRECT)

$307

2720

CROWN- RESIN WITH HIGH NOBLE METAL

$651

2750

CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL

$767

2751

CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

$748

2752

CROWN - PORCELAIN FUSED TO NOBLE METAL

$759

2790

CROWN - FULL CAST HIGH NOBLE METAL

$784

2791

CROWN - FULL CAST PREDOMINANTLY BASE METAL

$743

2930

PREFABRICATED STAINLESS STEEL CROWN - PRIMARY

$153

2931

PREFABRICATED STAINLESS STEEL CROWN - PERMANENT

$172

2950

CORE BUILDUP - INCLUDING ANY PINS

$150

2951

PIN RETENTION PER TOOTH IN ADDITION TO RESTORATION

$38

2952

POST AND CORE IN ADDITION TO CROWN, INDIRECTLY FABRICATED

$248

2954

PREFABRICATED POST AND CORE IN ADDITION TO CROWN

$188

ENDODONTICS (Root Canals, etc.)

3110

PULP CAP DIRECT (EXCLUDING FINAL RESTORATION)

$38

3120

PULP CAP INDIRECT (EXCLUDING FINAL RESTORATION)

$36

3220

THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION)

$87

3310

ROOT CANAL - ANTERIOR (EXCLUDING FINAL RESTORATION)

$471

3320

ROOT CANAL - BICUSPID (EXCLUDING FINAL RESTORATION)

$557

3330

ROOT CANAL - MOLAR (EXCLUDING FINAL RESTORATION)

$700

PERIODONTICS (Scaling / Deep Cleaning / Root Planing, etc.)

4210

GINGIVECTOMY OR GINGIVOPLASTY - FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUADRANT

$485

4341

PERIODONTAL SCALING AND ROOT PLANING - FOUR OR MORE TEETH PER QUADRANT

$158

4910

PERIODONTAL MAINTENANCE

$98

PROSTHODONTICS - REMOVABLE (Dentures, Partials, etc.)

5110

COMPLETE DENTURE - MAXILLARY

$1016

5120

COMPLETE DENTURE - MANDIBULAR

$1016

5130

IMMEDIATE DENTURE - MAXILLARY

$1070

5140

IMMEDIATE DENTURE - MANDIBULAR

$1070

5211

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

$999

5212

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

$999

5213

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

$1142

5214

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

$1142

5410

ADJUST COMPLETE DENTURE - MAXILLARY

$54

5411

ADJUST COMPLETE DENTURE - MANDIBULAR

$54

5510

REPAIR BROKEN COMPLETE DENTURE BASE

$93

5520

REPLACE MISSING OR BROKEN TEETH

$87

5630

REPAIR OR REPLACE BROKEN CLASP

$107

5650

ADD TOOTH TO EXISTING PARTIAL DENTURE

$93

5660

ADD CLASP TO EXISTING PARTIAL DENTURE

$117

5730

RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE)

$212

5731

RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE)

$212

5740

RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE)

$199

5741

RELINE MANDIBULAR PARTIAL DENT (CHAIRSIDE)

$199

5750

RELINE COMPLETE MAXILLARY DENTURE (LAB)

$274

5751

RELINE COMPLETE MANDIBULAR DENTURE (LAB)

$274

PROSTHODONTICS - FIXED (Bridges, Implants, etc.)

6040

SURGICAL PLACEMENT: EPOSTEAL IMPLANT

20% Discount

6050

SURGICAL PLACEMENT: TRANSOSTEAL IMPLANT

20% Discount

6065

IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWN

20% Discount

6066

IMPLANT SUPPORTED PORCELAIN FUSED TO METAL CROWN (TITANIUM, TITANIUM ALLOY, HIGH NOBLE METAL)

20% Discount

6067

IMPLANT SUPPORTED METAL CROWN (TITANIUM, TITANIUM ALLOY, HIGH NOBLE METAL)

20% Discount

6240

PONTIC - PORCELAIN FUSED TO HIGH NOBLE METAL

$703

6241

PONTIC - PORCELAIN FUSED TO PREDOM BASE METAL

$649

6242

PONTIC - PORCELAIN FUSED TO NOBLE METAL

$669

6750

CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL

$748

6751

CROWN - PORCELAIN FUSED TO PREDOM BASE METAL

$705

6752

CROWN - PORCELAIN FUSED TO NOBLE METAL

$732

ORAL SURGERY (Tooth Extractions, etc.)

7140

EXTRACTION,ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPTS

$87

7210

SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING ELEVATION OF MUCOPERIOSTEAL

$183

7220

REMOVAL OF IMPACTED TOOTH - SOFT TISSUE

$179

7230

REMOVAL OF IMPACTED TOOTH - PARTIALLY BONY

$233

7240

REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY

$306

7250

SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS

$168

7310

ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTION PER QUAD

$150

7320

ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTION PER QUAD

$216

7510

INCISION/DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE

$111

ORTHODONTICS (Braces - Children and Adults, etc.)

8070

COMPLETE ORTHODONTIC TREATMENT - TRANSITIONAL DENTITION

20% Discount

8080

COMPLETE ORTHODONTIC TREATMENT - ADOLESCENT DENTITION

20% Discount

8090

COMPLETE ORHTODONTIC TREATMENT - ADULT DENTITION

20% Discount

ADJUNCTIVE SERVICES (Anesthesia, Analgesia, etc.)

9110

PALLIATIVE TREATMENT DENTAL PAIN - MINOR PROCEDURE

$57

9215

LOCAL ANESTHESIA

$23

9230

ANALGESIA

$38

9951

OCCLUSAL ADJUSTMENT LIMITED

$80

9952

OCCLUSAL ADJUSTMENT COMPLETE

$324

*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.

*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.

*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 800-515-7401 if you have any further questions.

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