DentalCareRx
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| BENEFITS SCHEDULE | CORRESPONDING STATES |
|---|---|
| Plan 501 | AL, FL, IL, KS, KY, LA, MN, MO, MS, NE, OH, OK, PA, TN, TX, VA |
| Plan 502 | AZ, CO, IN, MD, MI |
| Plan 503 | AR, HI, MA, ND, NJ, SD, WV |
| Plan 504 | DC, IA, NC, NY, SC |
| Plan 505 | CT, ID, ME, MT, OR, UT, VT, WI, WY |
| Plan 506 | AK, DE, NH, RI |
| Plan 507 | CA |
| DIAGNOSTIC & PREVENTIVE SERVICES |
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|---|---|---|---|---|---|---|---|---|
| ADA CODE | BENEFIT DESCRIPTION | Plan 501 | Plan 502 | Plan 503 | Plan 504 | Plan 505 | Plan 506 | Plan 507 |
| 120 | PERIODIC ORAL EVALUATION | $13.00 | $14.00 | $15.00 | $16.00 | $17.00 | $20.00 | $21.00 |
| 140 | LIMITED ORAL EVALUATION-PROBLEM FOCUS | $15.00 | $17.00 | $17.00 | $20.00 | $22.00 | $24.00 | $31.00 |
| 150 | COMPREHENSIVE ORAL EVALUATION-NEW OR ESTABLISHED PATIENT | $15.00 | $17.00 | $17.00 | $20.00 | $22.00 | $24.00 | $35.00 |
| 210 | X-RAYS-INTRAORAL-COMPLETE SERIES (INCLUDING BITEWINGS) | $38.00 | $43.00 | $45.00 | $50.00 | $52.00 | $60.00 | $60.00 |
| 220 | X-RAYS-INTRAORAL-PERIAPICAL-1ST FILM | $9.00 | $10.00 | $10.00 | $11.00 | $12.00 | $14.00 | $12.00 |
| 230 | X-RAYS-INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM | $4.00 | $5.00 | $5.00 | $5.00 | $5.00 | $7.00 | $9.00 |
| 270 | BITEWING X-RAY-SINGLE FILM | $9.00 | $10.00 | $10.00 | $11.00 | $13.00 | $14.00 | $11.00 |
| 272 | BITEWINGS-TWO FILMS | $12.00 | $13.00 | $14.00 | $15.00 | $16.00 | $17.00 | $16.00 |
| 274 | BITEWINGS-FOUR FILMS | $19.00 | $22.00 | $23.00 | $25.00 | $26.00 | $26.00 | $24.00 |
| 330 | PANORAMIC FILM | $38.00 | $43.00 | $45.00 | $50.00 | $52.00 | $60.00 | $51.00 |
| 1110 | PROPHYLAXIS-ADULT CLEANING | $27.00 | $32.00 | $33.00 | $36.00 | $39.00 | $44.00 | $40.00 |
| 1120 | PROPHYLAXIS-CHILD CLEANING | $20.00 | $23.00 | $27.00 | $31.00 | $32.00 | $36.00 | $31.00 |
| 1201 | TOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHYLAXIS)-CHILD | $25.00 | $32.00 | $38.00 | $40.00 | $44.00 | $49.00 | $41.00 |
| 1351 | SEALANT-PER TOOTH | $19.00 | $22.00 | $23.00 | $24.00 | $25.00 | $31.00 | $24.00 |
| 1510 | SPACE MAINTAINER-FIXED-UNILATERAL | $82.00 | $92.00 | $98.00 | $108.00 | $114.00 | $131.00 | $150.00 |
| 1515 | SPACE MAINTAINER-FIXED-BILATERAL | $120.00 | $135.00 | $144.00 | $160.00 | $168.00 | $193.00 | $214.00 |
| 1520 | SPACE MAINTAINER-REMOVEABLE-UNILATERAL | $107.00 | $120.00 | $128.00 | $142.00 | $149.00 | $170.00 | $179.00 |
| 1525 | SPACE MAINTAINER-REMOVEABLE-BILATERAL | $135.00 | $153.00 | $164.00 | $181.00 | $190.00 | $217.00 | $223.00 |
| RESTORATIVE | ||||||||
| ADA CODE | BENEFIT DESCRIPTION | Plan 501 | Plan 502 | Plan 503 | Plan 504 | Plan 505 | Plan 506 | Plan 507 |
| 2140 | AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT | $38.00 | $43.00 | $45.00 | $50.00 | $52.00 | $60.00 | $50.00 |
| 2150 | AMALGAM-TWO SURFACES, PRIMARY OR PERMANENT | $48.00 | $53.00 | $58.00 | $64.00 | $66.00 | $76.00 | $66.00 |
| 2160 | AMALGAM-THREE SURFACES, PRIMARY OR PERMANENT | $57.00 | $64.00 | $68.00 | $75.00 | $78.00 | $90.00 | $80.00 |
| 2161 | AMALGAM-FOUR OR MORE SURFACES, PRIMARY OR PERMANENT | $69.00 | $77.00 | $83.00 | $92.00 | $97.00 | $110.00 | $98.00 |
| 2330 | RESIN-BASED COMPOSITE-ONE SURFACE, ANTERIOR | $48.00 | $53.00 | $58.00 | $64.00 | $66.00 | $76.00 | $62.00 |
| 2331 | RESIN-BASED COMPOSITE-TWO SURFACES, ANTERIOR | $58.00 | $65.00 | $69.00 | $76.00 | $81.00 | $93.00 | $78.00 |
| 2332 | RESIN-BASED COMPOSITE-THREE SURFACES, ANTERIOR | $73.00 | $83.00 | $88.00 | $97.00 | $101.00 | $117.00 | $101.00 |
| 2335 | RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, ANTERIOR | $92.00 | $102.00 | $110.00 | $122.00 | $128.00 | $147.00 | $125.00 |
| 2391 | RESIN-BASED COMPOSITE-ONE SURFACE, POSTERIOR | $60.00 | $71.00 | $75.00 | $81.00 | $88.00 | $98.00 | $70.00 |
| 2392 | RESIN-BASED COMPOSITE-TWO SURFACES, POSTERIOR | $89.00 | $104.00 | $108.00 | $117.00 | $125.00 | $143.00 | $98.00 |
| 2393 | RESIN-BASED COMPOSITE-THREE SURFACES, POSTERIOR | $112.00 | $128.00 | $136.00 | $150.00 | $167.00 | $181.00 | $125.00 |
| 2394 | RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, POSTERIOR | $130.00 | $146.00 | $157.00 | $173.00 | $192.00 | $207.00 | $148.00 |
| 2750 | CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL | $446.00 | $505.00 | $540.00 | $561.00 | $600.00 | $670.00 | $535.00 |
| 2751 | CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL | $404.00 | $458.00 | $491.00 | $511.00 | $541.00 | $654.00 | $480.00 |
| 2752 | CROWN-PORCELAIN FUSED TO NOBLE METAL | $422.00 | $476.00 | $526.00 | $545.00 | $572.00 | $663.00 | $501.00 |
| 2790 | CROWN-FULL CAST HIGH NOBLE METAL | $439.00 | $497.00 | $528.00 | $550.00 | $578.00 | $685.00 | $518.00 |
| 2791 | CROWN-FULL CAST PREDOMINANTLY BASE METAL | $393.00 | $463.00 | $491.00 | $518.00 | $550.00 | $649.00 | $452.00 |
| 2930 | PREFABRICATED STAINLESS STEEL CROWN-PRIMARY | $88.00 | $99.00 | $106.00 | $117.00 | $123.00 | $134.00 | $121.00 |
| 2931 | PREFABRICATED STAINLESS STEEL CROWN-PERMANENT | $100.00 | $113.00 | $120.00 | $133.00 | $141.00 | $150.00 | $140.00 |
| 2950 | CORE BUILDUP-INCLUDING ANY PINS | $88.00 | $99.00 | $106.00 | $117.00 | $123.00 | $131.00 | $122.00 |
| 2951 | PIN RETENTION PER TOOTH IN ADDITION TO RESTORATION | $22.00 | $24.00 | $25.00 | $26.00 | $28.00 | $33.00 | $26.00 |
| 2952 | CAST POST AND CORE IN ADDITION TO CROWN | $138.00 | $156.00 | $166.00 | $183.00 | $193.00 | $217.00 | $191.00 |
| 2954 | PREFABRICATED POST AND CORE IN ADDITION TO CROWN | $108.00 | $122.00 | $129.00 | $143.00 | $150.00 | $164.00 | $150.00 |
| ENDODONTICS | ||||||||
| ADA CODE | BENEFIT DESCRIPTION | Plan 501 | Plan 502 | Plan 503 | Plan 504 | Plan 505 | Plan 506 | Plan 507 |
| 3110 | PULP CAP DIRECT (EXCLUDING FINAL RESTORATION) | $20.00 | $22.00 | $24.00 | $26.00 | $27.00 | $33.00 | $32.00 |
| 3120 | PULP CAP INDIRECT (EXCLUDING FINAL RESTORATION) | $20.00 | $22.00 | $24.00 | $26.00 | $27.00 | $31.00 | $32.00 |
| 3220 | THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) | $48.00 | $53.00 | $58.00 | $64.00 | $66.00 | $76.00 | $76.00 |
| 3310 | ROOT CANAL-ANTERIOR (EXCLUDING FINAL RESTORATION) | $257.00 | $291.00 | $308.00 | $320.00 | $360.00 | $411.00 | $305.00 |
| 3320 | ROOT CANAL-BICUSPID (EXCLUDING FINAL RESTORATION) | $304.00 | $344.00 | $366.00 | $384.00 | $426.00 | $487.00 | $366.00 |
| 3330 | ROOT CANAL-MOLAR (EXCLUDING FINAL RESTORATION) | $383.00 | $433.00 | $459.00 | $487.00 | $535.00 | $611.00 | $461.00 |
| PERIODONTICS | ||||||||
| ADA CODE | BENEFIT DESCRIPTION | Plan 501 | Plan 502 | Plan 503 | Plan 504 | Plan 505 | Plan 506 | Plan 507 |
| 4210 | GINGIVECTOMY OR GINGIVOPLASTY-FOUR OR MORE CONTIGUOUS TEETH OR BONDED TEETH SPACES PER QUADRANT | $256.00 | $295.00 | $307.00 | $338.00 | $360.00 | $424.00 | $289.00 |
| 4341 | PERIODONTAL SCALING AND ROOT PLANING-FOUR OR MORE CONTIGUOUS TEETH OR BONDED TEETH SPACES PER QUADRANT | $89.00 | $98.00 | $109.00 | $111.00 | $120.00 | $138.00 | $107.00 |
| 4910 | PERIODONTAL MAINTENANCE (FOLLOWING ACTIVE THERAPY) | $57.00 | $60.00 | $65.00 | $71.00 | $76.00 | $86.00 | $62.00 |
| PROSTHODONTICS (REMOVABLE) |
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| ADA CODE | BENEFIT DESCRIPTION | Plan 501 | Plan 502 | Plan 503 | Plan 504 | Plan 505 | Plan 506 | Plan 507 |
| 5110 | COMPLETE DENTURE-MAXILLARY | $561.00 | $634.00 | $675.00 | $722.00 | $779.00 | $888.00 | $689.00 |
| 5120 | COMPLETE DENTURE-MANDIBULAR | $561.00 | $634.00 | $675.00 | $722.00 | $779.00 | $888.00 | $689.00 |
| 5130 | IMMEDIATE DENTURE-MAXILLARY | $584.00 | $661.00 | $701.00 | $777.00 | $828.00 | $935.00 | $725.00 |
| 5140 | IMMEDIATE DENTURE-MANDIBULAR | $584.00 | $661.00 | $701.00 | $777.00 | $828.00 | $935.00 | $730.00 |
| 5211 | MAXILLARY PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) | $550.00 | $578.00 | $659.00 | $707.00 | $764.00 | $873.00 | $517.00 |
| 5212 | MANDIBULAR PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) | $550.00 | $578.00 | $659.00 | $707.00 | $764.00 | $873.00 | $517.00 |
| 5213 | MAXILLARY PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS OR TEETH) | $637.00 | $719.00 | $765.00 | $823.00 | $870.00 | $997.00 | $741.00 |
| 5214 | MANDIBULAR PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS, AND TEETH) | $637.00 | $719.00 | $765.00 | $823.00 | $870.00 | $997.00 | $744.00 |
| 5410 | ADJUST COMPLETE DENTURE-MAXILLARY | $32.00 | $33.00 | $38.00 | $39.00 | $41.00 | $47.00 | $37.00 |
| 5411 | ADJUST COMPLETE DENTURE-MANDIBULAR | $32.00 | $33.00 | $38.00 | $39.00 | $41.00 | $47.00 | $37.00 |
| 5510 | REPAIR BROKEN COMPLETE DENTURE BASE | $50.00 | $57.00 | $60.00 | $66.00 | $70.00 | $81.00 | $83.00 |
| 5520 | REPLACE MISSING OR BROKEN TEETH | $48.00 | $53.00 | $58.00 | $64.00 | $66.00 | $76.00 | $75.00 |
| 5630 | REPAIR OR REPLACE BROKEN CLASP | $58.00 | $65.00 | $69.00 | $76.00 | $81.00 | $93.00 | $107.00 |
| 5650 | ADD TOOTH TO EXISTING PARTIAL DENTURE | $50.00 | $57.00 | $60.00 | $66.00 | $70.00 | $81.00 | $92.00 |
| 5660 | ADD CLASP TO EXISTING PARTIAL DENTURE | $64.00 | $73.00 | $76.00 | $85.00 | $89.00 | $102.00 | $112.00 |
| 5730 | RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) | $119.00 | $134.00 | $143.00 | $158.00 | $167.00 | $185.00 | $157.00 |
| 5731 | RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) | $119.00 | $134.00 | $143.00 | $158.00 | $167.00 | $185.00 | $157.00 |
| 5740 | RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) | $113.00 | $128.00 | $135.00 | $150.00 | $158.00 | $174.00 | $146.00 |
| 5741 | RELINE MANDIBULAR PARTIAL DENT (CHAIRSIDE) | $113.00 | $128.00 | $135.00 | $150.00 | $158.00 | $174.00 | $146.00 |
| 5750 | RELINE COMPLETE MAXILLARY DENTURE (LAB) | $156.00 | $175.00 | $186.00 | $207.00 | $218.00 | $240.00 | $210.00 |
| 5751 | RELINE COMPLETE MANDIBULAR DENTURE (LAB) | $156.00 | $175.00 | $186.00 | $207.00 | $218.00 | $240.00 | $208.00 |
| PROSTHODONTICS (FIXED) |
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| ADA CODE | BENEFIT DESCRIPTION | Plan 501 | Plan 502 | Plan 503 | Plan 504 | Plan 505 | Plan 506 | Plan 507 |
| 6240 | PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL | $388.00 | $435.00 | $463.00 | $508.00 | $588.00 | $614.00 | $517.00 |
| 6241 | PONTIC-PORCELAIN FUSED TO PREDOM BASE METAL | $358.00 | $404.00 | $428.00 | $468.00 | $492.00 | $587.00 | $482.00 |
| 6242 | PONTIC-PORCELAIN FUSED TO NOBLE METAL | $374.00 | $423.00 | $449.00 | $489.00 | $535.00 | $586.00 | $498.00 |
| 6750 | CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL | $427.00 | $483.00 | $507.00 | $529.00 | $561.00 | $654.00 | $534.00 |
| 6751 | CROWN-PORCELAIN FUSED TO PREDOM BASE METAL | $385.00 | $435.00 | $461.00 | $491.00 | $522.00 | $616.00 | $482.00 |
| 6752 | CROWN-PORCELAIN FUSED TO NOBLE METAL | $400.00 | $451.00 | $480.00 | $510.00 | $534.00 | $640.00 | $499.00 |
| ORAL SURGERY | ||||||||
| ADA CODE | BENEFIT DESCRIPTION | Plan 501 | Plan 502 | Plan 503 | Plan 504 | Plan 505 | Plan 506 | Plan 507 |
| 7140 | EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT | $48.00 | $53.00 | $58.00 | $64.00 | $66.00 | $76.00 | $64.00 |
| 7220 | REMOVAL OF IMPACTED TOOTH-SOFT TISSUE | $98.00 | $110.00 | $118.00 | $131.00 | $136.00 | $157.00 | $142.00 |
| 7230 | REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY | $128.00 | $144.00 | $153.00 | $170.00 | $179.00 | $204.00 | $180.00 |
| 7240 | REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY | $185.00 | $202.00 | $215.00 | $221.00 | $239.00 | $267.00 | $222.00 |
| 7250 | SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS | $98.00 | $111.00 | $111.00 | $118.00 | $125.00 | $147.00 | $131.00 |
| 7310 | ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTION PER QUAD | $82.00 | $92.00 | $98.00 | $108.00 | $114.00 | $131.00 | $129.00 |
| 7320 | ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTION PER QUAD | $118.00 | $133.00 | $142.00 | $157.00 | $166.00 | $189.00 | $181.00 |
| 7510 | INCISION/DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE | $60.00 | $68.00 | $73.00 | $81.00 | $84.00 | $97.00 | $85.00 |
| ORTHODONTICS | ||||||||
| ADA CODE | BENEFIT DESCRIPTION | Plan 501 | Plan 502 | Plan 503 | Plan 504 | Plan 505 | Plan 506 | Plan 507 |
| 8070 | COMPLETE ORTHODONTIC TREATMENT-TRANSITIONAL DENTITION | 20% Discount | 20% Discount | 20% Discount | 20% Discount | 20% Discount | 20% Discount | 20% Discount |
| 8080 | COMPLETE ORTHODONTIC TREATMENT-ADOLESCENT DENTITION | 20% Discount | 20% Discount | 20% Discount | 20% Discount | 20% Discount | 20% Discount | 20% Discount |
| 8090 | COMPLETE ORHTODONTIC TREATMENT-ADULT DENTITION | 20% Discount | 20% Discount | 20% Discount | 20% Discount | 20% Discount | 20% Discount | 20% Discount |
| MISCELLANEOUS SERVICES |
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| ADA CODE | BENEFIT DESCRIPTION | Plan 501 | Plan 502 | Plan 503 | Plan 504 | Plan 505 | Plan 506 | Plan 507 |
| 9110 | PALLIATIVE TREATMENT DENTAL PAIN-MINOR PROCEDURE | $32.00 | $35.00 | $38.00 | $41.00 | $44.00 | $50.00 | $46.00 |
| 9215 | LOCAL ANESTHESIA | $11.00 | $13.00 | $14.00 | $15.00 | $16.00 | $20.00 | $20.00 |
| 9230 | ANALGESIA | $23.00 | $24.00 | $25.00 | $27.00 | $27.00 | $33.00 | $27.00 |
| 9951 | OCCLUSAL ADJUSTMENT LIMITED | $44.00 | $50.00 | $52.00 | $59.00 | $61.00 | $70.00 | $71.00 |
| 9952 | OCCLUSAL ADJUSTMENT COMPLETE | $177.00 | $199.00 | $211.00 | $235.00 | $247.00 | $283.00 | $289.00 |
*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% 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 877-201-2080 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 877-201-2080 if you have any further questions.