NHCD Careington Dental Fee Schedule

NHCD Careington Dental Fee Schedule

Plan 501
AL
FL
GA
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 and Preventive Services
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
0120
PERIODIC ORAL EVALUATION
$12.00
$13.00
$14.00
$15.00
$16.00
$18.00
$19.00
0140
LIMITED ORAL EVALUATION-PROBLEM FOCUS
$14.00
$16.00
$16.00
$18.00
$20.00
$22.00
$28.00
0150
COMPREHENSIVE ORAL EVALUATION-NEW OR ESTABLISHED PATIENT
$14.00
$16.00
$16.00
$18.00
$20.00
$22.00
$32.00
0210
X-RAYS-INTRAORAL-COMPLETE SERIES (INCLUDING BITEWINGS)
$35.00
$39.00
$41.00
$46.00
$48.00
$55.00
$55.00
0220
X-RAYS-INTRAORAL-PERIAPICAL-1ST FILM
$8.00
$9.00
$9.00
$10.00
$11.00
$13.00
$11.00
0230
X-RAYS-INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM
$4.00
$5.00
$5.00
$5.00
$5.00
$6.00
$8.00
0270
BITEWING X-RAY-SINGLE FILM
$8.00
$9.00
$9.00
$10.00
$12.00
$13.00
$10.00
0272
BITEWINGS-TWO FILMS
$10.00
$12.00
$13.00
$14.00
$15.00
$16.00
$15.00
0274
BITEWINGS-FOUR FILMS
$17.00
$20.00
$21.00
$23.00
$24.00
$28.00
$22.00
0330
PANORAMIC FILM
$35.00
$39.00
$41.00
$46.00
$48.00
$55.00
$47.00
1110
PROPHYLAXIS-ADULT CLEANING
$25.00
$29.00
$30.00
$33.00
$36.00
$40.00
$37.00
1120
PROPHYLAXIS-CHILD CLEANING
$18.00
$21.00
$25.00
$28.00
$29.00
$33.00
$28.00
1201
TOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHYLAXIS)-CHILD
$23.00
$29.00
$35.00
$37.00
$40.00
$45.00
$38.00
1351
SEALANT-PER TOOTH
$17.00
$20.00
$21.00
$22.00
$23.00
$28.00
$22.00
1510
SPACE MAINTAINER-FIXED-UNILATERAL
$75.00
$84.00
$90.00
$99.00
$105.00
$120.00
$138.00
1515
SPACE MAINTAINER-FIXED-BILATERAL
$110.00
$124.00
$132.00
$147.00
$154.00
$177.00
$196.00
1520
SPACE MAINTAINER-REMOVEABLE-UNILATERAL
$98.00
$110.00
$117.00
$130.00
$137.00
$156.00
$164.00
1525
SPACE MAINTAINER-REMOVEABLE-BILATERAL
$124.00
$140.00
$150.00
$166.00
$174.00
$199.00
$205.00

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
$35.00
$39.00
$41.00
$46.00
$48.00
$55.00
$46.00
2150
AMALGAM-TWO SURFACES, PRIMARY OR PERMANENT
$44.00
$49.00
$53.00
$59.00
$61.00
$70.00
$61.00
2160
AMALGAM-THREE SURFACES, PRIMARY OR PERMANENT
$52.00
$59.00
$62.00
$69.00
$72.00
$83.00
$73.00
2161
AMALGAM-FOUR OR MORE SURFACES, PRIMARY OR PERMANENT
$63.00
$71.00
$76.00
$84.00
$89.00
$101.00
$90.00
2330
RESIN-BASED COMPOSITE-ONE SURFACE, ANTERIOR
$44.00
$49.00
$53.00
$59.00
$61.00
$70.00
$57.00
2331
RESIN-BASED COMPOSITE-TWO SURFACES, ANTERIOR
$53.00
$60.00
$63.00
$70.00
$74.00
$85.00
$72.00
2332
RESIN-BASED COMPOSITE-THREE SURFACES, ANTERIOR
$67.00
$76.00
$81.00
$89.00
$93.00
$107.00
$93.00
2335
RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, ANTERIOR
$84.00
$94.00
$101.00
$112.00
$117.00
$135.00
$115.00
2391
RESIN-BASED COMPOSITE-ONE SURFACE, POSTERIOR
$55.00
$65.00
$69.00
$74.00
$81.00
$90.00
$64.00
2392
RESIN-BASED COMPOSITE-TWO SURFACES, POSTERIOR
$82.00
$95.00
$99.00
$107.00
$115.00
$131.00
$90.00
2393
RESIN-BASED COMPOSITE-THREE SURFACES, POSTERIOR
$103.00
$117.00
$125.00
$138.00
$153.00
$166.00
$115.00
2394
RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, POSTERIOR
$119.00
$134.00
$144.00
$159.00
$176.00
$190.00
$136.00
2750
CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL
$409.00
$463.00
$495.00
$515.00
$550.00
$615.00
$491.00
2751
CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL
$371.00
$420.00
$450.00
$469.00
$496.00
$600.00
$440.00
2752
CROWN-PORCELAIN FUSED TO NOBLE METAL
$387.00
$437.00
$483.00
$500.00
$525.00
$608.00
$460.00
2790
CROWN-FULL CAST HIGH NOBLE METAL
$403.00
$456.00
$484.00
$505.00
$530.00
$628.00
$475.00
2791
CROWN-FULL CAST PREDOMINANTLY BASE METAL
$361.00
$425.00
$450.00
$475.00
$505.00
$595.00
$415.00
2930
PREFABRICATED STAINLESS STEEL CROWN-PRIMARY
$81.00
$91.00
$97.00
$107.00
$113.00
$123.00
$111.00
2931
PREFABRICATED STAINLESS STEEL CROWN-PERMANENT
$92.00
$104.00
$110.00
$122.00
$129.00
$138.00
$128.00
2950
CORE BUILDUP-INCLUDING ANY PINS
$81.00
$91.00
$97.00
$107.00
$113.00
$120.00
$112.00
2951
PIN RETENTION PER TOOTH IN ADDITION TO RESTORATION
$20.00
$22.00
$23.00
$24.00
$26.00
$30.00
$24.00
2952
CAST POST AND CORE IN ADDITION TO CROWN
$127.00
$143.00
$152.00
$168.00
$177.00
$199.00
$175.00
2954
PREFABRICATED POST AND CORE IN ADDITION TO CROWN
$99.00
$112.00
$118.00
$131.00
$138.00
$150.00
$138.00

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)
$18.00
$20.00
$22.00
$24.00
$25.00
$30.00
$29.00
3120
PULP CAP INDIRECT (EXCLUDING FINAL RESTORATION)
$18.00
$20.00
$22.00
$24.00
$25.00
$28.00
$29.00
3220
THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION)
$44.00
$49.00
$53.00
$59.00
$61.00
$70.00
$70.00
3310
ROOT CANAL-ANTERIOR (EXCLUDING FINAL RESTORATION)
$236.00
$267.00
$283.00
$294.00
$330.00
$377.00
$280.00
3320
ROOT CANAL-BICUSPID (EXCLUDING FINAL RESTORATION)
$279.00
$316.00
$336.00
$352.00
$391.00
$447.00
$336.00
3330
ROOT CANAL-MOLAR (EXCLUDING FINAL RESTORATION)
$351.00
$397.00
$421.00
$447.00
$491.00
$561.00
$423.00

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
$235.00
$271.00
$282.00
$310.00
$330.00
$389.00
$265.00
4341
PERIODONTAL SCALING AND ROOT PLANING-FOUR OR MORE CONTIGUOUS TEETH OR BONDED TEETH SPACES PER QUADRANT
$82.00
$90.00
$100.00
$102.00
$110.00
$127.00
$98.00
4910
PERIODONTAL MAINTENANCE (FOLLOWING ACTIVE THERAPY)
$52.00
$55.00
$60.00
$65.00
$70.00
$79.00
$57.00

PROSTHODONTICS (REMOVABLE)

ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
5110
COMPLETE DENTURE-MAXILLARY
$515.00
$582.00
$619.00
$662.00
$715.00
$815.00
$632.00
5120
COMPLETE DENTURE-MANDIBULAR
$515.00
$582.00
$619.00
$662.00
$715.00
$815.00
$632.00
5130
IMMEDIATE DENTURE-MAXILLARY
$536.00
$606.00
$643.00
$713.00
$760.00
$858.00
$665.00
5140
IMMEDIATE DENTURE-MANDIBULAR
$536.00
$606.00
$643.00
$713.00
$760.00
$858.00
$670.00
5211
MAXILLARY PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)
$505.00
$530.00
$605.00
$649.00
$701.00
$801.00
$474.00
5212
MANDIBULAR PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)
$505.00
$530.00
$605.00
$649.00
$701.00
$801.00
$474.00
5213
MAXILLARY PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS OR TEETH)
$584.00
$660.00
$702.00
$755.00
$798.00
$915.00
$680.00
5214
MANDIBULAR PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS, AND TEETH)
$584.00
$660.00
$702.00
$755.00
$798.00
$915.00
$683.00
5410
ADJUST COMPLETE DENTURE-MAXILLARY
$29.00
$30.00
$35.00
$36.00
$38.00
$43.00
$34.00
5411
ADJUST COMPLETE DENTURE-MANDIBULAR
$29.00
$30.00
$35.00
$36.00
$38.00
$43.00
$34.00
5510
REPAIR BROKEN COMPLETE DENTURE BASE
$46.00
$52.00
$55.00
$61.00
$64.00
$74.00
$76.00
5520
REPLACE MISSING OR BROKEN TEETH
$44.00
$49.00
$53.00
$59.00
$61.00
$70.00
$69.00
5630
REPAIR OR REPLACE BROKEN CLASP
$53.00
$60.00
$63.00
$70.00
$74.00
$85.00
$98.00
5650
ADD TOOTH TO EXISTING PARTIAL DENTURE
$46.00
$52.00
$55.00
$61.00
$64.00
$74.00
$84.00
5660
ADD CLASP TO EXISTING PARTIAL DENTURE
$59.00
$67.00
$70.00
$78.00
$82.00
$94.00
$103.00
5730
RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE)
$109.00
$123.00
$131.00
$145.00
$153.00
$170.00
$144.00
5731
RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE)
$109.00
$123.00
$131.00
$145.00
$153.00
$170.00
$144.00
5740
RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE)
$104.00
$117.00
$124.00
$138.00
$145.00
$160.00
$134.00
5741
RELINE MANDIBULAR PARTIAL DENT (CHAIRSIDE)
$104.00
$117.00
$124.00
$138.00
$145.00
$160.00
$134.00
5750
RELINE COMPLETE MAXILLARY DENTURE (LAB)
$143.00
$161.00
$171.00
$190.00
$200.00
$220.00
$193.00
5751
RELINE COMPLETE MANDIBULAR DENTURE (LAB)
$143.00
$161.00
$171.00
$190.00
$200.00
$220.00
$191.00

PROSTHODONTICS (FIXED)

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
$356.00
$399.00
$425.00
$466.00
$539.00
$563.00
$474.00
6241
PONTIC-PORCELAIN FUSED TO PREDOM BASE METAL
$328.00
$371.00
$393.00
$429.00
$451.00
$520.00
$442.00
6242
PONTIC-PORCELAIN FUSED TO NOBLE METAL
$343.00
$388.00
$412.00
$449.00
$491.00
$538.00
$457.00
6750
CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL
$392.00
$443.00
$465.00
$485.00
$515.00
$600.00
$490.00
6751
CROWN-PORCELAIN FUSED TO PREDOM BASE METAL
$353.00
$399.00
$423.00
$450.00
$479.00
$565.00
$442.00
6752
CROWN-PORCELAIN FUSED TO NOBLE METAL
$367.00
$414.00
$440.00
$468.00
$490.00
$587.00
$458.00

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
$44.00
$49.00
$53.00
$59.00
$61.00
$70.00
$59.00
7220
REMOVAL OF IMPACTED TOOTH-SOFT TISSUE
$90.00
$101.00
$108.00
$120.00
$125.00
$144.00
$130.00
7230
REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY
$117.00
$132.00
$140.00
$156.00
$164.00
$187.00
$165.00
7240
REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY
$170.00
$185.00
$197.00
$203.00
$219.00
$245.00
$204.00
7250
SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS
$90.00
$102.00
$102.00
$108.00
$115.00
$135.00
$120.00
7310
ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTION PER QUAD
$75.00
$84.00
$90.00
$99.00
$105.00
$120.00
$118.00
7320
ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTION PER QUAD
$108.00
$122.00
$130.00
$144.00
$152.00
$173.00
$166.00
7510
INCISION/DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE
$55.00
$62.00
$67.00
$74.00
$77.00
$89.00
$78.00

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

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
$29.00
$32.00
$35.00
$38.00
$40.00
$46.00
$42.00
9215
LOCAL ANESTHESIA
$10.00
$12.00
$13.00
$14.00
$15.00
$18.00
$18.00
9230
ANALGESIA
$21.00
$22.00
$23.00
$25.00
$25.00
$30.00
$25.00
9951
OCCLUSAL ADJUSTMENT LIMITED
$40.00
$46.00
$48.00
$54.00
$56.00
$64.00
$65.00
9952
OCCLUSAL ADJUSTMENT COMPLETE
$162.00
$183.00
$194.00
$216.00
$227.00
$260.00
$265.00
table end

Table with 4 columns and 15 rows

*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 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.
table end

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