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Careington Corporation
Care Platinum Series Schedule
CP-59
**Discount plans are not insurance**
This schedule applies to participating Careington General Dentists and should be used to establish the maximum fee that will be charged for each listed
procedure. Lab fees may not be charged in addition to the fee schedule price indicated. Procedures not listed on this schedule will be offered to the member at a
15% discount off of the participating General Dentist's usual fee for that procedure. If the participating General Dentist's usual fee is less than the fee listed on this
schedule, the member will receive a 15% discount off of the participating General Dentist's usual fee for that procedure. Participating Careington Specialists
(Board Certified or Advanced Degree) do not use this fee schedule. All participating Careington Specialists will give members a 5-15% discount off of their usual
fees. If you have any questions, please call 800-290-0523.
Code Description
Fee
Diagnostic
D0120 Periodic Oral Evaluation - Established Patient
$43
D0140 Limited Oral Evaluation-Problem Focused
$63
D0150 Comprehensive Oral Evaluation-New or Established Patient
$74
D0160 Detailed and Extensive Oral Evaluation-Problem Focused-By Report
$134
D0170 Re-Evaluation-Limited-Problem Focused
$58
D0180 Comprehensive Periodontal Evaluation-New or Established Patient
$77
D0210 Intraoral-Complete Series Including Bitewings
$113
D0220 Intraoral-Periapical-First Film
$25
D0230 Intraoral-Periapical-Each Additional Film
$20
D0240 Intraoral-Occlusal Film
$37
D0250 Extraoral-First Film
$55
D0260 Extraoral-Each Additional Film
$45
D0270 Bitewing-Single Film
$27
D0272 Bitewings-Two Films
$42
D0273 Bitewings-Three Films
$53
D0274 Bitewings-Four Films
$58
D0277 Vertical Bitewings-7 to 8 Films
$83
D0330 Panoramic Film
$105
D0340 Cephalometric Film
$112
D0350 Oral/Facial Photographic Images
$60
D0460 Pulp Vitality Tests
$49
D0470 Diagnostic Casts
$94
Preventive
D1110 Prophylaxis-Adult
$86
D1120 Prophylaxis-Child
$62
D1203 Topical Application of Fluoride Not Including Prophylaxis-Child
$32
D1204 Topical Application of Fluoride Not Including Prophylaxis-Adult
$32
D1330 Oral Hygiene Instructions
$48
D1351 Sealant-Per Tooth
$48
D1510 Space Maintainer-Fixed-Unilateral
$290
D1515 Space Maintainer-Fixed-Bilateral
$410
D1520 Space Maintainer-Removable-Unilateral
$358
D1525 Space Maintainer-Removable-Bilateral
$454
D1550 Recementation of Space Maintainer
$72
D1555 Removal of Fixed Space Maintainer
15% Discount
Restorative
D2140 Amalgam-One Surface, Primary or Permanent
$120
D2150 Amalgam-Two Surfaces, Primary or Permanent
$158
D2160 Amalgam-Three Surfaces, Primary or Permanent
$191
D2161 Amalgam-Four or More Surfaces, Primary or Permanent
$224
D2330 Resin-Based Composite-One Surface, Anterior
$146
D2331 Resin-Based Composite-Two Surfaces, Anterior
$184
D2332 Resin-Based Composite-Three Surfaces, Anterior
$223
D2335 Resin-Based Composite-Four or More Surfaces or Involving Incisal Angle, Anterior
$281
D2390 Resin-Based Composite Crown, Anterior
$422
D2391 Resin-Based Composite-One Surface, Posterior
$163
D2392 Resin-Based Composite-Two Surfaces, Posterior
$215
D2393 Resin-Based Composite-Three Surfaces, Posterior
$269
D2394 Resin-Based Composite-Four or More Surfaces, Posterior
$320
D2510 Inlay-Metallic-One Surface
$715
D2520 Inlay-Metallic-Two Surfaces
$775
D2530 Inlay-Metallic-Three or More Surfaces
$834
D2542 Onlay-Metallic-Two Surfaces
$864
D2543 Onlay-Metallic-Three Surfaces
$905
D2544 Onlay-Metallic-Four or More Surfaces
$948
D2610 Inlay-Porcelain/Ceramic-One Surface
$787
D2620 Inlay-Porcelain/Ceramic-Two Surfaces
$836
D2630 Inlay-Porcelain/Ceramic-Three or More Surfaces
$894
D2642 Onlay-Porcelain/Ceramic-Two Surfaces
$921
D2643 Onlay-Porcelain/Ceramic-Three Surfaces
$954
D2644 Onlay-Porcelain/Ceramic-Four or More Surfaces
$983
Provider - 2009-2010 CDT COMPLIANT
Effective February 1, 2010
CP-59 , 1 of 4
Code
D2650
D2651
D2652
D2662
D2663
D2664
D2710
D2720
D2721
D2722
D2740
D2750
D2751
D2752
D2780
D2781
D2782
D2783
D2790
D2791
D2792
D2910
D2920
D2930
D2931
D2932
D2933
D2940
D2950
D2951
D2952
D2953
D2954
D2955
D2957
D2960
D3110
D3120
D3220
D3221
D3230
D3240
D3310
D3320
D3330
D3331
D3332
D3333
D3346
D3347
D3348
D3351
D3352
D3353
D3410
D3421
D3425
D3426
D3430
D3450
D3470
D3910
D3920
D3950
D4210
D4211
D4230
D4231
D4240
D4241
D4245
D4249
D4260
Description
Inlay-Composite/Resin-One Surface
Inlay-Composite/Resin-Two Surfaces
Inlay-Composite/Resin-Three or More Surfaces
Onlay-Composite/Resin-Two Surfaces
Onlay-Composite/Resin-Three Surfaces
Onlay-Composite/Resin-Four or More Surfaces
Crown-Resin-Based Composite (Indirect)
Crown-Resin with High Noble Metal
Crown-Resin with Predominantly Base Metal
Crown-Resin with Noble Metal
Crown-Porcelain/Ceramic Substrate
Crown-Porcelain Fused to High Noble Metal
Crown-Porcelain Fused to Predominantly Base Metal
Crown-Porcelain Fused to Noble Metal
Crown-3/4 Cast to High Noble Metal
Crown-3/4 Cast to Predominantly Base Metal
Crown-3/4 Cast Noble Metal
Crown-3/4 Porcelain/Ceramic (Does not include facial veneers)
Crown-Full Cast High Noble Metal
Crown-Full Cast Predominantly Base Metal
Crown-Full Cast Noble Metal
Recement Inlay, Onlay, or Partial Coverage Restoration
Recement Crown
Prefabricated Stainless Steel Crown-Primary
Prefabricated Stainless Steel Crown-Permanent
Prefabricated Resin Crown
Prefabricated Stainless Steel Crown with Resin Window
Sedative Filling
Core Build-Up, Including Any Pins
Pin Retention/Tooth, In Addition to Restoration
Cast Post and Core In Addition to Crown
Each Additional Cast Post-Same Tooth
Prefabricated Post and Core in Addition to Crown
Post Removal Not in Conjunction with Endodontic Therapy
Each Additional Prefabricated Post-Same Tooth
Labial Veneer (Laminate)-Chairside
Endodontics
Pulp Cap-Direct (Excluding Final Restoration)
Pulp Cap-Indirect (Excluding Final Restoration)
Therapeutic Pulpotomy (Excluding Final Restoration)
Pulpal Debridement- Primary and Permanent Teeth
Pulpal Therapy-Resorbable Filling-Anterior Primary Tooth
Pulpal Therapy Resorbable Filling-Posterior Primary Tooth
Root Canal-Anterior (Excluding Final Restoration)
Root Canal-Bicuspid (Excluding Final Restoration)
Root Canal-Molar (Excluding Final Restoration)
Treatment of Root Canal Obstruction-Non-Surgical Access
Incomplete Endodontic Therapy-Inoperable, Unrestorable or Fractured Tooth
Internal Root Repair of Perforation Defects
Retreatment Previous Root Canal Therapy-Anterior
Retreatment Previous Root Canal Therapy-Bicuspid
Retreatment Previous Root Canal Therapy-Molar
Apexification/Recalcification-Initial Visit
Apexification/Recalcification-Interim Medication Replacement
Apexification/Recalcification-Final Visit
Apicoectomy/Periradicular Surgery-Anterior
Apicoectomy/Periradicular Surgery-Bicuspid (First Root)
Apicoectomy/Periradicular Surgery-Molar (First Root)
Apicoectomy/Periradicular Surgery (Each Additional Root)
Retrograde Filling-Per Root
Root Amputation-Per Root
Intentional Reimplantation (Including Necessary Splinting)
Surgical Procedure for Isolation of Tooth with Rubber Dam
Hemisection-Including Root Removal, Not Including Root Canal
Canal Preparation and Fitting of Preformed Dowel or Post
Periodontics
Gingivectomy or Gingivoplasty-Four or More Contiguous Teeth or Bounded Teeth Spaces Per Quadrant
Gingivectomy or Gingivoplasty-One to Three Contiguous Teeth or Bounded Teeth Spaces Per Quadrant
Anatomical Crown Exposure-Four or More Contiguous Teeth Per Quadrant
Anatomical Crown Exposure-One to Three Teeth Per Quadrant
Gingival Flap Procedure, Including Root Planing-Four or More Contiguous Teeth or Bounded Teeth Spaces Per Quad
Gingival Flap Procedure, Including Root Planing-One to Three Contiguous Teeth or Bounded Teeth Spaces Per Quad
Apically Positioned Flap
Clinical Crown Lengthening-Hard Tissue
Osseous Surgery (Inc. Flap Entry and Closure)-Four or More Contiguous Teeth or Bounded Teeth Spaces Per Quad
Provider - 2009-2010 CDT COMPLIANT
Effective February 1, 2010
Fee
$737
$775
$820
$858
$876
$917
$775
$924
$856
$894
$1,064
$1,045
$894
$936
$954
$893
$937
$994
$963
$864
$918
$95
$95
$238
$284
$300
$325
$101
$246
$60
$387
$252
$299
$268
$125
$536
$72
$74
$173
$191
$238
$268
$665
$792
$960
$393
$358
$221
$745
$830
$1,001
$312
$232
$441
$596
$656
$763
$312
$244
$422
$721
$179
$416
$228
$557
$209
15% Discount
15% Discount
$656
$567
$767
$668
$950
CP-59 , 2 of 4
Code
D4261
D4263
D4264
D4266
D4267
D4268
D4270
D4271
D4320
D4321
D4341
D4342
D4355
D4910
D4920
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5281
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5810
D5811
D5820
D5821
D5850
D5851
Description
Osseous Surgery (Inc. Flap Entry and Closure)-One to Three Contiguous Teeth or Bounded Teeth Spaces Per Quad
Bone Replacement Graft-First Site in Quadrant
Bone Replacement Graft-Each Additional Site in Quadrant
Guided Tissue Regeneration-Resorbable Barrier per Site
Guided Tissue Regeneration-Nonresorbable Barrier per Site
Surgical Revision Procedure, per Tooth
Pedicle Soft Tissue Graft Procedure
Free Soft Tissue Graft Procedure (Including Donor Site Surgery)
Provisional Splinting-Intracoronal
Provisional Splinting-Extracoronal
Periodontal Scaling and Root Planing-Four or More Teeth Per Quadrant
Periodontal Scaling and Root Planing-One to Three Teeth Per Quadrant
Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis
Periodontal Maintenance
Unscheduled Dressing Change (Not by Treating Dentist)
Prosthodontics (removable)
Complete Denture-Maxillary
Complete Denture-Mandibular
Immediate Denture-Maxillary
Immediate Denture-Mandibular
Maxillary Partial Denture-Resin Base (Clasp/Rests)
Mandibular Partial Denture-Resin Base (Clasp/Rests)
Maxillary Partial Denture-Metal Frame with Resin Base
Mandibular Partial Denture-Metal Frame with Resin Base
Removable Unilateral Partial Denture-One Piece Cast Metal
Adjust Complete Denture-Maxillary
Adjust Complete Denture-Mandibular
Adjust Partial Denture-Maxillary
Adjust Partial Denture-Mandibular
Repair Broken Complete Denture Base
Replace Missing or Broken Teeth-Complete Denture (Each Tooth)
Repair Resin Denture Base
Repair Cast Framework, Partial Denture
Repair or Replace Broken Clasp, Partial Denture
Replace Broken Teeth-Per Tooth, Partial Denture
Add Tooth to Existing Partial Denture
Add Clasp to Existing Partial Denture
Rebase Complete Maxillary Denture
Rebase Complete Mandibular Denture
Rebase Maxillary Partial Denture
Rebase Mandibular Partial Denture
Reline Complete Maxillary Denture (Chairside)
Reline Complete Mandibular Denture (Chairside)
Reline Maxillary Partial Denture (Chairside)
Reline Mandibular Partial Denture (Chairside)
Reline Complete Maxillary Denture (Laboratory)
Reline Complete Mandibular Denture (Laboratory)
Reline Maxillary Partial Denture (Laboratory)
Reline Mandibular Partial Denture (Laboratory)
Interim Complete Denture-Maxillary
Interim Complete Denture-Mandibular
Interim Partial Denture-Maxillary
Interim Partial Denture-Mandibular
Tissue Conditioning-Maxillary
Tissue Conditioning-Mandibular
Prosthodontics (fixed)
Pontic-Cast High Noble Metal
Pontic-Cast Predominantly Base Metal
Pontic-Cast Noble Metal
Pontic-Porcelain Fused to High Noble Metal
Pontic-Porcelain Fused to Predominantly Base Metal
Pontic-Porcelain Fused to Noble Metal
Pontic-Porcelain/Ceramic
Pontic-Resin with High Noble Metal
Pontic-Resin with Predominantly Base Metal
Pontic-Resin with Noble Metal
Retainer-Cast Metal for Resin Bonded Fixed Prosthesis
Retainer-Porcelain/Ceramic for Resin Bonded Fixed Prosthesis
Crown-Bridge Retainer-Resin with High Noble Metal
Crown-Bridge Retainer-Resin Predominantly Base Metal
Crown-Resin with Noble Metal
Crown-Porcelain/Ceramic
Provider - 2009-2010 CDT COMPLIANT
$1,431
$1,431
$1,550
$1,550
$1,080
$1,080
$1,520
$1,520
$894
$80
$80
$80
$80
$188
$160
$184
$267
$236
$166
$200
$244
$525
$525
$507
$507
$336
$336
$328
$328
$429
$429
$422
$422
$745
$745
$596
$596
$179
$179
15% Discount
D6000 through D6096 Implant Services
D6210
D6211
D6212
D6240
D6241
D6242
D6245
D6250
D6251
D6252
D6545
D6548
D6720
D6721
D6722
D6740
Fee
$778
$631
$453
$798
$923
$740
$733
$775
$471
$415
$242
$148
$177
$125
$92
Effective February 1, 2010
$978
$888
$930
$995
$906
$951
$983
$961
$917
$937
$685
$887
$954
$898
$948
$1,077
CP-59 , 3 of 4
Code
D6750
D6751
D6752
D6780
D6781
D6782
D6783
D6790
D6791
D6792
D6930
D6970
D6972
D6973
D6975
D6976
D6977
D7111
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7270
D7272
D7280
D7285
D7286
D7310
D7320
D7450
D7451
D7460
D7461
D7510
D7910
D7911
D7912
D7951
D7960
D7970
D7971
D8010
D8020
D8030
D8040
D8050
D8060
D8070
D8080
D8090
D8210
D8660
D9110
D9120
D9211
D9215
D9230
D9310
D9410
D9420
D9430
D9440
D9910
D9911
D9941
D9950
D9951
D9952
D9970
Description
Crown-Retainer-Porcelain Fused to High Noble Metal
Crown-Retainer-Porcelain Fused to Predominantly Base Metal
Crown-Retainer-Porcelain Fused to Noble Metal
Crown-Retainer 3/4 Cast High Noble Metal
Crown-Retainer 3/4 Predominantly Base Metal
Crown-Retainer 3/4 Cast Noble Metal
Crown-Retainer 3/4 Porcelain/Ceramic
Crown-Retainer-Full Cast High Noble Metal
Crown-Retainer-Full Cast Predominantly Base Metal
Crown-Retainer-Full Cast Noble Metal
Recement Fixed Partial Denture
Cast Post and Core/Addition to Bridge Retainer
Prefabricated Post and Core in Addition to Bridge Retainer
Core Buildup for Retainer, Including Any Pins
Coping-Metal
Each Additional Cast Post-Same Tooth
Each Additional Prefabricated Post-Same Tooth
Oral Surgery
Extraction, Coronal Remnants - Deciduous Tooth
Extraction-Erupted Tooth or Exposed Root (Elevation and/or Forcepts Removal)
Surgical Removal of Erupted Tooth Requiring Elevation of Mucoperiosteal Flap and Removal of Bone/Section of Tooth
Removal of Impacted Tooth-Soft Tissue
Removal of Impacted Tooth-Partially Bony
Removal of Impacted Tooth-Completely Bony
Removal of Impacted Tooth-Completely Bony with Unusual Complications
Surgical Removal of Residual Tooth Roots (Cutting Procedure)
Reimplantation or Stabilization of Accidentally Evulsed or Displaced Tooth
Tooth Transplantation
Surgical Access of an Unerupted Tooth
Biopsy of Oral Tissue-Hard (Bone, Tooth)
Biopsy of Oral Tissue-Soft
Alveoloplasty in Conjunction with Extractions-Per Quadrant
Alveoloplasty Not in Conjunction with Extractions-Per Quadrant
Removal of Benign Odontogenic Cyst or Tumor < 1.25 CM
Removal of Benign Odontogenic Cyst or Tumor > 1.25 CM
Removal of Benign Nonodontogenic Cyst or Tumor < 1.25 CM
Removal of Benign Nonodontogenic Cyst or Tumor > 1.25 CM
Incision and Drainage Abscess-Intraoral Soft Tissue
Suture of Recent Small Wounds up to 5 CM
Complicated Suture up to 5 CM, Meticulous Closure
Complicated Suture Greater Than 5 CM, Meticulous Closure
Sinus Augmentation With Bone or Bone Substitutes
Frenulectomy (Frenectomy/Frenotomy) Separate Procedure
Excision of Hyperplastic Tissue/Per Arch
Excision of Pericoronal Gingiva
Orthodontics
Limited Orthodontic Treatment of the Primary Dentition
Limited Orthodontic Treatment of the Transitional Dentition
Limited Orthodontic Treatment of the Adolescent Dentition
Limited Orthodontic Treatment of the Adult Dentition
Interceptive Orthodontic Treatment of the Primary Dentition
Interceptive Orthodontic Treatment of the Transitional Dentition
Comprehensive Orthodontic Treatment of the Transitional Dentition
Comprehensive Orthodontic Treatment of the Adolescent Dentition
Comprehensive Orthodontic Treatment of the Adult Dentition
Removable Appliance Therapy
Pre-Orthodontic Treatment Visit
Adjunctive Services
Palliative (Emergency) Treatment-Dental Pain-Minor Procedure
Fixed Partial Denture Sectioning
Regional Block Anesthesia
Local Anesthesia
Analgesia
Consultation (Diagnostic Service by Dentist or Physician Other Than Practitioner Providing Treatment)
Professional Visit-House Call
Professional Visit-Hospital Call
Office Visit for Observation (Regular Hours) No Other Services Performed
Office Visit-After Regular Hours
Application-Desensitizing Medicament
Application-Desensitizing Resin for Cervical and/or Root Surface
Fabrication of Athletic Mouthguard
Occlusion Analysis-Mounted Case
Occlusal Adjustment-Limited
Occlusal Adjustment-Complete
Enamel Microabrasion
Fee
$1,070
$906
$954
$983
$924
$947
$983
$983
$893
$941
$149
$395
$298
$246
$652
$243
$138
$124
$146
$238
$277
$358
$447
$527
$271
$484
$626
$355
$343
$274
$262
$384
$430
$600
$449
$684
$205
$263
$404
$588
15% Discount
$392
$453
$209
15% Discount
15% Discount
15% Discount
15% Discount
15% Discount
15% Discount
15% Discount
15% Discount
15% Discount
15% Discount
15% Discount
$107
15% Discount
$89
$54
$60
$107
$201
$215
$66
$149
$55
$72
$215
$298
$155
$620
$191
Please Call (800) 290-0523 for Member Eligibility Verification
Provider - 2009-2010 CDT COMPLIANT
Effective February 1, 2010
CP-59 , 4 of 4