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SoloCare Plans CAREINGTON MMC-6, CARE PPO/POS Dental Plans This schedule is an extensive list of most common procedures. Lab fees are not included and are to be paid in full by the member. The purpose of this schedule is to establish the maximum fee that you will charge the members of the various administered plans. Note: Unless otherwise noted, fee schedule is determined by zip code of doctor’s office. Code Diagnostic 0120 0140 0150 0160 0210 0220 0230 0240 0250 0260 0270 0272 0274 0330 0340 0460 0470 0471 Preventive 1110 1120 1201 1203 1204 1205 1330 1351 1510 1515 1520 1525 1550 Restorative 2110 2120 2130 2131 2140 2150 Code Schedule CI-6 Description Fee Schedule Periodic Oral Evaluation Limited Oral Evaluation-Problem Focused Comprehensive Oral Evaluation Detailed Exten Oral Eval-Problem Focus-By Report Intraoral-Complete Series Including Bitewings Intraoral-Periapical-First Film Intraoral-Periapical-Each Additional Film Intraoral-Occlusal Film Extraoral-First Film Extraoral-Each Additional Film Bitewings-Single Film Bitewings-Two Films Bitewings-Four Films Panoramic Film Cephalometric Film Pulp Vitality Tests Diagnostic Casts Diagnostic Photographs $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 18.00 30.00 30.00 52.00 53.00 10.00 8.00 15.00 20.00 18.00 11.00 17.00 25.00 48.00 56.00 23.00 40.00 24.00 Prophylaxis-Adult Prophylaxis-Child Topical Application of Fluoride Incl/PXS Child Topical Application of Fluoride PXS not Incl-Child Topical Application of Fluoride PXS not Incl-Adult Topical Application of Fluoride Incl/PXS Adult Oral Hygiene Instructions Sealant-Per Tooth Space Maintainer-Fixed-Unilateral Space Maintainer-Fixed-Bilateral Space Maintainer-Removable-Unilateral Space Maintainer-Removable-Bilateral Recementation of Space Maintainer $ $ $ $ $ $ $ $ $ $ $ $ $ 37.00 26.00 38.00 16.00 16.00 46.00 21.00 20.00 134.00 175.00 163.00 208.00 30.00 Amalgam-One Surface, Primary Amalgam-Two Surfaces, Primary Amalgam-Three Surfaces, Primary Amalgam-Four or More Surfaces, Primary Amalgam-One Surface, Permanent Amalgam-Two Surfaces, Permanent Description $ 41.00 $ 51.00 $ 62.00 $ 75.00 $ 44.00 $ 56.00 PPO Fee Schedule 1 2160 2161 2210 2330 2331 2332 2335 2336 2380 2381 2382 2385 2386 2387 2510 2520 2530 2543 2544 2610 2620 2630 2642 2643 2644 2650 2651 2652 2710 2720 2721 2722 2740 2750 2751 2752 2790 2791 2792 2810 2910 2920 2930 2931 2932 2933 2940 2950 2951 2952 2954 2955 Schedule CI-6 Amalgam-Three Surfaces, Permanent Amalgam-Four or More Surfaces, Permanent Silicate Cement-Per Restoration Resin, One Surface, Anterior Resin-Two Surfaces, Anterior Resin-Three Surfaces, Anterior Resin-Four +Surfaces or Invl Incisal Angle (Anterior) Composite Resin Crown-Anterior-Primary Resin-One Surface, Posterior-Primary Resin-Two Surfaces, Posterior-Primary Resin-Three or More Surfaces, Posterior-Primary Resin-One Surface, Posterior-Permanent Resin-Two Surfaces, Posterior-Permanent Resin-Three or More Surfaces, Posterior-Permanent Inlay-Metallic-One Surface Inlay-Metallic-Two Surfaces Inlay-Metallic-Three or More Surfaces Metallic-Onlay 3 Surfaces Metallic-Onlay 4 or More Surfaces Inlay-Porcelain/Ceramic-One Surface Inlay-Porcelain/Ceramic-Two Surfaces Inlay-Porcelain/Ceramic-Three or More Surfaces Porcelain/Ceramic-Onlay 2 Surfaces Porcelain/Ceramic-Onlay 3 Surfaces Porcelain/Ceramic-Onlay 4 or More Surfaces Composite/Resin-Inlay One Surface Lab Processed Inlay-Composite/Resin-Two Surfaces (Lab. Processed) Inlay-Composite/Resin-Three or > Surf (Lab. Processed) Crown-Resin-Laboratory Crown-Resin with High Noble Metal Crown-Resin with Predominately Base Metal Crown-Resin with Noble Metal Crown-Porcelain/Ceramic Substrate Crown-Porcelain Fused to High Noble Metal Crown-Porcelain Fused to Predominately Base Metal Crown-Porcelain Fused to Noble Metal Crown-Full Cast High Noble Metal Crown-Full Cast Predominately Base Metal Crown-Full Cast Noble Metal Crown-3/4 Cast Metallic Recement Inlay Recement Crown Prefabricated Stainless Steel Crown-Primary Prefabricated Stainless Steel Crown-Permanent Prefabricated Resin Crown Prefab. 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 Prefabricated Post and Core in Addition to Crown Post Removal Not in Conjunction w/Endodontic Therapy $ $ $ $ $ $ $ 100.00 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 478.00 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 70.00 86.00 39.00 55.00 68.00 85.00 118.00 60.00 70.00 82.00 60.00 82.00 102.00 315.00 376.00 414.00 445.00 453.00 356.00 397.00 440.00 430.00 450.00 470.00 310.00 363.00 400.00 285.00 480.00 428.00 460.00 496.00 445.00 466.00 475.00 420.00 460.00 460.00 37.00 39.00 108.00 125.00 132.00 152.00 40.00 105.00 22.00 165.00 130.00 116.00 2 Code Description 2960 Labial Veneer (Laminate)-Chairside 2970 Temporary Crown (Fractured Tooth) Endodontics 3110 Pulp Cap-Direct (Excluding Final Restoration) 3120 Pulp Cap-Indirect (Excluding Final Restoration) 3220 Therapeutic Pulpotomy (Excluding Final Restoration) 3230 Pulpal Therapy-Resorbable Fill -ant Primary Tooth 3240 Pulpal Therapy Resorbable Fill -post Primary Tooth 3310 Root Canal-Anterior (Excluding Final Restoration) 3320 Root Canal-Bicuspid (Excluding Final Restoration) 3330 Root Canal-Molar (Excluding Final Restoration) 3346 Retreatment Previous Root Canal Therapy-Anterior 3347 Retreatment Previous Root Canal Therapy-Bicuspid 3348 Retreatment Previous Root Canal Therapy-Molar 3351 Apex./Recal.Initial Visit (Ap. Clos./Cal.Rep.Etc) 3352 Apex/Recal-Interim Medication Replacement 3353 Apexification/Recalcification-Final Visit 3410 Apicoectomy/Periradicular Surgery-Anterior 3421 Apicoectomy/Periradicular Surgery-Bicuspid (First Root) 3425 Apicoectomy/Periradicular Surgery-Molar (First Root) 3426 Apicoectomy/Periradicular Surgery (Ea. Add’l Root) 3430 Retrograde Filling-Per Root 3450 Root Amputation-Per Root 3470 Intentional Replantation Include Necessary Splinting 3910 Surg Procedure for Isolation Tooth with R Dam 3920 Hemisection (Incl Root Removal) Not Incl Endo 3950 Canal Prep and Fitting of Preformed Dowel/Post 3960 Bleaching of Discolored Tooth Periodontics 4210 Gingivectomy or Gingivoplasty-Per Quadrant 4211 Gingivectomy or Gingivoplasty-Per Tooth 4220 Gingival Curettage, Surgical, Per Quad, By Report 4240 Gingival Flap Procedure Incl Root Planing/Quad 4249 Clinical Crown Lengthening-Hard Tissue 4250 Mucogingival Surgery-Per Quadrant 4260 Osseous Surgery Incl Flap Entry/Closure/Quad 4263 Bone Replacement Graft First Site in Quadrant 4264 Bone Replacement Graft-Ea. Add’l Site in Quadrant 4266 Guided Tissue Regen-Resorb Barrier/Site/Tooth 4267 Guided Tissue Regen-Non Resorb Per Site, Tooth 4270 Pedicle Soft Tissue Graft Procedure 4271 Free Soft Tissue Graft Proc. (Include Donor Site Surg) 4320 Provisional Splinting Intracoronal 4321 Provisional Splinting-Extracoronal 4341 Perio Scaling and Root Planing-Per Quadrant 4355 Full Mouth Debride-Enable Periodontal Eval & DX 4910 Perio Maintenance Proc Following Active Therapy 4920 Unschd. Drsg Chng (Not by Treating Dentist) Prosthodontics (removable) 5110 Complete Denture-Maxillary 5120 Complete Denture-Mandibular 5130 Immediate Denture-Maxillary Schedule CI-6 PPO Fee Schedule $ 219.00 $ 100.00 $ $ $ 70.00 $ $ $ $ $ $ $ $ $ $ $ $ 259.00 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 28.00 31.00 90.00 80.00 270.00 335.00 428.00 317.00 366.00 460.00 141.00 90.00 168.00 296.00 336.00 124.00 97.00 180.00 274.00 55.00 160.00 75.00 122.00 240.00 70.00 100.00 295.00 280.00 386.00 446.00 282.00 219.00 409.00 466.00 336.00 360.00 184.00 160.00 104.00 67.00 59.00 38.00 $ 600.00 $ 600.00 $ 650.00 3 Code Description 5140 Immediate Denture-Mandibular 5211 Maxillary Part Denture-Resin Base (Clasp/Rests) 5212 Mandibular Part Denture-Resin Base (Clasp/Rests) 5213 Maxillary Part Denture-Metal Frame with Resin Base 5214 Mandibular Part Denture-Metal Frame with Resin Base 5281 Remov Unilat Part Denture-1 Piece Metal (w/Teeth) 5410 Adjust Complete Denture-Maxillary 5411 Adjust Complete Denture-Mandibular 5421 Adjust Partial Denture-Maxillary 5422 Adjust Partial Denture-Mandibular 5510 Repair Broken Complete Denture Base 5520 Replace Miss/Brkn Teeth-Complete Denture/Tooth 5610 Repair Resin Denture Base 5620 Repair Cast Framework, Partial Denture 5630 Repair or Replace Broken Clasp, Partial Denture 5640 Replace Broken Teeth-Per Tooth, Partial Denture 5650 Add Tooth to Existing Partial Denture 5660 Add Clasp to Existing Partial Denture 5710 Rebase Complete Maxillary Denture 5711 Rebase Complete Mandibular Denture 5720 Rebase Maxillary Partial Denture 5721 Rebase Mandibular Partial Denture 5730 Reline Complete Maxillary Denture (Chairside) 5731 Reline Complete Mandibular Denture (Chairside) 5740 Reline Maxillary Partial Denture (Chairside) 5741 Reline Mandibular Partial Denture (Chairside) 5750 Reline Complete Maxillary Denture (Laboratory) 5751 Reline Compete Mandibular Denture (Laboratory) 5760 Reline Maxillary Partial Denture (Laboratory) 5761 Reline Mandibular Partial Denture (Laboratory) 5810 Interim Complete Denture (Maxillary) 5820 Interim Partial Denture (Maxillary) 5821 Interim Partial Denture (Mandibular) 5850 Tissue Conditioning Maxillary 5851 Tissue Conditioning Mandibular Prosthodontics (fixed) 6210 Pontic-Cast High Noble Metal 6211 Pontic-Cast Predominately Base Metal 6212 Pontic-Cast Noble Metal 6240 Pontic-Porcelain Fused to High Noble Metal 6241 Pontic-Porcelain Fused to Predom. Base Metal 6242 Pontic-Porcelain Fused to Noble Metal 6250 Pontic-Resin with High Noble Metal 6251 Pontic-Resin with Predominately Base Metal 6252 Pontic-Resin with Noble Metal 6520 Retainer-Inlay-Metallic-Two Surfaces 6530 Inlay Metallic 3 Surfaces 6543 Onlay Metallic 3 Surfaces 6544 Onlay-Metallic 4 or More Surfaces 6545 Retainer-Cast Metal-Resin Bonded Fixed Prosthes 6720 Crown-Bridge Retainer-Resin with High Noble Metal 6721 Crown-Bridge Retainer-Resin Predom. Base Metal Schedule CI-6 PPO Fee Schedule $ 650.00 $ 460.00 $ 464.00 $ 680.00 $ 680.00 $ 360.00 $ 30.00 $ 30.00 $ 30.00 $ 30.00 $ 69.00 $ 50.00 $ 65.00 $ 117.00 $ 87.00 $ 55.00 $ 75.00 $ 100.00 $ 220.00 $ 220.00 $ 210.00 $ 210.00 $ 145.00 $ 145.00 $ 138.00 $ 138.00 $ 190.00 $ 190.00 $ 190.00 $ 190.00 $ 320.00 $ 280.00 $ 280.00 $ 50.00 $ 50.00 $ $ $ $ $ $ $ $ 431.00 $ $ $ $ $ $ $ 475.00 $ 470.00 420.00 430.00 470.00 431.00 445.00 460.00 454.00 350.00 411.00 445.00 460.00 265.00 437.00 4 Code Description PPO Fee Schedule $ 454.00 $ 490.00 $ 448.00 $ 464.00 $ 460.00 $ 467.00 $ 426.00 $ 460.00 $ 57.00 $ 161.00 $ 160.00 $ 131.00 $ 109.00 $ 280.00 6722 Crown (Resin with Noble Metal) 6750 Crown-Retainer-Porcelain Fused High Noble Metal 6751 Crown-Retainer-Porcelain Fused Predom. Base Metal 6752 Crown-Retainer-Porcelain Fused to Noble Metal 6780 Crown-Retainer 3/4 Cast High Noble Metal 6790 Crown-Retainer-Full Cast High Noble Metal 6791 Crown-Retainer-Full Cast Predom. Base Metal 6792 Crown-Retainer-Full Cast Noble Metal 6930 Recement Fixed Partial Denture 6970 Cast Post and Core/Addition to Bridge Retainer 6971 Cast Post Part of Bridge Retainer 6972 Prefab Post and Core in Addition to Bridge Ret 6973 Core Buildup for Retainer, Including Any Pins 6975 Coping-Metal Oral Surgery 7110 Extraction-Single Tooth $ 56.00 7120 Extraction-Each Additional Tooth $ 52.00 7130 Root Removal-Exposed Root $ 72.00 7210 Surg. Rem. Erup Tooth Req. Flap/Bone Rem/Sec Tooth $ 111.00 7220 Removal of Impacted Tooth-Soft Tissue $ 132.00 7230 Removal of Impacted Tooth-Partial Bony $ 169.00 7240 Removal of Impacted Tooth-Complete Bony $ 206.00 7241 Rem Impac. Tooth-Comp Bony/Unusual Complications $ 240.00 7250 Surg. Rem or Residual Tooth Roots (Cutting Proc) $ 117.00 7260 Oral Antral Fistula Closure $ 260.00 7270 Reimplant or Stab Accid Evul Tooth and/or Alveol $ 208.00 7280 Surg Exp-Imp/Unerup Tooth for Ortho Include Attach $ 196.00 7281 Surg. Exp-Imp/Unerup Tooth to Aid Eruption $ 140.00 7285 Biopsy of Oral Tissue-Hard $ 154.00 7286 Biopsy of Oral Tissue-Soft $ 120.00 7310 Alveoloplasty in Conjunc with Exts-Per Quad $ 120.00 7320 Alveoloplasty Not in Conjunc with Exts-Per Quad $ 168.00 7430 Excision of Benign Tumor Lesion < 1.25 CM $ 196.00 7431 Excision of Benign Tumor Lesion > 1.25 CM $ 249.00 7450 Removal of Odontogenic Cyst/Tumor/Lesion < 1.25 CM $ 190.00 7451 Removal of Odontogenic Cyst/Tumor/Lesion > 1.25 CM $ 268.00 7460 Rem of Nonodontogenic Cyst/Tumor/Lesion < 1.25 CM $ 197.00 7470 Removal of Exostosis-Maxilla or Mandible $ 240.00 7510 Incision and Drainage Abscess Intraoral-Soft Tissue $ 80.00 7910 Suture of Recent Small Wounds up to 5 CM $ 75.00 7911 Complicated Suture up to 5 CM, Meticulous Closure $ 150.00 7960 Frenulectomy (Frenectomy/Frenotomy) Sep. Proc. $ 180.00 7970 Excision of Hyperplastic Tissue/Per Arch $ 189.00 7971 Excision of Pericoronal Gingiva $ 69.00 Orthodontics 8070 Comprehensive Ortho Treatment of the Transitional Dentition $2660.00 8080 Comprehensive Ortho Treatment of the Adolescent Dentition $2770.00 8090 Comprehensive Ortho Treatment of the Adult Dentition $2860.00 8210 Removable Appliance Therapy $ 340.00 8660 Pre-Orthodontic Treatment Visit $ 110.00 Adjunctive Services 9110 Palliative (Emergency) Tx-Dental Pain-Minor Procedure $ 40.00 Schedule CI-6 5 Code Description 9210 9211 9215 9230 9310 9410 9420 9430 9440 9910 9941 9950 9951 9952 9970 Local Anesthesia Not in Conjunc with Operative Regional Block Anesthesia Local Anesthesia Analgesia Prof Consult (Diag Serv by Other Dentist/Phys) Professional Visit-House Call Professional Visit-Hospital Call Office Visit for Obser (Reg. Hours) No Other Servs Office Visit-After Regular Hours Application-Desensitizing Medicament Fabrication of Athletic Mouthguard Occlusion Analysis-Mounted Case Occlusion Adjustment-Limited Occlusion Adjustment-Complete Enamel Microabrasion Schedule CI-6 PPO Fee Schedule $ 20.00 $ 22.00 $ 18.00 $ 22.00 $ 47.00 $ 54.00 $ 72.00 $ 29.00 $ 55.00 $ 25.00 $ 90.00 $ 120.00 $ 67.00 $ 270.00 $ 76.00 6
