CarePOS Dental Plan Highlights

Transcription

1 CarePOS Dental Plan Highlights The CarePOS is a National network dental plan that will enable you to save an average of 20 to 60% on all Dental services. All the discounts on this plan have been pre-negotiated in advance with the over 211,000 credentialed dental providers in the network. Simply pay the discounted amount directly to the network dentist at the time services are rendered it s that easy. Please refer to the full fee schedule. To find a full CarePOS fee schedule in your area, go to and click on the All Plan Fee Schedule link in the quick links box. Then go to the Careington POS Fee Schedule box and enter your zip code. Your zip code specific fee schedule will appear in a PDF format. You will then be able to open the PDF file showing the discounted fees in your area. It is important on this plan to receive services from a CarePOS Dentist from the list of participating dentists. To find a contracted CarePOS dentist, go to and click on thee Provider Locator link in the quick links box. Then go to the Careington logo and click on the logo. Then enter your zip code. Average savings of 20 60% on dental services Very low month cost No waiting on any services, including Major and Ortho Cosmetic dentistry included (teeth whitening) Unlimited services - use this plan as much as you like Orthodontia (child & adult) Significant savings No deductibles, No pre-authorizations Example of CI-5 Fee Schedule Zip Code & Example Of Cleaning At The Dentist ADA code Dental Procedure Description Normal Fee CarePOS 9430 Office Visit $35 20% discount 0150 Comprehensive oral exam $91 $ X-rays Bitewings 4 film $99 $ Prophylaxis-adult $93 $48 Other Most Commonly Utilized Dental Procedures ADA Code Dental Procedure Description Normal fee CarePOS Fee 0120 Periodic oral exam-established patient $51 $ Intraoral- complete series $148 $ Bitewing single film $29 $ Bitewing two films $46 $ Resin based composite-1 surface $156 $ * Crown-full cast high noble metal $1,123 $ Molar (excluding final restoration) $1,212 $ Periodontal Scaling/Root Planting $268 $ * Complete denture-maxillary $1,756 $ Extraction erupted tooth $177 $ Analgesia (anesthesia) of nitrous $82 $28 This plan is not insurance, it is a discount plan

2 CarePOS Schedule CI-5 Please Call for Customer Service ***Discount plans are not insurance*** This schedule applies to services provided by a participating General Dentist and is an extensive list of most common procedures. The purpose of this schedule is to establish the maximum fee that a General Dentist will charge for each listed procedure. Fee schedules are determined by the zip code of the participating provider. Participating Specialists (Board Certified or Advanced Degree) do not charge according to this fee schedule. Participating Specialists will give a 20% discount.* PLEASE READ IMPORTANT PLAN INFORMATION AT THE END OF THIS SCHEDULE Code Description Regular Cost Plan Cost Savings Diagnostic (Exams, X-Rays) D0120 Periodic Oral Evaluation - Established Patient $51 $24 53% D0140 Limited Oral Evaluation - Problem Focused $86 $40 54% D0150 Comprehensive Oral Evaluation - New Or Established Patient $91 $41 55% D0160 Detailed And Extensive Oral Evaluation - Problem Focused, By Report $181 $107 41% D0170 Re-Evaluation - Limited, Problem Focused (Established Patient; Not Post-Operative Visit) $60 $30 50% D0180 Comprehensive Periodontal Evaluation - New Or Established Patient $98 $33 66% D0210 Intraoral - Complete Series Of Radiographic Images $148 $72 51% D0220 Intraoral - Periapical First Radiographic Image $29 $14 52% D0230 Intraoral - Periapical Each Additional Radiographic Image $27 $11 59% D0240 Intraoral - Occlusal Radiographic Image $46 $20 56% D0250 Extraoral - First Radiographic Image $56 $28 50% D0260 Extraoral - Each Additional Radiographic Image $52 $27 48% D0270 Bitewing - Single Radiographic Image $29 $14 52% D0272 Bitewings - Two Radiographic Images $46 $22 53% D0273 Bitewings - Three Radiographic Images $57 $27 52% D0274 Bitewings - Four Radiographic Images $65 $31 52% D0277 Vertical Bitewings - 7 To 8 Radiographic Images $99 $40 59% D0330 Panoramic Radiographic Image $124 $58 53% D0340 Cephalometric Radiographic Image $140 $72 49% D0350 Oral/Facial Photographic Images $67 $34 49% D0460 Pulp Vitality Tests $64 $29 55% D0470 Diagnostic Casts $140 $60 57% Preventive (Cleanings, ect.) D1110 Prophylaxis - Adult $93 $48 48% D1120 Prophylaxis - Child $64 $34 47% D1208 Topical Application Of Fluoride $37 $21 43% D1330 Oral Hygiene Instructions $68 $35 48% D1351 Sealant - Per Tooth $55 $27 51% D1510 Space Maintainer - Fixed - Unilateral $359 $170 53% D1515 Space Maintainer - Fixed - Bilateral $503 $224 55% D1520 Space Maintainer - Removable - Unilateral $395 $210 47% D1525 Space Maintainer - Removable - Bilateral $610 $289 53% D1550 Re-Cementation Of Space Maintainer $78 $37 52% D1555 Removal Of Fixed Space Maintainer $75 20% Discount Restorative (Fillings, Crowns) D2140 Amalgam - One Surface, Primary Or Permanent $139 $63 55% D2150 Amalgam - Two Surfaces, Primary Or Permanent $179 $81 55% D2160 Amalgam - Three Surfaces, Primary Or Permanent $217 $99 54% D2161 Amalgam - Four Or More Surfaces, Primary Or Permanent $264 $121 54% D2330 Resin-Based Composite - One Surface, Anterior $156 $74 52% D2331 Resin-Based Composite - Two Surfaces, Anterior $199 $94 53% D2332 Resin-Based Composite - Three Surfaces, Anterior $243 $114 53% D2335 Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle (Anterior) $288 $136 53% D2390 Resin-Based Composite Crown, Anterior $319 $192 40% D2391 Resin-Based Composite - One Surface, Posterior $182 $83 54% D2392 Resin-Based Composite - Two Surfaces, Posterior $239 $114 52% D2393 Resin-Based Composite - Three Surfaces, Posterior $296 $142 52% D2394 Resin-Based Composite - Four Or More Surfaces, Posterior $363 $149 59% D2510 Inlay - Metallic - One Surface $841 $348 59% D2520 Inlay - Metallic - Two Surfaces $953 $394 59% D2530 Inlay - Metallic - Three Or More Surfaces $1,099 $454 59% D2542 Onlay - Metallic-Two Surfaces $1,078 $417 61% D2543 Onlay - Metallic-Three Surfaces $1,127 $467 59% D2544 Onlay - Metallic-Four Or More Surfaces $1,172 $486 59% D2610 Inlay - Porcelain/Ceramic - One Surface $989 $409 59% D2620 Inlay - Porcelain/Ceramic - Two Surfaces $1,044 $432 59% Member - CDT Compliant Effective February 1, 2010 CI-5, Page 1 of 5

3 Code Description Regular Cost Fee Savings D2630 Inlay - Porcelain/Ceramic - Three Or More Surfaces $1,112 $461 59% D2642 Onlay - Porcelain/Ceramic - Two Surfaces $1,081 $446 59% D2643 Onlay - Porcelain/Ceramic - Three Surfaces $1,165 $482 59% D2644 Onlay - Porcelain/Ceramic - Four Or More Surfaces $1,236 $512 59% D2650 Inlay - Resin-Based Composite - One Surface $650 $268 59% D2651 Inlay - Resin-Based Composite - Two Surfaces $774 $320 59% D2652 Inlay - Resin-Based Composite - Three Or More Surfaces $814 $337 59% D2662 Onlay - Resin-Based Composite - Two Surfaces $706 $426 40% D2663 Onlay - Resin-Based Composite - Three Surfaces $831 $434 48% D2664 Onlay - Resin-Based Composite - Four Or More Surfaces $890 $456 49% D2710 Crown - Resin-Based Composite (Indirect) $466 $215 54% D2720 Crown - Resin With High Noble Metal $1,149 $593 48% D2721 Crown - Resin With Predominantly Base Metal $1,077 $555 48% D2722 Crown - Resin With Noble Metal $1,101 $568 48% D2740 Crown - Porcelain/Ceramic Substrate $1,179 $606 49% D2750 Crown - Porcelain Fused To High Noble Metal $1,164 $600 48% D2751 Crown - Porcelain Fused To Predominantly Base Metal $1,084 $558 49% D2752 Crown - Porcelain Fused To Noble Metal $1,110 $571 49% D2780 Crown - 3/4 Cast High Noble Metal $1,116 $588 47% D2781 Crown - 3/4 Cast Predominantly Base Metal $1,051 $565 46% D2782 Crown - 3/4 Cast Noble Metal $1,085 $584 46% D2783 Crown - 3/4 Porcelain/Ceramic $1,148 $622 46% D2790 Crown - Full Cast High Noble Metal $1,123 $578 49% D2791 Crown - Full Cast Predominantly Base Metal $1,064 $551 48% D2792 Crown - Full Cast Noble Metal $1,084 $560 48% D2910 Recement Inlay, Onlay, Or Partial Coverage Restoration $110 $50 55% D2920 Recement Crown $111 $52 53% D2930 Prefabricated Stainless Steel Crown - Primary Tooth $304 $141 54% D2931 Prefabricated Stainless Steel Crown - Permanent Tooth $344 $160 53% D2932 Prefabricated Resin Crown $366 $174 53% D2933 Prefabricated Stainless Steel Crown With Resin Window $420 $194 54% D2940 Protective Restoration $116 $54 53% D2950 Core Buildup, Including Any Pins $290 $135 53% D2951 Pin Retention - Per Tooth, In Addition To Restoration $66 $28 57% D2952 Post And Core In Addition To Crown, Indirectly Fabricated $458 $206 55% D2953 Each Additional Indirectly Fabricated Post - Same Tooth $229 $130 43% D2954 Prefabricated Post And Core In Addition To Crown $366 $171 53% D2955 Post Removal $282 $128 55% D2957 Each Additional Prefabricated Post - Same Tooth $183 $62 66% D2960 Labial Veneer (Resin Laminate) - Chairside $885 $417 53% Endodontics (Root Canals, ect.) D3110 Pulp Cap - Direct (Excluding Final Restoration) $99 $37 63% D3120 Pulp Cap - Indirect (Excluding Final Restoration) $79 $29 63% D3220 Therapeutic Pulpotomy (Excluding Final Restoration) - Removal Of Pulp Coronal To The Dentinocemental Junction And Application Of Medicament $203 $87 57% D3221 Pulpal Debridement, Primary And Permanent Teeth $222 $86 61% D3230 Pulpal Therapy (Resorbable Filling) - Anterior, Primary Tooth (Excluding Final Restoration) $203 $92 55% D3240 Pulpal Therapy (Resorbable Filling) - Posterior, Primary Tooth (Excluding Final Restoration) $250 $99 60% D3310 Endodontic Therapy, Anterior Tooth (Excluding Final Restoration) $797 $368 54% D3320 Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration) $977 $450 54% D3330 Endodontic Therapy, Molar (Excluding Final Restoration) $1,212 $580 52% D3331 Treatment Of Root Canal Obstruction; Non-Surgical Access $313 $220 30% D3332 Incomplete Endodontic Therapy; Inoperable, Unrestorable Or Fractured Tooth $594 $203 66% D3333 Internal Root Repair Of Perforation Defects $274 $99 64% D3346 Retreatment Of Previous Root Canal Therapy - Anterior $1,063 $495 53% D3347 Retreatment Of Previous Root Canal Therapy - Bicuspid $1,251 $583 53% D3348 Retreatment Of Previous Root Canal Therapy - Molar $1,548 $703 55% D3351 Apexification/Recalcification/Pulpal Regeneration Initial Visit (Apical Closure/Calcific Repair Of Perforations, Root Resorption, Pulp Space Disinfection, Etc.) $480 $209 56% D3352 Apexification/Recalcification/Pulpal Regeneration - Interim Medication Replacement (Apical $215 $92 57% Closure/Calcific Repair Of Perforations, Root Resorption, Pulp Space Disinfection, Etc.) D3353 Apexification/Recalcification - Final Visit (Includes Completed Root Canal Therapy - Apical Closure/Calcific Repair Of Perforations, Root Resorption, Etc.) $662 $308 53% D3410 Apicoectomy/Periradicular Surgery - Anterior $952 $421 56% D3421 Apicoectomy/Periradicular Surgery - Bicuspid (First Root) $1,059 $461 56% D3425 Apicoectomy/Periradicular Surgery - Molar (First Root) $1,200 $520 57% D3426 Apicoectomy/Periradicular Surgery (Each Additional Root) $405 $174 57% D3430 Retrograde Filling - Per Root $298 $127 57% D3450 Root Amputation - Per Root $621 $259 58% D3470 Intentional Reimplantation (Including Necessary Splinting) $1,183 $516 56% D3910 Surgical Procedure For Isolation Of Tooth With Rubber Dam $166 $67 60% Member - CDT Compliant Effective February 1, 2010 CI-5, Page 2 of 5

4 D3920 Hemisection (Including Any Root Removal), Not Including Root Canal Therapy $472 $202 57% D3950 Canal Preparation And Fitting Of Preformed Dowel Or Post $215 $92 57% Code Description Regular Cost Fee Savings Periodontics (Scaling, Deep Cleaning, Root Planing, ect.) D4210 Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant $852 $360 58% D4211 Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant $379 $121 68% D4230 Anatomical Crown Exposure - Four Or More Contiguous Teeth Per Quadrant $1,193 20% Discount D4231 Anatomical Crown Exposure - One To Three Teeth Per Quadrant $568 20% Discount D4240 Gingival Flap Procedure, Including Root Planing - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant $1,079 $424 61% D4241 Gingival Flap Procedure, Including Root Planing - One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant $625 $306 51% D4245 Apically Positioned Flap $795 $383 52% D4249 Clinical Crown Lengthening - Hard Tissue $1,183 $484 59% D4260 Osseous Surgery (Including Flap Entry And Closure) - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant $1,798 $683 62% D4261 Osseous Surgery (Including Flap Entry And Closure) - One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant $965 $393 59% D4263 Bone Replacement Graft - First Site In Quadrant $644 $206 68% D4264 Bone Replacement Graft - Each Additional Site In Quadrant $549 $139 75% D4266 Guided Tissue Regeneration - Resorbable Barrier, Per Site $663 $250 62% D4267 Guided Tissue Regeneration - Nonresorbable Barrier, Per Site (Includes Membrane Removal) $852 $320 62% D4268 Surgical Revision Procedure, Per Tooth $942 $388 59% D4270 Pedicle Soft Tissue Graft Procedure $1,278 $505 60% D4320 Provisional Splinting - Intracoronal $466 $229 51% D4321 Provisional Splinting - Extracoronal $424 $200 53% D4341 Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant $268 $124 54% D4342 Periodontal Scaling And Root Planing - One To Three Teeth Per Quadrant $155 $60 61% D4355 Full Mouth Debridement To Enable Comprehensive Evaluation And Diagnosis $184 $83 55% D4910 Periodontal Maintenance $165 $74 55% D4920 Unscheduled Dressing Change (By Someone Other Than Treating Dentist) $120 $63 48% Prosthodontics (Dentures - Removable, Partials, ect. ) D5110 Complete Denture - Maxillary $1,756 $797 55% D5120 Complete Denture - Mandibular $1,756 $797 55% D5130 Immediate Denture - Maxillary $1,915 $868 55% D5140 Immediate Denture - Mandibular $1,915 $868 55% D5211 Maxillary Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth) $1,482 $781 47% D5212 D5213 D5214 Mandibular Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth) Maxillary Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth) Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth) $1,723 $781 55% $1,941 $880 55% $1,941 $880 55% D5281 Removable Unilateral Partial Denture - One Piece Cast Metal (Including Clasps And Teeth $1,131 $512 55% D5410 Adjust Complete Denture - Maxillary $96 $43 55% D5411 Adjust Complete Denture - Mandibular $96 $43 55% D5421 Adjust Partial Denture - Maxillary $96 $43 55% D5422 Adjust Partial Denture - Mandibular $96 $43 55% D5510 Repair Broken Complete Denture Base $192 $87 55% D5520 Replace Missing Or Broken Teeth - Complete Denture (Each Tooth) $160 $72 55% D5610 Repair Resin Denture Base $208 $95 54% D5620 Repair Cast Framework $224 $102 55% D5630 Repair Or Replace Broken Clasp $272 $124 54% D5640 Replace Broken Teeth - Per Tooth $176 $80 55% D5650 Add Tooth To Existing Partial Denture $240 $109 55% D5660 Add Clasp To Existing Partial Denture $289 $130 55% D5710 Rebase Complete Maxillary Denture $713 $323 55% D5711 Rebase Complete Mandibular Denture $681 $309 55% D5720 Rebase Maxillary Partial Denture $673 $306 55% D5721 Rebase Mandibular Partial Denture $673 $306 55% D5730 Reline Complete Maxillary Denture (Chairside) $402 $182 55% D5731 Reline Complete Mandibular Denture (Chairside) $402 $182 55% D5740 Reline Maxillary Partial Denture (Chairside) $369 $167 55% D5741 Reline Mandibular Partial Denture (Chairside) $369 $167 55% D5750 Reline Complete Maxillary Denture (Laboratory) $537 $244 55% D5751 Reline Complete Mandibular Denture (Laboratory) $537 $244 55% Member - CDT Compliant Effective February 1, 2010 CI-5, Page 3 of 5

5 D5760 Reline Maxillary Partial Denture (Laboratory) $529 $240 55% D5761 Reline Mandibular Partial Denture (Laboratory) $529 $240 55% D5810 Interim Complete Denture (Maxillary) $849 $394 54% D5811 Interim Complete Denture (Mandibular) $913 $394 57% D5820 Interim Partial Denture (Maxillary) $657 $316 52% D5821 Interim Partial Denture (Mandibular) $697 $316 55% D5850 Tissue Conditioning, Maxillary $168 $77 54% D5851 Tissue Conditioning, Mandibular $168 $77 54% Code Description Regular Cost Fee Savings D6000 through D6096 Implant Services 20% Discount Prosthodontics (Dentures - Fixed) D6210 Pontic - Cast High Noble Metal $1,148 $524 54% D6211 Pontic - Cast Predominantly Base Metal $1,075 $492 54% D6212 Pontic - Cast Noble Metal $1,119 $511 54% D6240 Pontic - Porcelain Fused To High Noble Metal $1,133 $517 54% D6241 Pontic - Porcelain Fused To Predominantly Base Metal $1,047 $479 54% D6242 Pontic - Porcelain Fused To Noble Metal $1,104 $505 54% D6245 Pontic - Porcelain/Ceramic $1,169 $514 56% D6250 Pontic - Resin With High Noble Metal $1,119 $511 54% D6251 Pontic - Resin With Predominantly Base Metal $1,032 $472 54% D6252 Pontic - Resin With Noble Metal $1,065 $487 54% D6545 Retainer - Cast Metal For Resin Bonded Fixed Prosthesis $425 $217 49% D6548 Retainer - Porcelain/Ceramic For Resin Bonded Fixed Prosthesis $467 $402 14% D6720 Crown - Resin With High Noble Metal $1,125 $578 49% D6721 Crown - Resin With Predominantly Base Metal $1,068 $547 49% D6722 Crown - Resin With Noble Metal $1,087 $557 49% D6740 Crown - Porcelain/Ceramic $1,183 $522 56% D6750 Crown - Porcelain Fused To High Noble Metal $1,153 $591 49% D6751 Crown - Porcelain Fused To Predominantly Base Metal $1,075 $552 49% D6752 Crown - Porcelain Fused To Noble Metal $1,101 $565 49% D6780 Crown - 3/4 Cast High Noble Metal $1,087 $557 49% D6781 Crown - 3/4 Cast Predominantly Base Metal $1,087 $492 55% D6782 Crown - 3/4 Cast Noble Metal $1,010 $497 51% D6783 Crown - 3/4 Porcelain/Ceramic $1,119 $506 55% D6790 Crown - Full Cast High Noble Metal $1,113 $570 49% D6791 Crown - Full Cast Predominantly Base Metal $1,055 $541 49% D6792 Crown - Full Cast Noble Metal $1,093 $560 49% D6930 Recement Fixed Partial Denture $165 $69 58% D6975 Coping $799 $343 57% Oral Surgery (Tooth Extractions, ect.) D7111 Extraction, Coronal Remnants - Deciduous Tooth $133 $68 49% D7140 Extraction, Erupted Tooth Or Exposed Root (Elevation And/Or Forceps Removal) $177 $81 54% D7210 Surgical Removal Of Erupted Tooth Requiring Removal Of Bone And/Or Sectioning Of Tooth, And Including Elevation Of Mucoperiosteal Flap If Indicated $287 $144 50% D7220 Removal Of Impacted Tooth - Soft Tissue $359 $160 55% D7230 Removal Of Impacted Tooth - Partially Bony $478 $214 55% D7240 Removal Of Impacted Tooth - Completely Bony $561 $251 55% D7241 Removal Of Impacted Tooth - Completely Bony, With Unusual Surgical Complications $705 $316 55% D7250 Surgical Removal Of Residual Tooth Roots (Cutting Procedure) $303 $135 55% D7270 Tooth Reimplantation And/Or Stabilization Of Accidentally Evulsed Or Displaced Tooth $638 $276 57% D7272 Tooth Transplantation (Includes Reimplantation From One Site To Another And Splinting And/Or Stabilization) $851 $314 63% D7280 Surgical Access Of An Unerupted Tooth $596 $302 49% D7285 Biopsy Of Oral Tissue - Hard (Bone, Tooth) $1,192 $491 59% D7286 Biopsy Of Oral Tissue - Soft $511 $220 57% D7310 Alveoloplasty In Conjunction With Extractions Four Or More Teeth Or Tooth Spaces, Per Quadrant $550 $149 73% D7320 Alveoloplasty Not In Conjunction With Extractions Four Or More Teeth Or Tooth Spaces, Per Quadrant $893 $374 58% D7450 Removal Of Benign Odontogenic Cyst Or Tumor - Lesion Diameter Up To 1.25 Cm $1,649 $437 74% D7451 Removal Of Benign Odontogenic Cyst Or Tumor - Lesion Diameter Greater Than 1.25 Cm $2,254 $687 70% D7460 Removal Of Benign Nonodontogenic Cyst Or Tumor - Lesion Diameter Up To 1.25 Cm $1,649 $437 74% D7461 Removal Of Benign Nonodontogenic Cyst Or Tumor - Lesion Diameter Greater Than 1.25 Cm $2,254 $687 70% D7510 Incision And Drainage Of Abscess - Intraoral Soft Tissue $591 $143 76% Member - CDT Compliant Effective February 1, 2010 CI-5, Page 4 of 5

6 D7910 Suture Of Recent Small Wounds Up To 5 Cm $902 $201 78% D7911 Complicated Suture - Up To 5 Cm $2,251 $499 78% D7912 Complicated Suture - Greater Than 5 Cm $4,051 $713 82% D7951 Sinus Augmentation With Bone Or Bone Substitutes Via A Lateral Open Approach $3,566 20% Discount D7960 Frenulectomy Also Known As Frenectomy Or Frenotomy Separate Procedure Not Incidental To Another Procedure $756 $253 67% D7970 Excision Of Hyperplastic Tissue - Per Arch $1,099 $325 70% D7971 Excision Of Pericoronal Gingiva $412 $104 75% Orthodontics (Braces - Children, Adults, ect.) D8010 Limited Orthodontic Treatment Of The Primary Dentition $2, % Discount D8020 Limited Orthodontic Treatment Of The Transitional Dentition $3, % Discount D8030 Limited Orthodontic Treatment Of The Adolescent Dentition $3, % Discount D8040 Limited Orthodontic Treatment Of The Adult Dentition $3, % Discount Code Description Regular Cost Fee Savings D8050 Interceptive Orthodontic Treatment Of The Primary Dentition $2, % Discount D8060 Interceptive Orthodontic Treatment Of The Transitional Dentition $3, % Discount D8070 Comprehensive Orthodontic Treatment Of The Transitional Dentition $5, % Discount D8080 Comprehensive Orthodontic Treatment Of The Adolescent Dentition $5, % Discount D8090 Comprehensive Orthodontic Treatment Of The Adult Dentition $5, % Discount D8210 Removable Appliance Therapy $ % Discount D8660 Pre-Orthodontic Treatment Visit $1, % Discount Adjunctive Services (Anesthesia, Analgesia, ect.) D9110 Palliative (Emergency) Treatment Of Dental Pain - Minor Procedure $127 $51 60% D9120 Fixed Partial Denture Sectioning $144 20% Discount D9211 Regional Block Anesthesia $55 $23 58% D9215 Local Anesthesia In Conjunction With Operative Or Surgical Procedures $41 $16 61% D9230 Inhalation Of Nitrous Oxide / Anxiolysis, Analgesia $82 $28 66% D9310 Consultation - Diagnostic Service Provided By Dentist Or Physician Other Than Requesting Den $168 $108 36% D9410 House/Extended Care Facility Call $193 $143 26% D9420 Hospital Or Ambulatory Surgical Center Call $312 $197 37% D9430 Office Visit For Observation (During Regularly Scheduled Hours) - No Other Services Performed $92 $36 61% D9440 Office Visit - After Regularly Scheduled Hours $105 $66 37% D9910 Application Of Desensitizing Medicament $70 $23 67% D9911 Application Of Desensitizing Resin For Cervical And/Or Root Surface, Per Tooth $97 $33 66% D9941 Fabrication Of Athletic Mouthguard $199 $82 59% D9950 Occlusion Analysis - Mounted Case $378 $143 62% D9951 Occlusal Adjustment - Limited $169 $65 62% D9952 Occlusal Adjustment - Complete $795 $367 54% D9970 Enamel Microabrasion $89 $48 46% * Regular Cost represents the average of resasonable and customary fees for all Careington CI-5 schedule practice areas based on 2010 Ingenix MDR Data. *It is the Member s responsibility to verify that the dentist is a participating Careington provider before seeking any treatment. Member is responsible for full payment for all charges at the time of service. Any dental procedures performed by a non-participating dentist are not discounted and are charged to the member 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% off of the General Dentist's normal fee. *Specialists will give a 20% discount off of their normal fees. *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 his normal fee. *Work in progress prior to enrollment on the dental plan must be completed by the dentist who started the work and is not subject to discount. *Careington cannot 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. *Some providers may charge for missed or broken appointments if no prior notice is given. *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. * Careington or its vendors may periodically adjust this fee schedule with 30 days notice to Client. *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 Corporation, Attn. Provider Relations, PO Box 2568, Frisco, Texas Please call if you have any further questions. Member - CDT Compliant Effective February 1, 2010 CI-5, Page 5 of 5

7 Check out these Free National Discount Programs! All employees and dependents enrolling in one of the attached dental plans can use any of the attached programs free of charge. It is our thanks to you for using Beta Health as your dental carrier! Simply follow the instructions on the attached discount program description sheets.it s that easy. You can photocopy these items and distribute to all of your dependents as well. If you have questions, please call Beta Health at or

8 Introducing Discount Services for Dental Plan Members Free of Charge The Vision Discount Plan Beta Health Association, Inc. has teamed up with EyeMed Vision Care to offer easy access to over 43,000 national, conveniently located vision care providers including optometrists, ophthalmologists, opticians and many leading optical retailers, such as LensCrafters, Target Optical, and most Sears Optical and Pearl Vision locations. This benefit is free of charge for Beta Health Dental Plan members. Note that this is not insurance, only a discount plan to save you and your family members $ as needed! Vision Care Services Exam with Dilation (as necessary) Contact Lens Fit and Follow-up Standard Premium In Network Only $5 off exam $10 off exam $10 off exam Frames When a complete pair of glasses is purchased (frame, lenses and lens options purchased in the same transaction) a 35% discount will apply.* Standard Plastic Lenses Member Pays Single Vision $50 Bifocal $70 Trifocal $105 Lens Options Member Pays UV Coating $15 Tint (Solid and Gradient) $15 Standard Scratch Resistant Coating $15 Standard Polycarbonate $40 Standard Anti-Reflective Coating $45 Standard Progressive (Add-on to Bifocal) $65 Other Add-ons and Services 20% off retail Contact Lens Materials (Discount applied to materials only) Conventional 15% off retail price Disposable no discount Laser Vision Correction** Lasik or PRK Frequency Examination Frame Lenses or Contact Lenses 15% off retail price or 5% promotional price Unlimited Unlimited Unlimited * Items purchased separately will be discounted 20% off of the retail price. ** Since Lasik or PRK vision correction is an elective procedure, performed by specially trained providers, this discount may not always be available from a provider in your immediate location. For a location near you and the discount authorization, please call LASER6.

9 Introducing Discount Services for Dental Plan Members Free of Charge The Hearing Discount Plan This hearing care program combines unlimited choices with quality and value. It s provided free of charge to all employees and family members enrolled in a Beta Health Association, Inc. dental plan. Beta Health and EPIC Hearing Health Care give you easy access to a large national network of thousands of hearing care professionals primarily physicians and audiologists who can help you achieve your maximum hearing potential throughout your life. The prices you get from EPIC may be as much as 50% below the manufacturer s suggested retail price and up to 35% lower than most discount offers. EPIC can coordinate the coverage with your existing healthcare plan. Note that this is not insurance, only a discount plan to save you and your family members $ as needed! To activate your hearing discount plan, call EPIC Hearing Health at EPIC will send you a card with all the information you need to access your benefits, including referrals to providers near you and activation forms to access them. Tell them that you are a Beta Health member and you will be connected to a personal EPIC phone contact who can answer any questions you may have. A booklet that outlines the plan benefits (as well as pricing) will be mailed to your home. Then you will follow through with an appointment, examination and treatment. All payments should be made to EPIC HSP. No other billing or payments should occur. Contact EPIC at any time for assistance, advice and information. Check out these benefits and savings! The hearing discount plan benefits and savings are: Hearing tests Hearing aids, aid cleaning supplies, accessories and batteries Ear protection, swim and musician earplugs Assistive listening devices TV ears (amplifies and clarifies television) Alerting and signaling devices The Prescription Drug Discount Plan Do you want to SAVE an average of 10% to 85% on the cost of prescription medications? With the HealthTrans nationwide national discount prescription drug program this is easy! It s simply a great way to save money on prescription drugs! After working closely with pharmacies and drug manufacturers, HealthTrans has negotiated lower prices for thousands of medications, and have passed these savings on to all Beta Health Association members and their families. The average discounts range from up to 16% on brand name and up to 55% on generic drugs. There are no limits on quantities and no paperwork to complete. Discounts are available at over 55,000 pharmacies nationwide and are also available to the entire family on an as needed basis! To use your HealthTrans discount drug card: 1.) Write in your specific member I.D. number on the member I.D. cards (attached) for use at the pharmacy. 2.) Take your card and prescription(s) to a participating pharmacy. Pharmacy locations can be found at the web site below. 3.) Pay the pharmacy the negotiated reduced discount! Note that this is not insurance, only a discount plan to save you and your family members $ as needed! See how much you can save today by going to

10 Thank you for choosing Beta Health Association, Inc. as your dental partner. We are proud to offer you, free of charge, the EyeMed Vision Discount Plan, the Epic Hearing Health Plan and the HealthTrans Prescription Discount Plan. Please use the ID cards provided below to access these Free of Charge benefits. Follow all instructions as identified on each set of cards. We appreciate our relationship! EyeMed Group Number: Group Name: Beta Health Association, Inc. Member Name: EyeMed Group Number: Group Name: Beta Health Association, Inc. Member Name: Call to locate the nearest EyeMed Provider. This is a discount program and not insurance. Call to locate the nearest EyeMed Provider. This is a discount program and not insurance. Epic Hearing: Call for ID card information. Group Name: Beta Health Association, Inc. Member Name: Epic Hearing: Call for ID card information. Group Name: Beta Health Association, Inc. Member Name: This is a discount program and not insurance. This is a discount program and not insurance. BIN #: Group ID: DDS01 Member ID: Please enter your initials & the last four digits of your phone #) Member Name: This is a discount program and not insurance. Visit for more information or call BIN #: Group ID: DDS01 Member ID: Please enter your initials & the last four digits of your phone #) Member Name: This is a discount program and not insurance. Visit for more information or call