Plan Information

Discount Fee Schedule

This schedule is an extensive list of most common procedures. Due to plan variations, however, not every procedure is discounted. 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 pay for the procedure listed below. Unless otherwise noted, fee schedule is determined by zip code of doctor's office.

Plan 501 Multi-Care Additional Services ...>> click here

Plan Features
Diagnostic
Clinical Oral Evaluation You Pay
D0120 periodic oral evaluation - established patient $15
D0140 limited oral evaluation - problem focused $19
D0150 comprehensive oral evaluation - new or established patient $19
Radiographs/Diagnostic Imaging (Including Interpretation) You Pay
D0210 intraoral - complete series (including bitewings) $43
D0220 intraoral - periapical first film $11
D0230 intraoral - periapical each additional film $6
D0270 bitewing - single film $11
D0272 bitewings - two films $14
D0273 bitewings - three films $18
D0274 bitewings - four films $22
D0330 panoramic film $43
Preventive
Dental Prophylaxis You Pay
D1110 prophylaxis - adult $31
D1120 prophylaxis - child $23
Other Preventive Services You Pay
D1351 sealant - per tooth $22
Space Maintenance (Passive Appliances) You Pay
D1510 space maintainer - fixed - unilateral $94
D1515 space maintainer - fixed - bilateral $137
D1520 space maintainer - removable - unilateral $122
D1525 space maintainer - removable - bilateral $154
Restorative
Amalgam Restorations (Including Polishing) You Pay
D2140 amalgam - one surface, primary or permanent $43
D2150 amalgam - two surfaces, primary or permanent $55
D2160 amalgam - three surfaces, primary or permanent $65
D2161 amalgam - four or more surfaces, primary or permanent $79
Resin - Based Composite Restorations - Direct You Pay
D2330 resin-based composite - one surface, anterior $55
D2331 resin-based composite - two surfaces, anterior $66
D2332 resin-based composite - three surfaces, anterior $83
D2335 resin-based composite - four or more surfaces or involving incisal angle (anterior) $106
D2391 resin-based composite - one surface, posterior $69
D2392 resin-based composite - two surfaces, posterior $102
D2393 resin-based composite - three surfaces, posterior $129
D2394 resin-based composite - four or more surfaces, posterior $149
Crowns - Single Restorations Only You Pay
D2710 crown - resin-based composite (indirect) $206
D2720 crown - resin with high noble metal $435
D2750 crown - porcelain fused to high noble metal $511
D2751 crown - porcelain fused to predominantly base metal $462
D2752 crown - porcelain fused to noble metal $483
D2790 crown - full cast high noble metal $502
D2791 crown - full cast predominantly base metal $450
Other Restorative Services You Pay
D2930 prefabricated stainless steel crown - primary tooth $100
D2931 prefabricated stainless steel crown - permanent tooth $114
D2950 core buildup, including any pins $100
D2951 pin retention - per tooth, in addition to restoration $25
D2952 post and core in additon to crown, indirectly fabricated $158
D2954 prefabricated post and core in addition to crown $123
Endodontics
Pulp Capping You Pay
D3110 pulp cap - direct (excluding final restoration) $23
D3120 pulp cap - indirect (excluding final restoration) $23
Pulpotomy You Pay
D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $55
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care) You Pay
D3310 endodontic therapy, anterior tooth (excluding final restoration) $294
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) $348
D3330 endodontic therapy, molar (excluding final restoration) $438
Periodontics
Surgical Services (Including Usual Postoperative Care) You Pay
D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant $293
Non-Surgical Periodontal Service You Pay
D4341 periodontal scaling and root planing - four or more teeth per quadrant 80%
Other Periodontal Services You Pay
D4910 periodontal maintenance $65
Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care) You Pay
D5110 complete denture - maxillary $643
D5120 complete denture - mandibular $643
D5130 immediate denture - maxillary $669
D5140 immediate denture - mandibular $669
Partial Dentures (Including Routine Post-Delivery Care) You Pay
D5211 maxillary partial denture - resin base (including any conventional clasps, rests and teeth) $630
D5212 mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $630
D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $729
D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $729
Adjustments to Dentures You Pay
D5410 adjust complete dentures - maxillary $37
D5411 adjust complete dentures - mandibular $37
Repairs to Complete Dentures You Pay
D5510 repair broken complete denture base $57
D5520 replace missing or broken teeth - complete denture (each tooth) $55
Repairs to Partial Dentures You Pay
D5630 repair or replace broken clasp $66
D5650 add tooth to existing partial denture $57
D5660 add clasp to existing partial denture $73
Denture Reline Procedures You Pay
D5730 reline complete maxillary denture (chairside) $136
D5731 reline complete mandibular denture (chairside) $136
D5740 reline maxillary partial denture (chairside) $130
D5741 reline mandibular partial denture (chairside) $130
D5750 reline complete maxillary denture (laboratory) $178
D5751 reline complete mandibular denture (laboratory) $178
Implant Services
Implant Services You Pay
D6000A implant services 80%
Prosthodontics, fixed
Fixed Partial Denture Pontics You Pay
D6240 pontic - porcelain fused to high noble metal $444
D6241 pontic - porcelain fused to predominantly base metal $409
D6242 pontic - porcelain fused to noble metal $427
Fixed Partial Denture Retainers-Crowns You Pay
D6750 crown - porcelain fused to high noble metal $489
D6751 crown - porcelain fused to predominantly base metal $441
D6752 crown - porcelain fused to noble metal $458
Oral and Maxillofacial Surgery
Extractions (Includes Local Anesthesia, Suturing, if Needed, and Routine Postoperative Care) You Pay
D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal) $55
Surgical Extractions (Includes Local Anesthesia, Suturing, If Needed, and Routine Postoperative Care You Pay
D7210 surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth. $140
D7220 removal of impacted tooth - soft tissue $112
D7230 removal of impacted tooth - partially bony $147
D7240 removal of impacted tooth - completely bony $212
D7250 surgical removal of residual tooth roots (cutting procedure) $112
Alveoloplasty-Surgical Preparation of Ridge for Dentures You Pay
D7310 alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant $94
D7320 alveoloplasty not in conjuction with extractions - four or more teeth or tooth spaces, per quadrant $135
Surgical Incision You Pay
D7510 incision and drainage of abscess - intraoral soft tissue $69
Orthodontics
Comprehensive Orthodontic Treatment You Pay
D8070 comprehensive orthodontic treatment of the transitional dentition 80%
D8080 comprehensive orthodontic treatment of the adolescent dentition 80%
D8090 comprehensive orthodontic treatment of the adult dentition 80%
Adjunctive General Services
Unclassified Treatment You Pay
D9110 palliative (emergency) treatment of dental pain-minor procedure $37
Anesthesia You Pay
D9215 local anesthesia $13
D9230 analgesia, anxiolysis, inhalation of nitrous oxide $26
Miscellaneous Services You Pay
D9951 occlusal adjustment - limited $51
D9952 occlusal adjustment - complete $203

Disclosures:

THIS PLAN IS NOT INSURANCE and is not intended to replace health insurance. This plan does not meet the minimum creditable coverage requirements under M.G.L. c.111M and 956 CMR 5.00. This plan is not a Qualified Health Plan under the Affordable Care Act. This is not a Medicare prescription drug plan. The range of discounts will vary depending on the type of provider and service. The plan does not pay providers directly. Plan members must pay for all services but will receive a discount from participating providers. The list of participating providers is available here. A written list of participating providers is available upon request. You may cancel within the first 30 days after receipt of membership materials and receive a full refund, less a nominal processing fee (nominal fee for MD residents is $5, AR and TN residents will be refunded processing fee). Discount Medical Plan Organization and administrator: Careington International Corporation, 7400 Gaylord Parkway, Frisco, TX 75034; phone 800-441-0380. This plan is not available in Vermont or Washington.