Plan Information

Fee Schedule

Primecare Dental benefit plans are 100% voluntary with limited underwriting guidelines and are complemented through an extensive network of dentists and dental professionals. The plan includes specialty features such as Implants, Veneers, Lumineers, Sedation, Cosmetics, Orthodontics and more.

Rates are guaranteed for 24 months. There are no waiting periods, no plan maximums, claim forms or deductibles.  Everyone is eligible. Everyone has access to coverage.

Click here to see a partial list of procedures discounted to fixed fees under the Primecare Dental Plan membership.

Copayment may vary depending on if the procedure is performed by a General Dentist or Specialist

Plan Features
Diagnostic
Clinical Oral Evaluation You Pay
D0110 comprehensive oral evaluation $0
D0120 periodic oral evaluation - established patient $0
D0130 limited oral evaluation-problem focused $0
Radiographs/Diagnostic Imaging (Including Interpretation) You Pay
D0210 intraoral - complete series (including bitewings) $25
D0220 intraoral - periapical first film $0
D0230 intraoral - periapical each additional film $0
D0240 intraoral - occlusal film $10
D0272 bitewings - two films $0
D0274 bitewings - four films $0
D0330 panoramic film $25
D0350 oral/facial photographic images $10
Tests and Examinations You Pay
D0415 collection of microorganisms for culture and sensitivity $10
D0460 pulp vitality tests $0
D0470 diagnostic casts $25
Preventive
Dental Prophylaxis You Pay
D1110 prophylaxis - adult $35
D1120 prophylaxis - child $25
Topical Fluoride Treatment (Office Procedure) You Pay
D1201 topical application of fluoride (including prophylaxis) - child $30
D1203 topical application of fluoride - child $22
D1206 topical fluoride varnish; therapeutic application for moderate to high caries risk patients $85
Other Preventive Services You Pay
D1310 nutritional counseling for control of dental disease $0
D1320 tobacco counseling for the control and prevention of oral disease $0
D1330 oral hygiene instructions $0
D1351 sealant - per tooth $15
Space Maintenance (Passive Appliances) You Pay
D1510 space maintainer - fixed - unilateral $135
D1515 space maintainer - fixed - bilateral $135
D1520 space maintainer - removable - unilateral $190
D1525 space maintainer - removable - bilateral $190
D1550 re-cementation of space maintainer $10
Restorative
Amalgam Restorations (Including Polishing) You Pay
D2110 amalgam-one surface, primary $35
D2120 amalgam-two surfaces, primary $40
D2130 amalgam-three surfaces, primary $50
D2131 amalgam-four or more surfaces, primary $52
D2140 amalgam - one surface, primary or permanent $45
D2150 amalgam - two surfaces, primary or permanent $50
D2160 amalgam - three surfaces, primary or permanent $60
D2161 amalgam - four or more surfaces, primary or permanent $65
Resin - Based Composite Restorations - Direct You Pay
D2330 resin-based composite - one surface, anterior $55
D2331 resin-based composite - two surfaces, anterior $60
D2332 resin-based composite - three surfaces, anterior $70
D2335 resin-based composite - four or more surfaces or involving incisal angle (anterior) $95
D2380 resin-one surface, posterior-primary $65
D2381 resin-two surfaces, posterior-primary $80
D2382 resin-three or more surfaces, posterior-primary $115
D2385 resin-one surface, posterior-permanent $65
D2386 resin-two surfaces, posterior-permanent $80
D2387 resin-three or more surfaces, posterior-permanent $115
D2390 resin-based composite crown, anterior $151
D2391 resin-based composite - one surface, posterior $114
D2392 resin-based composite - two surfaces, posterior $124
D2393 resin-based composite - three surfaces, posterior $152
D2394 resin-based composite - four or more surfaces, posterior $175
Crowns - Single Restorations Only You Pay
D2710 crown - resin-based composite (indirect) $195
D2721 crown - resin with predominantly base metal $285
D2740 crown - porcelain/ceramic substrate $575
D2750 crown - porcelain fused to high noble metal $550
D2751 crown - porcelain fused to predominantly base metal $375
D2783 crown - 3/4 porcelain/ceramic $575
D2790 crown - full cast high noble metal $618
D2791 crown - full cast predominantly base metal $345
D2792 crown - full cast noble metal $579
D2794 crown - titanium $579
D2810 crown 3/4 porcelain ceramic $365
Other Restorative Services You Pay
D2910 recement inlay, onlay, or partial coverage restoration $20
D2920 re-cement crown $30
D2930 prefabricated stainless steel crown - primary tooth $70
D2931 prefabricated stainless steel crown - permanent tooth $85
D2932 prefabricated resin crown $87
D2940 protective restoration $25
D2950 core buildup, including any pins $70
D2951 pin retention - per tooth, in addition to restoration $25
D2952 post and core in additon to crown, indirectly fabricated $115
D2954 prefabricated post and core in addition to crown $80
D2960 labial veneer (resin laminate) - chairside $264
D2961 labial veneer (resin laminate) - laboratory $379
Endodontics
Pulp Capping You Pay
D3110 pulp cap - direct (excluding final restoration) $30
D3120 pulp cap - indirect (excluding final restoration) $32
Pulpotomy You Pay
D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $45
D3221 pulpal debridement, primary and permanent teeth $45
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care) You Pay
D3310 endodontic therapy, anterior tooth (excluding final restoration) $225
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) $275
D3330 endodontic therapy, molar (excluding final restoration) $325
Endodontic Retreatment You Pay
D3346 retreatment of previous root canal therapy - anterior $539
D3347 retreatment of previous root canal therapy - bicuspid $605
D3348 retreatment of previous root canal therapy - molar $775
Apicoectomy/Periradicular Services You Pay
D3410 apicoectomy/periradicular surgery - anterior $160
D3421 apicoectomy/periradicular surgery - bicuspid (first root) $160
D3425 apicoectomy/periradicular surgery - molar (first root) $160
D3426 apicoectomy/periradicular surgery (each additonal root) $160
D3430 retrograde filling - per root $94
D3450 root amputation - per root $298
Periodontics
Surgical Services (Including Usual Postoperative Care) You Pay
D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant $200
D4211 gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant $75
D4220 gingival curettage, surgical, per quadrant, by report $100
D4230 anatomical crown exposure - four or more contiguous teeth per quadrant $640
D4231 anatomical crown exposure - one to three teeth per quadrant $340
D4240 gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quardant $339
D4241 gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quardant $171
D4249 clinical crown lengthening - hard tissue $459
D4250 mucogingival surgery-per quadrant $390
D4260 osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant $390
D4261 osseous surgery (including flap entry and closure) - one to three teeth contiguous teeth or tooth bounded spaces per quadrant $386
D4263 bone replacement graft - first site in quadrant $180
D4264 bone replacement graft - each additonal site in quadrant $105
D4266 guided tissue regeneration - resorbable barrier, per site $272
D4267 guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) $260
D4270 pedicle soft tissue graft procedure $470
D4271 free soft tissue graft procedure (including donor site surgery) $470
D4273 subepithelial connective tissue graft procedures, per tooth $573
D4274 distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) $272
D4275 soft tissue allograft $526
D4276 combined connective tissue and double pedicle graft, per tooth $1274
Non-Surgical Periodontal Service You Pay
D4320 provisional splinting - intracoronal $158
D4321 provisional splinting - extracoronal $158
D4341 periodontal scaling and root planing - four or more teeth per quadrant $90
D4342 periodontal scaling and root planing - one to three teeth per quadrant $83
D4355 full mouth debridement to enable comprehensive evaluation and diagnosis $20
D4381 localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report $58
Other Periodontal Services You Pay
D4910 periodontal maintenance $81
Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care) You Pay
D5110 complete denture - maxillary $520
D5120 complete denture - mandibular $520
D5130 immediate denture - maxillary $858
D5140 immediate denture - mandibular $858
Partial Dentures (Including Routine Post-Delivery Care) You Pay
D5211 maxillary partial denture - resin base (including any conventional clasps, rests and teeth) $400
D5212 mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $400
D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $600
D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $600
Adjustments to Dentures You Pay
D5410 adjust complete dentures - maxillary $25
D5411 adjust complete dentures - mandibular $25
D5421 adjust partial denture - maxillary $25
D5422 adjust partial denture - mandibular $25
Repairs to Complete Dentures You Pay
D5510 repair broken complete denture base $65
D5520 replace missing or broken teeth - complete denture (each tooth) $50
Repairs to Partial Dentures You Pay
D5610 repair resin denture base $55
D5630 repair or replace broken clasp $65
D5640 replace broken teeth - per tooth $55
D5650 add tooth to existing partial denture $55
D5660 add clasp to existing partial denture $75
D5670 replace all teeth and acrylic on cast metal framework (maxillary) $275
D5671 replace all teeth and acrylic on cast metal framework (mandibular) $275
Denture Rebase Procedures You Pay
D5710 rebase complete maxillary denture $225
D5711 rebase complete mandibular denture $225
D5720 rebase maxillary partial denture $225
D5721 rebase mandibular partial denture $225
Denture Reline Procedures You Pay
D5730 reline complete maxillary denture (chairside) $95
D5731 reline complete mandibular denture (chairside) $95
D5740 reline maxillary partial denture (chairside) $95
D5741 reline mandibular partial denture (chairside) $95
D5750 reline complete maxillary denture (laboratory) $150
D5751 reline complete mandibular denture (laboratory) $150
D5760 reline maxillary partial denture (laboratory) $150
D5761 reline mandibular partial denture (laboratory) $150
Interim Prosthesis You Pay
D5810 interim complete denture (maxillary) $400
D5811 interim complete denture (mandibular) $400
D5820 interim partial denture (maxillary) $230
D5821 interim partial denture (mandibular) $230
Other Removable Prosthetic Services You Pay
D5850 tissue conditioning, maxillary $45
D5851 tissue conditioning, mandibular $45
D5860 overdenture - complete, by report $858
D5861 overdenture - partial, by report $858
D5862 precision attachment, by report $200
Maxillofacial Prosthetics
Maxillofacial Prosthetics You Pay
D5982 surgical stent $286
Implant Services
Implant Services You Pay
D6010 surgical placement of implant body: endosteal implant $1500
Implant Supported Prosthetics You Pay
D6056 prefabricated abutment - includes placement $170
D6058 abutment supported porcelain/ceramic crown $969
D6059 abutment supported porcelain fused to metal crown (high noble metal) $957
D6060 abutment supported porcelain fused to metal crown (predominantly base metal) $904
D6061 abutment supported porcelain fused to metal crown (noble metal) $922
D6062 abutment supported cast metal crown (high noble metal) $875
D6063 abutment supported cast metal crown (predominantly base metal) $751
D6064 abutment supported cast metal crown (noble metal) $796
D6065 implant supported porcelain/ceramic crown $908
D6066 implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) $885
D6067 implant supported metal crown (titanium, titanium alloy, high noble metal) $858
D6068 abutment supported retainer for porcelain/ceramic FPD $969
D6069 abutment supported retainer for porcelain fused to metal FPD (high noble metal) $957
D6070 abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) $904
D6071 abutment supported retainer for porcelain fused to metal FPD (noble metal) $922
D6072 abutment supported retainer for cast metal FPD (high noble metal) $987
D6073 abutment supported retainer for cast metal FPD (predominantly base metal) $812
D6074 abutment supported retainer for cast metal FPD (noble metal) $875
D6075 implant supported retainer for ceramic FPD $953
D6076 implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) $1045
D6077 implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) $858
Other Implant Services You Pay
D6092 recement implant/abutment supported crown $36
D6093 recement implant/abutment supported fixed partial denture $53
Implant Supported Prosthetics You Pay
D6094 abutment supported crown - (titanium) $579
D6194 abutment supported retainer crown for FPD - (titanium) $579
Prosthodontics, fixed
Fixed Partial Denture Pontics You Pay
D6211 pontic - cast predominantly base metal $325
D6241 pontic - porcelain fused to predominantly base metal $365
D6245 pontic - porcelain/ceramic $575
D6251 pontic - resin with predominantly base metal $265
Other Fixed Partial Denture Services You Pay
D6930 re-cement fixed partial denture $45
Oral and Maxillofacial Surgery
Extractions (Includes Local Anesthesia, Suturing, if Needed, and Routine Postoperative Care) You Pay
D7110 single tooth $50
D7120 each additional tooth $45
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. $80
D7220 removal of impacted tooth - soft tissue $95
D7230 removal of impacted tooth - partially bony $135
D7240 removal of impacted tooth - completely bony $170
D7241 removal of impacted tooth - completely bony, with unusual surgical complications $333
D7250 surgical removal of residual tooth roots (cutting procedure) $80
Other Surgical Prodecures You Pay
D7260 oroantral fistula closure $423
D7261 primary closure of a sinus perforation $366
D7270 tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $293
D7272 tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) $293
D7280 surgical access of an unerupted tooth $311
D7285 biopsy of oral tissue - hard (bone, tooth) $148
D7286 biopsy of oral tissue - soft $118
D7287 exfoliative cytological sample collection $100
D7288 brush biopsy - transepithelial sample collection $47
D7291 transseptal fiberotomy/supra crestal fiberotomy, by report $34
Alveoloplasty-Surgical Preparation of Ridge for Dentures You Pay
D7310 alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant $70
D7311 alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant $69
D7320 alveoloplasty not in conjuction with extractions - four or more teeth or tooth spaces, per quadrant $185
D7321 alveoloplasty not in conjuction with extractions - one to three teeth or tooth spaces, per quadrant $93
Vestibuloplasty You Pay
D7340 vestibuloplasty - ridge extension (secondary epithelialization) $709
D7350 vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) $1092
Surgical Excision of Soft Tissue Lesions You Pay
D7410 excision of benign lesion up to 1.25 cm $167
D7411 excision of benign lesion greater than 1.25 cm $219
D7412 excision of benign lesion, complicated $313
D7413 excision of malignant lesion up to 1.25 cm $189
D7414 excision of malignant lesion greater than 1.25 cm $245
D7415 excision of malignant lesion, complicated $339
Surgical Excision of Intra-Osseous Lesions You Pay
D7440 excision of malignant tumor - lesion diameter up to 1.25 cm $210
D7441 excision of malignant tumor - lesion diameter greater than 1.25 cm $283
D7450 removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm $180
D7451 removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm $292
D7460 removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm $181
D7461 removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm $259
Excision of Bone Tissue You Pay
D7471 removal of lateral exostosis (maxilla or mandible) $330
D7472 removal of torus palatinus $367
D7473 removal of torus mandibularis $366
D7485 surgical reduction of osseous tuberosity $246
Surgical Incision You Pay
D7510 incision and drainage of abscess - intraoral soft tissue $80
D7530 removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue $82
Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfuctions You Pay
D7880 occlusal orthotic device, by report $447
Repair of Traumatic Wounds You Pay
D7910 suture of recent small wounds up to 5 cm $62
Complicated Suturing (Reconstruction Requiring Delicate Handling of Tissues and Wide Undermining for You Pay
D7911 complicated suture - up to 5 cm $74
D7912 complicated suture - greater than 5 cm $71
Other Repair Procedures You Pay
D7953 bone replacement graft for ridge preservation - per site $257
D7960 frenulectomy (frenectomy or frenotomy) - separate procedure $204
D7970 excision of hyperplastic tissue - per arch $167
D7971 excision of pericoronal gingiva $64
D7972 surgical reduction of fibrous tuberosity $269
Orthodontics
Limited Orthodontic Treatment You Pay
D8010 limited orthodontic treatment of the primary dentition $513
D8020 limited orthodontic treatment of the transitional dentition $1802
D8040 limited orthodontic treatment of the adult dentition $1802
Interceptive Orthodontic Treatment You Pay
D8050 interceptive orthodontic treatment of the primary dentition $513
D8060 interceptive orthodontic treatment of the transitional dentition $546
Comprehensive Orthodontic Treatment You Pay
D8070 comprehensive orthodontic treatment of the transitional dentition $3604
D8090 comprehensive orthodontic treatment of the adult dentition $3604
Other Orthodontic Services You Pay
D8680 orthodontic retention (removal of appliances, construction and placement of retainer(s)) $192
Adjunctive General Services
Unclassified Treatment You Pay
D9110 palliative (emergency) treatment of dental pain-minor procedure $20
Anesthesia You Pay
D9220 deep sedation/general anesthesia-first 30 minutes $204
D9221 deep sedation/general anesthesia-each additional 15 minutes $90
D9230 analgesia, anxiolysis, inhalation of nitrous oxide $40
D9241 intravenous conscious sedation/analgesia-first 30 minutes $149
D9242 intravenous conscious sedation/analgesia-each additional 15 minutes $57
D9248 non-intravenous conscious sedation $89
Professional Visits You Pay
D9430 office visit for observation (during regularly scheduled hours)-no other services performed $30
D9440 office visit-after regularly scheduled hours $52
Miscellaneous Services You Pay
D9940 occlusal guard, by report $219
D9951 occlusal adjustment - limited $64
D9952 occlusal adjustment - complete $174
D9972 external bleaching - per arch $146
D9973 external bleaching - per tooth $56
D9974 internal bleaching - per tooth $123