Plan Information

Schedule of Covered Services and Copayments

Primecare Dental benefit plans are 100% voluntary with limited underwriting guidelines and are complemented through an extensive network of dentists and dental professionals.  Plans include coverage for all areas of general dentistry.

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
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
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
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
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 $65
D2331 resin-based composite - two surfaces, anterior $70
D2332 resin-based composite - three surfaces, anterior $80
D2335 resin-based composite - four or more surfaces or involving incisal angle (anterior) $105
D2391 resin-based composite - one surface, posterior $75
D2392 resin-based composite - two surfaces, posterior $90
D2393 resin-based composite - three surfaces, posterior $125
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 $475
D2783 crown - 3/4 porcelain/ceramic $575
D2791 crown - full cast predominantly base metal $345
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
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) $325
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) $375
D3330 endodontic therapy, molar (excluding final restoration) $450
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
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
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
D4263 bone replacement graft - first site in quadrant $180
D4264 bone replacement graft - each additonal site in quadrant $105
Non-Surgical Periodontal Service You Pay
D4341 periodontal scaling and root planing - four or more teeth per quadrant $90
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
Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care) You Pay
D5110 complete denture - maxillary $600
D5120 complete denture - mandibular $600
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) $700
D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $700
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
D5862 precision attachment, by report $200
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
D7250 surgical removal of residual tooth roots (cutting procedure) $80
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
Adjunctive General Services
Miscellaneous Services You Pay
D9999 unspecified adjunctive procedure, by report $5