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Plan Details


The Patriot Premier Plan offers free oral exams and X-rays with a paid cleaning at select general practitioners nationwide. There are no waiting periods, no deductibles for any services and no annual maximum. Use the card as often as you like because the more you use it, the more you save.


  ANNUAL CHECK-UP (ADULT): (one per membership year) Any combination of exam procedure codes 0120, 0140, 0150, and x-ray procedure codes 0210, 0220, 0230 0270, 0272, 0274, 0330 WITH prophylaxis procedure code 1110 (DDS internal code 1130). $58.00
  ANNUAL CHECK-UP (CHILD): (one per membership year) Any combination of exam procedure codes 0120, 0150, and x-ray procedure codes 0210, 0270, 0272, 0274, 0330 WITH prophylaxis procedure code 1110 (DDS internal code 1140). Diagnostic procedures when performed outside of the annual check-up are subject to a 25% reduction from usual & customary fees. Children are up to and including 16 years old. $40.00
 

PREVENTATIVE PROCEDURES

D1110 Prophylaxis-adult (additional in same membership year) $39.00
D1120 Prophylaxis-child (additional in same membership year) $28.00
D1203 Topical application of fluoride (excluding prophylaxis-child) $14.00
D1204 Topical application of fluoride (excluding prophylaxis-adult) $12.00
D1351 Sealant - per tooth $18.00
D1510 Space maintainer-fixed unilateral type $118.00
D1515 Space maintainer-fixed bilateral type $172.00
 

RESTORATIVE PROCEDURES

D2140 Amalgam-1surface, permanent or primary $50.00
D2150 Amalgam-2 surface, permanent or primary $64.00
D2160 Amalgam-3 surface, permanent or primary $76.00
D2161 Amalgam-4 surface, permanent or primary $91.00
D2330 Resin-1 surface, anterior $61.00
D2331 Resin-2 surface, anterior $76.00
D2332 Resin-3 surface, anterior $95.00
D2335 Resin-4+ surfaces or involving incisal angle $119.00
D2391 Resin-1 surface, posterior $74.00
D2392 Resin-2 surface, posterior $101.00
D2393 Resin-3 surface, posterior $126.00
D2750 Crown-porcelain fused to high noble metal $534.00
D2751 Crown-porcelain fused to base metal $473.00
D2752 Crown-full cast (base metal) $501.00
D2791 Crown-full cast (base metal) $428.00
D2920 Recement crown $39.00
D2930 Prefab'd stainless steel crown-1 tooth $111.00
D2931 Prefab'd stainless steel crown-2 tooth $131.00
D2932 Prefab'd resin crown $123.00
D2940 Sedative filling $45.00
D2950 Core buildup, including any pins $111.00
D2951 Pin retention-per tooth, in add. to restoration $27.00
D2952 Cast post and core, in addition to crown $167.00
D2953 Cast post (each additional cast post as part of tooth) $134.00
D2954 Prefab'd post and core in add. to crown $139.00
D2960 Labial veneer (porcelain laminate), chairside $323.00
D2970 Temporary crown (Fractured tooth) $111.00
D2971 Additional procedures to construct new crown under existing partial denture framework $111.00
 

ENDODONTIC PROCEDURES (ROOT CANAL THERAPY)

 
D3110 Pulp cap-direct (exc final restoration) $28.00
D3120 Pulp cap-indirect (excl final restoration.) $28.00
D3220 Therapeutic pulpotomy (excl final restoration.) $67.00
D3310 Root canal therapy-anterior (excl final restoration.) $284.00
D3320 Root canal therapy-bicuspid (excl final restoration.) $342.00
D3330 Root canal therapy-molar (exc final restoration.) $428.00
D3920 Hemisection (incl root removal; excl root canal therapy) $145.00
 

PERIODONTIC PROCEDURES

 
D4210 Gingivectomy or gingivoplasty, 4+ contiguous teeth/ quadrant $234.00
D4211 Gingivectomy or gingivoplasty, 1-3 contiguous teeth/ quadrant $90.00
D4240 Gingival flap procedure-incl root planing per quadrant $312.00
D4260 Osseous surgery-incl flap entry and closure per quadrant $428.00
D4270 Pedicle soft tissue graft procedure $323.00
D4341 Periodontal scaling and root planing, per quadrant $101.00
D4345 Periodontal scaling in the presence of gingival inflammation $112.00
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis $84.00
D4910 Periodontal maintenance procedures (following active therapy) $61.00
 

PROSTHODONTICS, REMOVABLE

 
D5110 Complete upper denture, incl 6 months post-insertion care $623.00
D5120 Complete lower denture, incl 6 months post-insertion care $623.00
D5130 Immediate upper denture, incl 6 months post-insertion care; does not include required future rebasing/relining procedure(s) or a complete new denture $695.00
D5140 Immediate lower denture, incl 6 months post-insertion care; does not include required future rebasing/relining procedure(s) or a complete new denture $695.00
D5211 Upper partial denture-resin base, including any conventional clasps and rest $507.00
D5212 Lower partial denture-resin base, including any conventional clasps and rest $507.00
D5213 Upper partial denture - predominantly base cast base with resin base incl any conventional clasps and rests $657.00
D5214 Lower partial denture - predominantly base cast base with resin base incl any conventional clasps and rests $657.00
D5410 Adjust complete denture-upper (after 6 mos) $39.00
D5411 Adjust complete denture-lower (after 6 mos) $39.00
D5421 Adjust partial denture-upper (after 6 mos) $39.00
D5422 Adjust partial denture-lower (after 6 mos) $39.00
D5510 Repair broken complete denture base $70.00
D5520 Replace missing or broken teeth, complete denture (each tooth) $58.00
D5610 Repair partial denture resin saddle or base $78.00
D5630 Repair or replace partial denture broken clasp $84.00
D5640 Replace broken teeth-partial denture-per tooth $67.00
D5650 Add tooth to existing partial denture $83.00
D5660 Add clasp to existing partial denture $71.00
D5710 Rebase complete upper denture (LAB) $224.00
D5711 Rebase complete lower denture (LAB) $228.00
D5720 Rebase partial upper denture (LAB) $228.00
D5721 Rebase partial lower denture (LAB) $228.00
D5730 Reline complete upper denture (chairside) $145.00
D5731 Reline complete lower denture (chairside) $145.00
D5740 Reline upper partial denture (chairside) $145.00
D5741 Reline lower partial denture (chairside) $145.00
D5810 Temporary complete denture (upper) $339.00
D5811 Temporary complete denture (lower) $339.00
D5820 Temporary partial-stayplate denture (upper) $301.00
D5821 Temporary partial-stayplate denture (lower) $301.00
 

PROSTHODONTICS, FIXED BRIDGES OR IMPLANT SERVICES

 
D6210 Pontic - cast high noble metal $501.00
D6240 Pontic-porcelain Fused To high Noble Metal $498.00
D6241 Pontic-porcelain fused to base metal $462.00
D6545 Cast metal retainer for resin bonded fixed prosthesis $228.00
D6751 Crown (abutment)-porcelain fused to base metal $470.00
D6790 Crown - full cast high noble metal $504.00
D6791 Crown (abutment)-full cast base metal $420.00
D6930 Recement fixed partial denture $61.00
D6940 Stress breaker $173.00
D6950 Precision attachment (each) $306.00
D6970 Cast post and core in addition to bridge retainer $170.00
D6971 Cast post as part of bridge retainer $134.00
D6972 Prefab'd post and core in addition to bridge retainer $139.00
 

ORAL SURGERY

 
D7111 Extraction, coronal remnants - deciduous tooth $61.00
D7140 Extraction, erupted tooth or exposed root $75.00
D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and/or section of tooth-each tooth $94.00
D7220 Removal of impacted tooth, soft tissue $123.00
D7230 Removal of impacted tooth, partially bony $158.00
D7240 Removal of impacted tooth-completely bony $212.00
D7241 Removal of impacted tooth, completely bony, with unusual surgical complications $250.00
D7250 Surgical removal of residual tooth roots (cutting procedure) $106.00
D7280 Surgical access of an unerupted tooth $151.00
D7310 Alveolectomy or plasty in conjunction with extractions-per quadrant $94.00
D7320 Alveolectomy or plasty not in conjunction with extractionsper quadrant $139.00
D7960 Frenulectomy (frenectomy or frenotomy), separate procedure $139.00
D7970 Excision of hyperplastic tissue-per arch $106.00
D7971 Excision of periocoronal gingiva $78.00
  Surgical procedures listed above include the administration of local anesthesia only. The administration of nitrous oxide, intravenous sedation, or general anesthesia is available at a 25% discount from the usual and customary fee of the participating provider  
 

ADJUNCTIVE SERVICES UNCLASSIFIED TREATMENT

 
D9110 Palliative (emergency) treatment of dental pain, minor procedure, during regular office hours $24.00
D9440 Office visit after regularly scheduled hours $61.00
D9940 Occlusal guards $267.00
     
 

SPECIALIST SERVICES
as performed by Board Eligible or Board Certified dental specialist

 
     
 

ORAL SURGERY

 
D7111 Extraction, coronal remnants - deciduous tooth $99.00
D7140 Extraction, erupted tooth or exposed root $103.00
D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and/or section of tooth-each tooth $134.00
D7220 Removal of impacted tooth-soft tissue $173.00
D7230 Removal of impacted tooth-partially bony $212.00
D7240 Removal of impacted tooth-completely bony $257.00
D7241 Removal of impacted tooth-completely bony with unusual surgical complications $314.00
D7250 Surgical removal of residual tooth roots (cutting procedure) $162.00
D7280 Surgical access of an unerupted tooth $223.00
D7310 Alveolectomy or plasty in conjunction with extractions-per quadrant $134.00
D7320 Alveolectomy or plasty not in conjunction with extractionsper quadrant $180.00
D7960 Frenulectomy (frenectomy or frenotomy), separate procedures $212.00
D7970 Excision of hyperplastic tissue-per arch $253.00
D7971 Excision of pericoronal gingiva $142.00
  Surgical procedures listed above include the administration of local anesthesia only. The administration of nitrous oxide, intravenous sedation, or general anesthesia is available at a 25% discount from the usual and customary fee of the participating specialist.  
 

PERIODONTIC PROCEDURES

 
D4210 Gingivectomy or gingivoplasty, 4+ contiguous teeth/quadrant $356.00
D4211 Gingivectomy or gingivoplasty, 1-3 contiguous teeth/quadrant $151.00
D4240 Gingival flap procedure-incl root planing, per quadrant $435.00
D4260 Osseous surgery, incl flap entry and closure, per quadrant $613.00
D4270 Pedicle soft tissue graft procedure $360.00
D4341 Periodontal scaling and root planing, per quadrant $152.00
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis 112.00
D4910 Periodontal maintenance procedures following active therapy $78.00
 

ENDODONTICS (ROOT CANAL THERAPY)

 
D3310 Root canal therapy-anterior tooth (excl. final restoration) $339.00
D3320 Root canal therapy-bicuspid (excl. final restoration) $473.00
D3330 Root canal therapy-molar (excl. final restoration) $618.00
D3410 Apicoectomy (per tooth)-first root $356.00
D3426 Apicoectomy (per tooth)-each additional root $145.00
D3430 Retorgrade filling-per root $139.00
D3450 Root amputation-per root $178.00
D3920 Hemisection (incl. root removal; excl. root canal therapy) $200.00
 

ORTHODONTICS - COMPREHENSIVE CASE, CLASS 1, 11, 111 (up to and including age 16) D8070, D8080

 
  Orthodontic records, treatment plan and consultation $112.00
  Initial ortho. appliance, construction and installation $428.00
  Active treatment phase - up to 24 months $2587.00
  Retention phase per retainer $210.00
  Continuation of orthodontic treatment beyond 24 months and other orthodontic services available at a 25% discount from usual and customary fees charged by orthodontists listed in the DDS Dental Directory. Orthodontic treatment includes the treatment of mixed and/or permanent dentitions under the 08400 and 08500 series procedure code. Orthodontic treatment for patients over the age of 16 is a 25% reduction from the dentist's usual and customary fee. Invisalign braces are 25% off the usual and customary fee.  

The dental services appearing in this schedule are available from general practitioners and specialists listed in the DDS Dental Directory. Any services that are not listed are available at a 25% discount from usual and customary fees charged by participating general practitioners and specialists, including pedodontics, prosthodontics and implantology.

Aside from the Annual Check-up, additional exams, x-rays and consultations are available at a 25% discount at general practitioners. All exams, x-rays and consultations at all specialists are 25% off the dentist's usual and customary fee.

Britesmile is not a covered procedure.

All participating providers may charge an OSHA sterilization fee per visit and a lab fee for crown, bridge and denture work. The administration of nitrous oxide intravenous sedation or general anesthesia is available at a 25% discount from usual and customary fees charged by participating general practitioners and specialists.

Waiting Periods on Types of Services
   
Preventive None
Diagnostic None
Basic None
Major None
Orthodontia None

Preventive care
  • Routine oral exams
  • Prophylaxis (cleaning and scaling of teeth)
Diagnostic care
  • Intra-oral occlusal film
  • Bitewing X-rays (up to a set of four)
  • Full-mouth X-rays (panoramic film) - one annually.
Basic care
  • Simple extraction
  • Pin retention – per tooth, in addition to restorations
  • Fillings (restorations) – amalgam restorations, composite restorations for anterior teeth and bicuspids, and sedative fillings
  • Maintenance prosthodontics – denture repairs and adjustments, denture rebase and denture reline
Major care
  • Endodontic treatment
  • Periodontic services
  • Inlays, onlays and crowns
  • Prosthetic services – dentures or bridges
  • Oral surgery
Orthodontia
  • For children up to and including age 16. Adults receive a 25% discount.