| Code |
Description |
Enrollee Pays |
| D3110 |
Pulp cap - direct (excluding final restoration) |
$ 25 |
| D3120 |
Pulp cap - indirect (excluding final restoration) |
$ 25 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament |
No Cost |
| D3221 |
Pulpal debridement, primary and permanent teeth |
$ 45 |
| D3310 |
Root canal - anterior (excluding final restoration) |
$180 |
| D3320 |
Root canal - bicuspid (excluding final restoration) |
$230 |
| D3330 |
Root canal - molar (excluding final restoration) |
$375 |
| D3346 |
Retreatment of previous root canal therapy - anterior |
$280 |
| D3347 |
Retreatment of previous root canal therapy - bicuspid |
$330 |
| D3348 |
Retreatment of previous root canal therapy - molar |
$475 |
| D3410 |
Apicoectomy/periradicular surgery - anterior |
$270 |
| D3421 |
Apicoectomy/periradicular surgery - bicuspid (first root) |
$335 |
| D3425 |
Apicoectomy/periradicular surgery - molar (first root) |
$380 |
| D3426 |
Apicoectomy/periradicular surgery (each additional root) |
$105 |
| D3430 |
Retrograde filling - per root |
$ 50 |
| D3450 |
Root amputation, per root - not covered in conjunction with a hemisection |
$ 75 |
