| Code |
Description |
Enrollee Pays |
| D3110 |
Pulp cap - direct (excluding final restoration) |
$ 18.00 |
| D3120 |
Pulp cap - indirect (excluding final restoration) |
$ 18.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament |
$ 45.00 |
| D3221 |
Pulpal debridement, primary and permanent teeth |
$ 45.00 |
| D3222 |
Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development |
$ 45.00 |
| D3230 |
Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) |
$ 45.00 |
| D3240 |
Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) |
$ 45.00 |
| D3310 |
Root canal -
endodontic therapy, anterior tooth (excluding final restoration) |
$250.00 |
| D3320 |
Root canal -
endodontic therapy, bicuspid tooth (excluding final restoration) |
$375.00 |
| D3330 |
Root canal - endodontic therapy, molar (excluding final restoration) |
$425.00 |
| D3332 |
Incomplete endodontic therapy; inoperable, unrestorable or
fractured tooth |
$240.00 |
| D3346 |
Retreatment of previous root canal therapy - anterior |
$500.00 |
| D3347 |
Retreatment of previous root canal therapy - bicuspid |
$600.00 |
| D3348 |
Retreatment of previous root canal therapy - molar |
$725.00 |
| D3410 |
Apicoectomy/periradicular surgery - anterior |
$470.00 |
| D3421 |
Apicoectomy/periradicular surgery - bicuspid (first root) |
$535.00 |
| D3425 |
Apicoectomy/periradicular surgery - molar (first root) |
$580.00 |
| D3426 |
Apicoectomy/periradicular surgery (each additional root) |
$115.00 |
| D3430 |
Retrograde filling - per root |
$ 65.00 |
| D3450 |
Root amputation, per root |
$295.00 |
| D3920 |
Hemisection (including any root removal), not including root
canal therapy |
$ 95.00 |
