My Benefits



	Definitions Emergency Dental Services Specialized Services Benefits, Limitations and Exclusions Renewal, Cancellation and Termination of Benefits Grace Period Reinstatement Coverage Continuation Description of Benefits and Copayments (Schedule A) Limitations and Exclusions (Schedule B)

SCHEDULE OF BENEFITS AND COPAYMENTS

D3000-D3999 IV. Endodontics - When referable services are provided by a Contract Specialty Care Dentist, the Enrollee pays 75 percent of that Dentist's "filed fees." *

Code	Description	Enrollee Pays
D3110	Pulp cap - direct (excluding final restoration)	$ 18
D3120	Pulp cap - indirect (excluding final restoration)	$ 18
D3220	Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament	$ 30
D3221	Pulpal debridement, primary and permanent teeth	$ 40
D3230	Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) ⁵	$ 40
D3240	Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) ⁵	$ 40
D3310	Root canal - anterior (excluding final restoration) ⁵	$ 150
D3320	Root canal - bicuspid (excluding final restoration) ⁵	$ 220
D3330	Root canal - molar (excluding final restoration) ⁵	$ 270
D3346	Retreatment of previous root canal therapy - anterior ⁵	$ 170
D3347	Retreatment of previous root canal therapy - bicuspid ⁵	$ 240
D3348	Retreatment of previous root canal therapy - molar ⁵	$ 290
D3410	Apicoectomy/periradicular surgery - anterior ⁵	$ 150
D3421	Apicoectomy/periradicular surgery - bicuspid (first root) ⁵	$ 150
D3425	Apicoectomy/periradicular surgery - molar (first root) ⁵	$ 150
D3426	Apicoectomy/periradicular surgery (each additional root)	$ 75
D3430	Retrograde filling - per root	$ 65
D3450	Root amputation, per root - not covered in conjunction with a hemisection ⁵	$ 65

*If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Copayment. Listed, referable procedures that are not available in the contract facility or that require a Dentist to provide Specialized Services may be provided by a contracted oral surgeon, endodontist, periodontist or pediatric dentist at 75 percent of the Contract Specialty Care Dentist's "filed fees." Specialized Services are only available upon referral by the assigned Contract Dentist.