My Benefits



	Definitions Emergency Dental Services Specialized Services Benefits, Limitations and Exclusions Renewal, Cancellation and Termination of Benefits Grace Period Reinstatement 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)	$ 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)	$ 165
D3320	Root canal - bicuspid (excluding final restoration)	$ 230
D3330	Root canal - molar (excluding final restoration)	$ 340
D3346	Retreatment of previous root canal therapy - anterior	$ 265
D3347	Retreatment of previous root canal therapy - bicuspid	$ 330
D3348	Retreatment of previous root canal therapy - molar	$ 440
D3410	Apicoectomy/periradicular surgery - anterior	$ 225
D3421	Apicoectomy/periradicular surgery - bicuspid (first root	$ 290
D3425	Apicoectomy/periradicular surgery - molar (first root)	$ 335
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

**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, or periodontist at 75 percent of the Contract Specialty Care Dentist's "filed fees." Specialized Services are only available upon referral by the assigned Contract Dentist.