| 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 |
$ 45 |
| D3221 |
Pulpal debridement, primary and permanent teeth |
$ 45 |
| D3230 |
Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) |
$ 45 |
| D3240 |
Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) |
$ 45 |
| D3310 |
Root canal - anterior (excluding final restoration) 4 |
$250 |
| D3320 |
Root canal - bicuspid (excluding final restoration) 4 |
$350 |
| D3330 |
Root canal - molar (excluding final restoration) 4 |
$400 |
| D3346 |
Retreatment of previous root canal therapy - anterior 4 |
$500 |
| D3347 |
Retreatment of previous root canal therapy - bicuspid 4 |
$600 |
| D3348 |
Retreatment of previous root canal therapy - molar 4 |
$725 |
| D3410 |
Apicoectomy/periradicular surgery - anterior 4 |
$400 |
| D3421 |
Apicoectomy/periradicular surgery - bicuspid (first root) 4 |
$450 |
| D3425 |
Apicoectomy/periradicular surgery - molar (first root) 4 |
$425 |
| D3426 |
Apicoectomy/periradicular surgery (each additional root) 4 |
$115 |
| D3430 |
Retrograde filling - per root 4 |
$ 65 |
| D3450 |
Root amputation, per root - not covered in conjunction with a hemisection 4 |
$315 |
