My Benefits



	Emergency Services Specialist Services Benefits, Limitations and Exclusions Renewal, Cancellation and Termination of Benefits Extension of Benefits Conversion Entire Contract Schedule A Description of Benefits and Copayments Schedule B Limitations and Exclusions

SCHEDULE A
DESCRIPTION OF BENEFITS AND COPAYMENTS

D3000-D3999 IV. Endodontics - When referable services are provided by a Contract Specialist, 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	$ 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	$180
D3320	Root canal - bicuspid (excluding final restoration) ⁴	$230
D3330	Root canal - molar (excluding final restoration) ⁴	$375
D3346	Retreatment of previous root canal therapy - anterior ⁴	$280
D3347	Retreatment of previous root canal therapy - bicuspid ⁴	$330
D3348	Retreatment of previous root canal therapy - molar ⁴	$475
D3410	Apicoectomy/periradicular surgery - anterior ⁴	$270
D3421	Apicoectomy/periradicular surgery - bicuspid (first root) ⁴	$335
D3425	Apicoectomy/periradicular surgery - molar (first root) ⁴	$380
D3426	Apicoectomy/periradicular surgery (each additional root) ⁴	$105
D3430	Retrograde filling - per root ⁴	$ 65
D3450	Root amputation, per root - not covered in conjunction with a hemisection ⁴	$315

* 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 Specialist's "filed fees." Specialist services are only available in areas where there is a DeltaCare USA Contract Specialist, and upon referral by the assigned Contract Dentist.