Laserfiche WebLink
SCHEDULE OF BENEFITS (Continued) <br />Periodontics <br />D4210 <br />Gingivectomy or gingivoplasty — four or more contiguous teeth or tooth <br />Your and Your <br />bounded spaces per quadrant <br />Dependent's <br />Code <br />Service <br />Co -Payment <br />D2794 <br />Crown — titanium <br />$0 <br />D2910 <br />Re -cement or re -bond inlay, onlay, veneer or partial coverage restoration <br />$0 <br />D2915 <br />Re -cement or re -bond indirectly fabricated or prefabricated post and core <br />$0 <br />D2920 <br />Re -cement or re -bond crown <br />$0 <br />D2930 <br />Prefabricated stainless steel crown — primary tooth <br />$0 <br />D2931 <br />Prefabricated stainless steel crown — permanent tooth <br />$0 <br />D2940 <br />Protective restoration <br />$0 <br />D2950 <br />Core buildup, including any pins when required <br />$0 <br />D2951 <br />Pin retention — per tooth, in addition to restoration <br />$0 <br />D2952 <br />Post and core in addition to crown, Indirectly fabricated <br />$0 <br />D2953 <br />Each additional indirectly fabricated post — same tooth <br />$0 <br />D2954 <br />Prefabricated post and core in addition to crown <br />$0 <br />D2970 <br />Temporary crown (fractured tooth) <br />$0 <br />Endodontics <br />All procedures exclude final restoration. <br />$0 <br />D3110 <br />Pulp cap — direct (excluding final restoration) <br />$0 <br />D3120 <br />Pulp cap — indirect (excluding final restoration) <br />$0 <br />D3220 <br />Therapeutic pulpotomy (excluding final restoration) — removal of pulp coronal to <br />$0 <br />the dentinocemental junction and application of medicament <br />D3310 <br />Endodontic therapy, anterior tooth (excluding final restoration) <br />$0 <br />D3320 <br />Endodontic therapy, bicuspid tooth (excluding final restoration) <br />$0 <br />D3330 <br />Endodontic therapy, molar tooth (excluding final restoration) <br />$0 <br />D3332 <br />Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth <br />$0 <br />D3346 <br />Retreatment of previous root canal therapy — anterior <br />$0 <br />D3347 <br />Retreatment of previous root canal therapy — bicuspid <br />$0 <br />D3348 <br />Retreatment of previous root canal therapy — molar <br />$0 <br />D3351 <br />Apexification/recalcification — initial visit (apical closure / calcific repair of <br />$0 <br />perforations, root resorption, etc.) <br />D3410 <br />Apicoectomy — anterior <br />$0 <br />D3421 <br />Apicoectomy— bicuspid (first root) <br />$0 <br />D3425 <br />Apiccectomy— molar (first root) <br />$0 <br />D3426 <br />Apicoectomy (each additional root) <br />$0 <br />D3430 <br />Retrograde filling — per root <br />$0 <br />Periodontics <br />D4210 <br />Gingivectomy or gingivoplasty — four or more contiguous teeth or tooth <br />$0 <br />bounded spaces per quadrant <br />D4211 <br />Gingivectomy or gingivoplasty — one to three contiguous teeth or tooth bounded <br />$0 <br />spaces per quadrant <br />D4240 <br />Gingival flap procedure, including root planing — four or more contiguous teeth <br />$0 <br />or tooth bounded spaces per quadrant <br />D4241 <br />Gingival flap procedure, including root planing — one to three contiguous teeth <br />$0 <br />or tooth bounded spaces per quadrant <br />D4260 <br />Osseous surgery (including elevation of a full thickness flap and closure) — four <br />$0 <br />or more contiguous teeth or tooth bounded spaces per quadrant <br />0041 -D -SOB <br />25C-42 <br />3 <br />