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Advantage AVF-1 Schedule of Benefits

Endodontics Schedule

Limitations and Exclusions

ADA
CODE
Procedure Member
Pays
D3220 THERAPEUTIC PULPOTOMY EXCL FINAL RESTORATION $24
D3310 ROOT CANAL THERAPY - ANTERIOR EXCL FINAL RESTORATION $271
D3320 ROOT CANAL THERAPY - BICUSPID EXCL FINAL RESTORATION $331
D3330 ROOT CANAL THERAPY - MOLAR EXCL FINAL RESTORATION $428
D3346 RETREAT PREVIOUS ROOT CANAL - ANTERIOR $365
D3347 RETREAT PREVIOUS ROOT CANAL - BICUSPID $430
D3348 RETREAT PREVIOUS ROOT CANAL - MOLAR $517
D3410 APICOECTOMY/PERIRADICULAR SURGERY - ANTERIOR $310
D3421 APICOECTOMY/PERIRADICULAR SURGERY - BICUSPID 1st ROOT $339
D3425 APICOECTOMY/PERIRADICULAR SURGERY - MOLAR 1st ROOT $383
D3426 APICOECTOMY/PERIRADICULAR SURGERY - EACH ADDITIONAL ROOT $128
D3430 RETROGRADE FILLING - PER ROOT $94

Note:
All procedures listed might not be performed by the Participating General Dentist you select. The co - payments shown apply to those Participating General Dentists who do perform those services. Therefore, you are encouraged to discuss the availability of the scheduled services with your Participating General Dentist. Procedures not listed on this schedule of benefits, that are performed by the Participating General Dentist, will be charged at that Participating General Dentist's usual and customary fee less 20%.

Specialist Services
Should you need a specialist (i.e. Endodontist, Oral Surgeon, Orthodontist, Periodontist, Prosthodontist, Pediatric Dentist), you may be referred by your Participating General Dentist. Co - payment percentage amounts are applicable when treatment is performed by a Participating Specialist. Procedures not listed on this schedule of benefits, that are performed by a Participating Specialist, will be charged at that Participating Specialist's usual and customary fee less 20%.

 



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