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BENEFITS SCHEDULE
Office Information
Name:
Address:
Primary Contact:
Phone:
COVERED SERVICES
DIAGNOSTIC
Co-Payment
COVERED SERVICES
Endodontics
Co-Payment
Consultation
(excluding specialist)
Initial Exam
Periodic Exam
Limited Exam
X-Rays
Full Mouth
4 Bite wing x-rays
Single Film
Root Canal Therapy
Anterior
Bicuspid
Posterior
Therapeutic pulpotomy (primary)
Therapeutic pulpotomy (permanent)
Apicoectomy (first root)
Retrograde filling (per root)
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