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Sealants (once per tooth in 3 years per provider or location); sealants over restored tooth surfaces are not covered.

Space maintainers.

Group 2 services are dental services furnished by a Dentist generally to restore or remove diseased or fractured natural teeth and treat oral disease. These covered dental services include:

For All Members (regardless of age):

For Members Eligible for Pediatric Essential Benefits:

For Other Members:

Composite resin fillings (one filling per tooth surface in 12 months). For primary, back teeth, payment for a composite filling will not be more than the allowed amount for an amalgam filling.

Temporary fillings (one filling per tooth surface).

Root canals on permanent teeth (once per tooth).

Vital pulpotomy.