Page 6 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D2961 Labial veneer (resin laminate) – laboratory $300 D2962 Labial veneer (porcelain laminate) – laboratory $350 D2970 Temporary crown (fractured tooth) $0 D2971 Additional procedures to customize a crown to fit under an existing partial denture framework. This procedure is in addition to the separate a crown procedure documented with its own code. $50 D2976 Band stabilization – per tooth $7 D2980 Crown repair necessitated by restorative material failure $0 D2981 Inlay repair necessitated by restorative material failure $0 D2982 Onlay repair necessitated by restorative material failure $0 D2983 Veneer repair necessitated by restorative material failure $0 D2989 Excavation of a tooth resulting in the determination of non-restorability $0 D2990 Resin infiltration of incipient smooth surface lesions $0 Endodontics • All procedures exclude final restoration. D3110 Pulp cap – direct (excluding final restoration) $5 D3120 Pulp cap – indirect (excluding final restoration) $5 D3220 Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament $30 D3221 Pulpal debridement, primary and permanent teeth $55 D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development $30 D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) $40 D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration) $40 D3310 Endodontic therapy, anterior tooth (excluding final restoration) $100 D3320 Endodontic therapy, premolar tooth (excluding final restoration) $152 D3330 Endodontic therapy, molar tooth (excluding final restoration) $210 D3331 Treatment of root canal obstruction; non-surgical access $85 D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $96 D3333 Internal root repair of perforation defects: Non-surgical seal of perforation caused by resorption and/or decay but not iatrogenic by same provider. $85 D3346 Retreatment of previous root canal therapy – anterior $180 D3347 Retreatment of previous root canal therapy – premolar $280 D3348 Retreatment of previous root canal therapy – molar $325 D3351 Apexification/recalcification – initial visit (apical closure / calcific repair of perforations, root resorption, etc.) $70 D3352 Apexification/recalcification – interim medication replacement $70 D3353 Apexification/recalcification – final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc.) $70 D3355 Pulpal regeneration - initial visit $70 D3356 Pulpal regeneration - interim medication replacement $35