Page 5 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D2663 Onlay – resin-based composite – three surfaces $245 D2664 Onlay – resin-based composite – four or more surfaces $245 D2710 Crown – resin-based composite (indirect) $245 D2712 Crown – ¾ resin-based composite (indirect) $245 D2720 Crown – resin with high noble metal $245 D2721 Crown – resin with predominantly base metal $245 D2722 Crown – resin with noble metal $245 D2740 Crown – porcelain/ceramic $245 D2750 Crown – porcelain fused to high noble metal $245 D2751 Crown – porcelain fused to predominantly base metal $245 D2752 Crown – porcelain fused to noble metal $245 D2753 Crown – porcelain fused to titanium and titanium alloys $245 D2780 Crown – ¾ cast high noble metal $245 D2781 Crown – ¾ cast predominantly base metal $245 D2782 Crown – ¾ cast noble metal $245 D2783 Crown – ¾ porcelain/ceramic $245 D2790 Crown – full cast high noble metal $245 D2791 Crown – full cast predominantly base metal $245 D2792 Crown – full cast noble metal $245 D2794 Crown – titanium and titanium alloys $245 D2799 Interim crown – further treatment or completion of diagnosis necessary prior to final impression. Further treatment or completion of diagnosis necessary prior to final impression. Not to be used as a temporary crown for a routine prosthetic restoration. $70 D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration $0 D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core $0 D2920 Re-cement or re-bond crown $0 D2928 Prefabricated porcelain/ceramic crown – permanent tooth $123 D2930 Prefabricated stainless steel crown – primary tooth $25 D2931 Prefabricated stainless steel crown – permanent tooth $25 D2932 Prefabricated resin crown $45 D2933 Prefabricated stainless steel crown with resin window $45 D2940 Placement of interim direct restoration Direct placement of a restorative material to protect tooth and/or tissue form. This procedure may be used to relieve pain, promote healing, manage caries, create a seal for endodontic isolation, or prevent further deterioration until definitive treatment can be rendered. Not to be used for endodontic access closure, or as a base or liner under restoration. $0 D2950 Core buildup, including any pins when required $70 D2951 Pin retention – per tooth, in addition to restoration $10 D2952 Post and core in addition to crown, indirectly fabricated $50 D2953 Each additional indirectly fabricated post – same tooth $50 D2954 Prefabricated post and core in addition to crown $30 D2955 Post removal $10 D2957 Each additional prefabricated post – same tooth $30 D2960 Labial veneer (resin laminate) – chairside $250