GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 5 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment 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 $0 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 Endodontics • All procedures exclude final restoration. D3110 Pulp cap – direct (excluding final restoration) $0 D3120 Pulp cap – indirect (excluding final restoration) $0 D3220 Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament $0 D3221 Pulpal debridement, primary and permanent teeth $20 D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development $0 D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) $5 D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration) $10 D3310 Endodontic therapy, anterior tooth (excluding final restoration) $40 D3320 Endodontic therapy, premolar tooth (excluding final restoration) $65 D3330 Endodontic therapy, molar tooth (excluding final restoration) $95 D3331 Treatment of root canal obstruction; non-surgical access $55 D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $50 D3333 Internal root repair of perforation defects: Non-surgical seal of perforation caused by resorption and/or decay but not iatrogenic by same provider. $55 D3346 Retreatment of previous root canal therapy – anterior $65 D3347 Retreatment of previous root canal therapy – premolar $90 D3348 Retreatment of previous root canal therapy – molar $160 D3351 Apexification/recalcification – initial visit (apical closure / calcific repair of perforations, root resorption, etc.) $65 D3352 Apexification/recalcification – interim medication replacement $65 D3353 Apexification/recalcification – final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc.) $65 D3410 Apicoectomy – anterior $95 D3421 Apicoectomy – premolar (first root) $95 D3425 Apicoectomy – molar (first root) $95 D3426 Apicoectomy (each additional root) $60 D3430 Retrograde filling – per root $10 D3450 Root amputation – per root $95 D3471 Surgical repair of root resorption – anterior $72 D3472 Surgical repair of root resorption – premolar $72 D3473 Surgical repair of root resorption – molar $72