Procedure Description Copayment Notes Re-cement or rebond indirectly fabricated or prefabricated post D2915 and core 0 D2920 Re-cement or rebond crown 0 D2921 Reattachment of tooth fragment, incisal edge or cusp 15 D2930 Prefabricated stainless steel crown - primary tooth 100 D2931 Prefabricated stainless steel crown - permanent tooth 100 D2932 Prefabricated resin crown anterior teeth only 100 Gap D2940 Sedative filling 20 D2941 Restorative foundation for an indirect restoration 20 D2950 Crown build-up (substructure) including any pins when required 0 D2951 Pin retention - per tooth, in addition to restoration 0 D2952 Post and core in addition to crown, indirectly fabricated 0 D2953 Each additional indirectly fabricated post – same tooth 0 D2954 Prefabricated post and core in addition to crown 0 D2957 Each additional prefabricated post - same tooth 0 Additional procedures to customize a crown to fit under an D2971 existing partial denture framework 0 D2976 Band stabilization - per tooth 0 D2980 Crown repair necessitated by restorative material failure 30 D2981 Inlay repair necessitated by restorative material failure 30 D2982 Onlay repair necessitated by restorative material failure 30 D2983 Veneer repair necessitated by restorative material failure 30 Excavation of a tooth resulting in the determination of non- D2989 restorability 0 D3000 - D3999 V. Endodontics D3110 Pulp cap-direct (excluding final restoration) 0 D3120 Pulp cap-indirect (excluding final restoration) 0 Therapeutic pulpotomy (excluding final restoration) - removal of D3220 pulp 0 D3221 Gross pulpal debridement, primary and permanent teeth NB Pulpal therapy (resorbable filling), primary tooth (excluding final D3230 restoration) NB Pulpal therapy (resorbable filling), primary tooth (excluding final D3240 restoration) NB D3310 Root canal therapy - anterior (excluding final restoration) 100 D3320 Root canal therapy – premolar (excluding final restoration) 125 D3330 Root canal therapy – molar tooth (excluding final restoration) 150 R D3346 Retreatment of previous root canal therapy - anterior 100 R D3347 Retreatment of previous root canal therapy – premolar 125 R D3348 Retreatment of previous root canal therapy - molar 150 R Apexification/recalcification – initial visit (apical closure / calcific repair of perforations, root resorption, pulp space disinfection, D3351 etc.) 10 R D3352 Apexification/recalcification - interim visit 10 R D3353 Apexification/recalcification - final visit 10 R D3410 Apicoectomy – anterior 70 R D3421 Apicoectomy – premolar (first root) 50 R 2024-01-03100-BB 9 DCL 20240101