| Restorative (D2000-D2999) |
Members’ Cost |
| Amalgam restoration (including polishing) |
|
| D2140 amalgam one surface, primary or permanent |
$119.20 |
| D2150 amalgam two surfaces, primary or permanent |
$149.22 |
| D2160 amalgam three surfaces, primary or permanent |
$181.00 |
| D2161 amalgam four or more surfaces, primary or permanent |
$215.26 |
| Resin-based composite restorations direct |
|
| D2330 resin-based composite one surface, anterior |
$137.70 |
| D2331 resin-based composite two surfaces, anterior |
$172.17 |
| D2332 resin-based composite three surfaces, anterior |
$211.92 |
| D2335 resin-based composite four or more surfaces or involving incisal angle, anterior |
$264.91 |
| D2390 resin-based composite crown, anterior |
$375.24 |
| D2391 resin-based composite one surface, posterior |
$153.61 |
| D2392 resin-based composite two surfaces, posterior |
$198.70 |
| D2393 resin-based composite three surfaces, posterior |
$245.39 |
| D2394 resin-based composite four or more surfaces, posterior |
$290.46 |
| Inlay/onlay restorations |
Members’ Cost |
| D2510 inlay metallic one surface |
$707.61 |
| D2520 inlay metallic two surfaces |
$771.73 |
| D2530 inlay metallic three surfaces |
$830.03 |
| D2542 onlay metallic-two surfaces |
$835.25 |
| D2543 onlay metakkuc-three surfaces |
$869.89 |
| D2544 onlay metallic-four or more surfaces |
$906.74 |
| Porcelain/ceramic inlays/onlays include all indirect ceramic and porcelain type inlays/onlays |
|
| D2610 inlay porcelain/ceramic one surface |
$773.50 |
| D2620 inlay porcelain/ceramic two surfaces |
$784.48 |
| D2630 inlay porcelain/ceramic three surfaces |
$834.55 |
| D2642 onlay porcelain/ceramic two surfaces |
$851.45 |
| D2643 onlay porcelain/ceramic three surfaces |
$905.94 |
| D2644 onlay porcelain/ceramic four or more surfaces |
$931.53 |
| Resin-based composite inlays/onlays must utilize indirect technique |
|
| D2650 inlay resin based composite one surface |
$730.26 |
| D2651 inlay resin based composite two surfaces |
$759.46 |
| D2652 inlay resin based composite three surfaces |
$794.08 |
| D2662 onlay resin based composite two surfaces |
$812.34 |
| D2663 onlay resin based composite three surfaces |
$842.95 |
| D2664 onlay resin based composite four or more surfaces |
$863.69 |
| Crowns single restorations only |
|
| D2710 crown resin-based composite (indirect) |
$779.69 |
| D2712 crown resin-based composite (indirect) |
$879.46 |
| D2720 crown resin with high noble metal |
$920.03 |
| D2721 crown resin with predominantly base metal |
$849.45 |
| D2722 crown resin with noble metal |
$883.03 |
| D2740 crown porcelain/ceramic substrate |
$958.89 |
| D2750 crown porcelain fused to high noble metal |
$955.42 |
| D2751 crown porcelain fused to predominantly base metal |
$882.15 |
| D2752 crown porcelain fused to noble metal |
$916.59 |
| D2780 crown cast high noble metal |
$927.77 |
| D2781 crown cast predominantly base metal |
$888.39 |
| D2782 crown cast noble metal |
$907.76 |
| D2783 crown porcelain/ceramic |
$952.08 |
| D2790 crown full cast high noble metal |
$962.47 |
| D2791 crown full cast predominantly base metal |
$869.78 |
| D2792 crown full cast noble metal |
$909.47 |
| D2794 crown titanium |
$927.18 |
| D2799 provisional crown-further treatment or completion of diagnosis necessary prior to final impression |
$359.31 |
| Other restorative services |
Members’ Cost |
| D2910 recement inlay, onlay, or partial coverage restoration |
$92.73 |
| D2915 recement cast or prefabricated post and core |
$95.30 |
| D2920 recement crown |
$93.58 |
| D2930 prefabricated stainless steel crown primary tooth |
$229.57 |
| D2931 prefabricated stainless steel crown permanent tooth |
$276.37 |
| D2932 prefabricated resin crown |
$303.75 |
| D2933 prefabricated stainless steel crown with resin window |
$309.02 |
| D2934 prefabricated esthetic coated stainless steel crown primary tooth |
$310.14 |
| D2940 protective restoration |
$101.55 |
| D2950 core buildup, including pins |
$233.13 |
| D2951 pin retention per tooth, in addition to restoration |
$60.89 |
| D2952 post and core in addition to crown, indirectly fabricated |
$357.59 |
| D2953 each additional indirectly fabricated post same tooth |
$260.45 |
| D2954 prefabricated post and core in addition to crown |
$290.85 |
| D2955 post removal |
$251.62 |
| D2957 each additional prefabricated post same tooth |
$171.32 |
| D2960 labial veneer (resin laminate) chairside |
$551.88 |
| D2961 labial veneer (resin laminate) laboratory |
$836.39 |
| D2962 labial veneer (porcelain laminate) laboratory |
$979.24 |
| D2970 temporary crown (fractured tooth) |
$309.93 |
| D2971 additional procedures to construct new crown under existing partial denture framework |
$144.87 |
| D2975 coping |
$525.42 |
| D2980 crown repair necessitated by restorative material |
$246.35 |
