| Restorative (D2000-D2999) |
Members’ Cost |
| Amalgam restoration (including polishing) |
|
| D2140 amalgam one surface, primary or permanent |
$127.52 |
| D2150 amalgam two surfaces, primary or permanent |
$158.34 |
| D2160 amalgam three surfaces, primary or permanent |
$192.07 |
| D2161 amalgam four or more surfaces, primary or permanent |
$228.42 |
| Resin-based composite restorations direct |
|
| D2330 resin-based composite one surface, anterior |
$146.12 |
| D2331 resin-based composite two surfaces, anterior |
$182.70 |
| D2332 resin-based composite three surfaces, anterior |
$224.95 |
| D2335 resin-based composite four or more surfaces or involving incisal angle, anterior |
$281.11 |
| D2390 resin-based composite crown, anterior |
$398.18 |
| D2391 resin-based composite one surface, posterior |
$162.99 |
| D2392 resin-based composite two surfaces, posterior |
$210.85 |
| D2393 resin-based composite three surfaces, posterior |
$260.49 |
| D2394 resin-based composite four or more surfaces, posterior |
$308.22 |
| Inlay/onlay restorations |
Members’ Cost |
| D2510 inlay metallic one surface |
$750.88 |
| D2520 inlay metallic two surfaces |
$818.92 |
| D2530 inlay metallic three surfaces |
$880.79 |
| D2542 onlay metallic-two surfaces |
$886.33 |
| D2543 onlay metakkuc-three surfaces |
$923.09 |
| D2544 onlay metallic-four or more surfaces |
$962.19 |
| Porcelain/ceramic inlays/onlays include all indirect ceramic and porcelain type inlays/onlays |
|
| D2610 inlay porcelain/ceramic one surface |
$820.80 |
| D2620 inlay porcelain/ceramic two surfaces |
$832.46 |
| D2630 inlay porcelain/ceramic three surfaces |
$885.59 |
| D2642 onlay porcelain/ceramic two surfaces |
$903.53 |
| D2643 onlay porcelain/ceramic three surfaces |
$961.35 |
| D2644 onlay porcelain/ceramic four or more surfaces |
$988.50 |
| Resin-based composite inlays/onlays must utilize indirect technique |
|
| D2650 inlay resin based composite one surface |
$775.02 |
| D2651 inlay resin based composite two surfaces |
$806.22 |
| D2652 inlay resin based composite three surfaces |
$842.64 |
| D2662 onlay resin based composite two surfaces |
$862.03 |
| D2663 onlay resin based composite three surfaces |
$894.50 |
| D2664 onlay resin based composite four or more surfaces |
$916.51 |
| Crowns single restorations only |
|
| D2710 crown resin-based composite (indirect) |
$827.37 |
| D2712 crown resin-based composite (indirect) |
$933.25 |
| D2720 crown resin with high noble metal |
$976.29 |
| D2721 crown resin with predominantly base metal |
$901.40 |
| D2722 crown resin with noble metal |
$937.03 |
| D2740 crown porcelain/ceramic substrate |
$1,017.54 |
| D2750 crown porcelain fused to high noble metal |
$1,013.85 |
| D2751 crown porcelain fused to predominantly base metal |
$936.09 |
| D2752 crown porcelain fused to noble metal |
$972.64 |
| D2780 crown cast high noble metal |
$984.51 |
| D2781 crown cast predominantly base metal |
$942.73 |
| D2782 crown cast noble metal |
$963.27 |
| D2783 crown porcelain/ceramic |
$1,010.30 |
| D2790 crown full cast high noble metal |
$1,030.86 |
| D2791 crown full cast predominantly base metal |
$922.97 |
| D2792 crown full cast noble metal |
$965.08 |
| D2794 crown titanium |
$983.87 |
| D2799 provisional crown-further treatment or completion of diagnosis necessary prior to final impression |
$381.29 |
| Other restorative services |
Members’ Cost |
| D2910 recement inlay, onlay, or partial coverage restoration |
$98.39 |
| D2915 recement cast or prefabricated post and core |
$101.13 |
| D2920 recement crown |
$99.30 |
| D2930 prefabricated stainless steel crown primary tooth |
$243.61 |
| D2931 prefabricated stainless steel crown permanent tooth |
$293.27 |
| D2932 prefabricated resin crown |
$321.75 |
| D2933 prefabricated stainless steel crown with resin window |
$329.11 |
| D2934 prefabricated esthetic coated stainless steel crown primary tooth |
$327.91 |
| D2940 protective restoration |
$107.76 |
| D2950 core buildup, including pins |
$247.39 |
| D2951 pin retention per tooth, in addition to restoration |
$64.61 |
| D2952 post and core in addition to crown, indirectly fabricated |
$376.31 |
| D2953 each additional indirectly fabricated post same tooth |
$276.38 |
| D2954 prefabricated post and core in addition to crown |
$308.64 |
| D2955 post removal |
$267.00 |
| D2957 each additional prefabricated post same tooth |
$181.80 |
| D2960 labial veneer (resin laminate) chairside |
$586.66 |
| D2961 labial veneer (resin laminate) laboratory |
$887.55 |
| D2962 labial veneer (porcelain laminate) laboratory |
$1,038.12 |
| D2970 temporary crown (fractured tooth) |
$329.60 |
| D2971 additional procedures to construct new crown under existing partial denture framework |
$158.34 |
| D2975 coping |
$557.55 |
| D2980 crown repair necessitated by restorative material |
$261.78 |
