| Restorative (D2000-D2999) |
Members’ Cost |
| Amalgam restoration (including polishing) |
|
| D2140 amalgam one surface, primary or permanent |
$136.36 |
| D2150 amalgam two surfaces, primary or permanent |
$169.32 |
| D2160 amalgam three surfaces, primary or permanent |
$205.38 |
| D2161 amalgam four or more surfaces, primary or permanent |
$244.26 |
| Resin-based composite restorations direct |
|
| D2330 resin-based composite one surface, anterior |
$156.25 |
| D2331 resin-based composite two surfaces, anterior |
$195.34 |
| D2332 resin-based composite three surfaces, anterior |
$240.54 |
| D2335 resin-based composite four or more surfaces or involving incisal angle, anterior |
$300.60 |
| D2390 resin-based composite crown, anterior |
$428.78 |
| D2391 resin-based composite one surface, posterior |
$174.28 |
| D2392 resin-based composite two surfaces, posterior |
$225.46 |
| D2393 resin-based composite three surfaces, posterior |
$278.55 |
| D2394 resin-based composite four or more surfaces, posterior |
$329.59 |
| Inlay/onlay restorations |
Members’ Cost |
| D2510 inlay metallic one surface |
$802.91 |
| D2520 inlay metallic two surfaces |
$875.34 |
| D2530 inlay metallic three surfaces |
$941.82 |
| D2542 onlay metallic-two surfaces |
$947.75 |
| D2543 onlay metakkuc-three surfaces |
$987.04 |
| D2544 onlay metallic-four or more surfaces |
$1,028.86 |
| Porcelain/ceramic inlays/onlays include all indirect ceramic and porcelain type inlays/onlays |
|
| D2610 inlay porcelain/ceramic one surface |
$877.68 |
| D2620 inlay porcelain/ceramic two surfaces |
$890.15 |
| D2630 inlay porcelain/ceramic three surfaces |
$947.06 |
| D2642 onlay porcelain/ceramic two surfaces |
$966.14 |
| D2643 onlay porcelain/ceramic three surfaces |
$1,027.97 |
| D2644 onlay porcelain/ceramic four or more surfaces |
$1,057.00 |
| Resin-based composite inlays/onlays must utilize indirect technique |
|
| D2650 inlay resin based composite one surface |
$828.72 |
| D2651 inlay resin based composite two surfaces |
$862.09 |
| D2652 inlay resin based composite three surfaces |
$901.03 |
| D2662 onlay resin based composite two surfaces |
$921.76 |
| D2663 onlay resin based composite three surfaces |
$956.48 |
| D2664 onlay resin based composite four or more surfaces |
$980.12 |
| Crowns single restorations only |
|
| D2710 crown resin-based composite (indirect) |
$884.70 |
| D2712 crown resin-based composite (indirect) |
$997.92 |
| D2720 crown resin with high noble metal |
$1,043.95 |
| D2721 crown resin with predominantly base metal |
$967.62 |
| D2722 crown resin with noble metal |
$1,001.95 |
| D2740 crown porcelain/ceramic substrate |
$1,088.05 |
| D2750 crown porcelain fused to high noble metal |
$1,084.10 |
| D2751 crown porcelain fused to predominantly base metal |
$1,000.95 |
| D2752 crown porcelain fused to noble metal |
$1,040.03 |
| D2780 crown cast high noble metal |
$1,052.73 |
| D2781 crown cast predominantly base metal |
$1,008.05 |
| D2782 crown cast noble metal |
$1,030.02 |
| D2783 crown porcelain/ceramic |
$1,080.31 |
| D2790 crown full cast high noble metal |
$1,102.28 |
| D2791 crown full cast predominantly base metal |
$986.73 |
| D2792 crown full cast noble metal |
$1,031.94 |
| D2794 crown titanium |
$1,052.04 |
| D2799 provisional crown-further treatment or completion of diagnosis necessary prior to final impression |
$407.74 |
| Other restorative services |
Members’ Cost |
| D2910 recement inlay, onlay, or partial coverage restoration |
$105.14 |
| D2915 recement cast or prefabricated post and core |
$104.37 |
| D2920 recement crown |
$105.91 |
| D2930 prefabricated stainless steel crown primary tooth |
$260.60 |
| D2931 prefabricated stainless steel crown permanent tooth |
$313.59 |
| D2932 prefabricated resin crown |
$344.05 |
| D2933 prefabricated stainless steel crown with resin window |
$349.81 |
| D2934 prefabricated esthetic coated stainless steel crown primary tooth |
$350.63 |
| D2940 protective restoration |
$115.23 |
| D2950 core buildup, including pins |
$261.42 |
| D2951 pin retention per tooth, in addition to restoration |
$69.09 |
| D2952 post and core in addition to crown, indirectly fabricated |
$402.40 |
| D2953 each additional indirectly fabricated post same tooth |
$295.54 |
| D2954 prefabricated post and core in addition to crown |
$330.03 |
| D2955 post removal |
$285.50 |
| D2957 each additional prefabricated post same tooth |
$194.41 |
| D2960 labial veneer (resin laminate) chairside |
$627.32 |
| D2961 labial veneer (resin laminate) laboratory |
$949.05 |
| D2962 labial veneer (porcelain laminate) laboratory |
$1,110.37 |
| D2970 temporary crown (fractured tooth) |
$352.44 |
| D2971 additional procedures to construct new crown under existing partial denture framework |
$169.32 |
| D2975 coping |
$596.19 |
| D2980 crown repair necessitated by restorative material |
$279.92 |
