| Restorative (D2000-D2999) |
Members’ Cost |
| Amalgam restoration (including polishing) |
|
| D2140 amalgam one surface, primary or permanent |
$128.80 |
| D2150 amalgam two surfaces, primary or permanent |
$159.93 |
| D2160 amalgam three surfaces, primary or permanent |
$193.99 |
| D2161 amalgam four or more surfaces, primary or permanent |
$230.71 |
| Resin-based composite restorations direct |
|
| D2330 resin-based composite one surface, anterior |
$147.59 |
| D2331 resin-based composite two surfaces, anterior |
$184.53 |
| D2332 resin-based composite three surfaces, anterior |
$227.20 |
| D2335 resin-based composite four or more surfaces or involving incisal angle, anterior |
$283.93 |
| D2390 resin-based composite crown, anterior |
$402.17 |
| D2391 resin-based composite one surface, posterior |
$164.62 |
| D2392 resin-based composite two surfaces, posterior |
$212.96 |
| D2393 resin-based composite three surfaces, posterior |
$263.10 |
| D2394 resin-based composite four or more surfaces, posterior |
$311.31 |
| Inlay/onlay restorations |
Members’ Cost |
| D2510 inlay metallic one surface |
$758.39 |
| D2520 inlay metallic two surfaces |
$827.11 |
| D2530 inlay metallic three surfaces |
$889.60 |
| D2542 onlay metallic-two surfaces |
$895.20 |
| D2543 onlay metakkuc-three surfaces |
$932.32 |
| D2544 onlay metallic-four or more surfaces |
$971.82 |
| Porcelain/ceramic inlays/onlays include all indirect ceramic and porcelain type inlays/onlays |
|
| D2610 inlay porcelain/ceramic one surface |
$829.21 |
| D2620 inlay porcelain/ceramic two surfaces |
$840.79 |
| D2630 inlay porcelain/ceramic three surfaces |
$894.55 |
| D2642 onlay porcelain/ceramic two surfaces |
$912.57 |
| D2643 onlay porcelain/ceramic three surfaces |
$970.97 |
| D2644 onlay porcelain/ceramic four or more surfaces |
$998.39 |
| Resin-based composite inlays/onlays must utilize indirect technique |
|
| D2650 inlay resin based composite one surface |
$782.77 |
| D2651 inlay resin based composite two surfaces |
$814.29 |
| D2652 inlay resin based composite three surfaces |
$851.07 |
| D2662 onlay resin based composite two surfaces |
$870.65 |
| D2663 onlay resin based composite three surfaces |
$903.45 |
| D2664 onlay resin based composite four or more surfaces |
$925.68 |
| Crowns single restorations only |
|
| D2710 crown resin-based composite (indirect) |
$835.65 |
| D2712 crown resin-based composite (indirect) |
$942.59 |
| D2720 crown resin with high noble metal |
$986.06 |
| D2721 crown resin with predominantly base metal |
$910.42 |
| D2722 crown resin with noble metal |
$946.40 |
| D2740 crown porcelain/ceramic substrate |
$1,027.724 |
| D2750 crown porcelain fused to high noble metal |
$1,023.99 |
| D2751 crown porcelain fused to predominantly base metal |
$945.45 |
| D2752 crown porcelain fused to noble metal |
$982.37 |
| D2780 crown cast high noble metal |
$994.36 |
| D2781 crown cast predominantly base metal |
$952.16 |
| D2782 crown cast noble metal |
$972.91 |
| D2783 crown porcelain/ceramic |
$1,020.41 |
| D2790 crown full cast high noble metal |
$1,041.17 |
| D2791 crown full cast predominantly base metal |
$932.20 |
| D2792 crown full cast noble metal |
$974.73 |
| D2794 crown titanium |
$993.71 |
| D2799 provisional crown-further treatment or completion of diagnosis necessary prior to final impression |
$385.11 |
| Other restorative services |
Members’ Cost |
| D2910 recement inlay, onlay, or partial coverage restoration |
$99.38 |
| D2915 recement cast or prefabricated post and core |
$102.15 |
| D2920 recement crown |
$100.30 |
| D2930 prefabricated stainless steel crown primary tooth |
$246.05 |
| D2931 prefabricated stainless steel crown permanent tooth |
$296.21 |
| D2932 prefabricated resin crown |
$324.97 |
| D2933 prefabricated stainless steel crown with resin window |
$330.41 |
| D2934 prefabricated esthetic coated stainless steel crown primary tooth |
$331.19 |
| D2940 protective restoration |
$108.84 |
| D2950 core buildup, including pins |
$249.87 |
| D2951 pin retention per tooth, in addition to restoration |
$65.26 |
| D2952 post and core in addition to crown, indirectly fabricated |
$380.08 |
| D2953 each additional indirectly fabricated post same tooth |
$279.15 |
| D2954 prefabricated post and core in addition to crown |
$311.73 |
| D2955 post removal |
$269.67 |
| D2957 each additional prefabricated post same tooth |
$183.62 |
| D2960 labial veneer (resin laminate) chairside |
$592.53 |
| D2961 labial veneer (resin laminate) laboratory |
$896.43 |
| D2962 labial veneer (porcelain laminate) laboratory |
$1,048.51 |
| D2970 temporary crown (fractured tooth) |
$332.90 |
| D2971 additional procedures to construct new crown under existing partial denture framework |
$159.93 |
| D2975 coping |
$563.13 |
| D2980 crown repair necessitated by restorative material |
$266.40 |
