| Restorative (D2000-D2999) |
Members’ Cost |
| Amalgam restoration (including polishing) |
|
| D2140 amalgam one surface, primary or permanent |
$126.14 |
| D2150 amalgam two surfaces, primary or permanent |
$154.17 |
| D2160 amalgam three surfaces, primary or permanent |
$187.02 |
| D2161 amalgam four or more surfaces, primary or permanent |
$222.41 |
| Resin-based composite restorations direct |
|
| D2330 resin-based composite one surface, anterior |
$142.27 |
| D2331 resin-based composite two surfaces, anterior |
$177.89 |
| D2332 resin-based composite three surfaces, anterior |
$219.03 |
| D2335 resin-based composite four or more surfaces or involving incisal angle, anterior |
$273.72 |
| D2390 resin-based composite crown, anterior |
$387.71 |
| D2391 resin-based composite one surface, posterior |
$158.70 |
| D2392 resin-based composite two surfaces, posterior |
$205.30 |
| D2393 resin-based composite three surfaces, posterior |
$253.54 |
| D2394 resin-based composite four or more surfaces, posterior |
$300.11 |
| Inlay/onlay restorations |
Members’ Cost |
| D2510 inlay metallic one surface |
$731.14 |
| D2520 inlay metallic two surfaces |
$797.39 |
| D2530 inlay metallic three surfaces |
$857.63 |
| D2542 onlay metallic-two surfaces |
$863.02 |
| D2543 onlay metakkuc-three surfaces |
$898.82 |
| D2544 onlay metallic-four or more surfaces |
$936.89 |
| Porcelain/ceramic inlays/onlays include all indirect ceramic and porcelain type inlays/onlays |
|
| D2610 inlay porcelain/ceramic one surface |
$799.22 |
| D2620 inlay porcelain/ceramic two surfaces |
$810.57 |
| D2630 inlay porcelain/ceramic three surfaces |
$862.30 |
| D2642 onlay porcelain/ceramic two surfaces |
$879.77 |
| D2643 onlay porcelain/ceramic three surfaces |
$936.07 |
| D2644 onlay porcelain/ceramic four or more surfaces |
$962.51 |
| Resin-based composite inlays/onlays must utilize indirect technique |
|
| D2650 inlay resin based composite one surface |
$754.54 |
| D2651 inlay resin based composite two surfaces |
$785.02 |
| D2652 inlay resin based composite three surfaces |
$820.48 |
| D2662 onlay resin based composite two surfaces |
$839.36 |
| D2663 onlay resin based composite three surfaces |
$870.98 |
| D2664 onlay resin based composite four or more surfaces |
$892.41 |
| Crowns single restorations only |
|
| D2710 crown resin-based composite (indirect) |
$805.61 |
| D2712 crown resin-based composite (indirect) |
$908.71 |
| D2720 crown resin with high noble metal |
$950.62 |
| D2721 crown resin with predominantly base metal |
$877.70 |
| D2722 crown resin with noble metal |
$912.39 |
| D2740 crown porcelain/ceramic substrate |
$990.78 |
| D2750 crown porcelain fused to high noble metal |
$987.19 |
| D2751 crown porcelain fused to predominantly base metal |
$911.48 |
| D2752 crown porcelain fused to noble metal |
$947.07 |
| D2780 crown cast high noble metal |
$958.62 |
| D2781 crown cast predominantly base metal |
$917.94 |
| D2782 crown cast noble metal |
$937.94 |
| D2783 crown porcelain/ceramic |
$983.74 |
| D2790 crown full cast high noble metal |
$1,003.75 |
| D2791 crown full cast predominantly base metal |
$898.70 |
| D2792 crown full cast noble metal |
$939.71 |
| D2794 crown titanium |
$958.00 |
| D2799 provisional crown-further treatment or completion of diagnosis necessary prior to final impression |
$371.26 |
| Other restorative services |
Members’ Cost |
| D2910 recement inlay, onlay, or partial coverage restoration |
$95.80 |
| D2915 recement cast or prefabricated post and core |
$98.47 |
| D2920 recement crown |
$96.69 |
| D2930 prefabricated stainless steel crown primary tooth |
$237.20 |
| D2931 prefabricated stainless steel crown permanent tooth |
$285.56 |
| D2932 prefabricated resin crown |
$313.84 |
| D2933 prefabricated stainless steel crown with resin window |
$319.29 |
| D2934 prefabricated esthetic coated stainless steel crown primary tooth |
$320.45 |
| D2940 protective restoration |
$104.92 |
| D2950 core buildup, including pins |
$240.88 |
| D2951 pin retention per tooth, in addition to restoration |
$62.91 |
| D2952 post and core in addition to crown, indirectly fabricated |
$366.41 |
| D2953 each additional indirectly fabricated post same tooth |
$269.11 |
| D2954 prefabricated post and core in addition to crown |
$300.52 |
| D2955 post removal |
$259.98 |
| D2957 each additional prefabricated post same tooth |
$177.02 |
| D2960 labial veneer (resin laminate) chairside |
$571.23 |
| D2961 labial veneer (resin laminate) laboratory |
$864.21 |
| D2962 labial veneer (porcelain laminate) laboratory |
$1,011.80 |
| D2970 temporary crown (fractured tooth) |
$320.93 |
| D2971 additional procedures to construct new crown under existing partial denture framework |
$154.17 |
| D2975 coping |
$542.89 |
| D2980 crown repair necessitated by restorative material |
$254.54 |
