| Code |
Description |
Enrollee Pays |
| D2140 |
Amalgam - one surface, primary or permanent |
$ 32.00 |
| D2150 |
Amalgam - two surfaces, primary or permanent |
$ 42.00 |
| D2160 |
Amalgam - three surfaces, primary or permanent |
$ 50.00 |
| D2161 |
Amalgam - four or more surfaces, primary or permanent |
$ 60.00 |
| D2330 |
Resin-based composite - one surface, anterior |
$ 65.00 |
| D2331 |
Resin-based composite - two surfaces, anterior |
$ 75.00 |
| D2332 |
Resin-based composite - three surfaces, anterior |
$ 85.00 |
| D2335 |
Resin-based composite - four or more surfaces or involving incisal angle (anterior) |
$115.00 |
| D2390 |
Resin-based composite crown, anterior |
$ 95.00 |
| D2391 |
Resin-based composite - one surface, posterior |
$ 85.00 |
| D2392 |
Resin-based composite - two surfaces, posterior |
$ 95.00 |
| D2393 |
Resin-based composite - three surfaces, posterior |
$125.00 |
| D2394 |
Resin-based composite - four or more surfaces, posterior |
$135.00 |
| D2510 |
Inlay - metallic - one surface 1 |
$260.00 |
| D2520 |
Inlay - metallic - two surfaces 1 |
$270.00 |
| D2530 |
Inlay - metallic - three or more surfaces 1 |
$280.00 |
| D2542 |
Onlay - metallic - two surfaces 1 |
$270.00 |
| D2543 |
Onlay - metallic - three surfaces 1 |
$290.00 |
| D2544 |
Onlay - metallic - four or more surfaces 1 |
$300.00 |
| D2610 |
Inlay - porcelain/ceramic - one surface 2 |
$330.00 |
| D2620 |
Inlay - porcelain/ceramic - two surfaces 2 |
$365.00 |
| D2630 |
Inlay - porcelain/ceramic - three or more surfaces 2 |
$385.00 |
| D2642 |
Onlay - porcelain/ceramic - two surfaces 2 |
$415.00 |
| D2643 |
Onlay - porcelain/ceramic - three surfaces 2 |
$415.00 |
| D2644 |
Onlay - porcelain/ceramic - four or more surfaces 2 |
$425.00 |
| D2650 |
Inlay - resin-based composite - one surface 2 |
$230.00 |
| D2651 |
Inlay - resin-based composite - two surfaces 2 |
$255.00 |
| D2652 |
Inlay - resin-based composite - three or more surfaces 2 |
$290.00 |
| D2662 |
Onlay - resin-based composite - two surfaces 2 |
$285.00 |
| D2663 |
Onlay - resin-based composite - three surfaces 2 |
$310.00 |
| D2664 |
Onlay - resin-based composite - four or more surfaces 2 |
$355.00 |
| D2710 |
Crown - resin-based composite (indirect) 2 |
$125.00 |
| D2712 |
Crown – ¾ resin-based composite (indirect) 2 |
$125.00 |
| D2720 |
Crown - resin with high noble metal 2 |
$425.00 |
| D2721 |
Crown - resin with predominantly base metal 2 |
$325.00 |
| D2722 |
Crown - resin with noble metal 2 |
$425.00 |
| D2740 |
Crown - porcelain/ceramic substrate 3 |
$575.00 |
| D2750 |
Crown - porcelain fused to high noble metal 2, 3 |
$440.00 |
| D2751 |
Crown - porcelain fused to predominantly base metal 2 |
$340.00 |
| D2752 |
Crown - porcelain fused to noble metal 2 |
$425.00 |
| D2780 |
Crown - ¾ cast high noble metal |
$440.00 |
| D2781 |
Crown - ¾ cast predominantly base metal |
$340.00 |
| D2782 |
Crown - ¾ cast noble metal |
$425.00 |
| D2783 |
Crown - ¾ porcelain/ceramic 2, 3 |
$495.00 |
| D2790 |
Crown - full cast high noble metal |
$440.00 |
| D2791 |
Crown - full cast predominantly base metal |
$340.00 |
| D2792 |
Crown - full cast noble metal |
$425.00 |
| D2794 |
Crown - titanium |
$440.00 |
| D2910 |
Recement inlay, onlay or partial coverage restoration |
$ 25.00 |
| D2915 |
Recement cast or prefabricated post and core |
$ 25.00 |
| D2920 |
Recement crown |
$ 25.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
$ 55.00 |
| D2931 |
Prefabricated stainless steel crown - permanent tooth |
$ 55.00 |
| D2932 |
Prefabricated resin crown - anterior primary tooth |
$ 95.00 |
| D2933 |
Prefabricated stainless steel crown with resin window - anterior primary tooth |
$ 95.00 |
| D2940 |
Sedative filling |
$ 10.00 |
| D2950 |
Core buildup, including any pins |
$ 85.00 |
| D2951 |
Pin retention - per tooth, in addition to restoration |
$ 30.00 |
| D2952 |
Post and core in addition to crown, indirectly fabricated - includes canal preparation 1 |
$ 95.00 |
| D2953 |
Each additional indirectly fabricated post - same tooth - includes canal preparation 1 |
$ 50.00 |
| D2954 |
Prefabricated post and core in addition to crown - base metal post; includes canal preparation |
$ 75.00 |
| D2955 |
Post removal (not in conjunction with endodontic therapy) |
$ 65.00 |
| D2957 |
Each additional prefabricated post - same tooth - base metal post; includes canal preparation |
$ 45.00 |
| D2970 |
Temporary crown (fractured tooth) -palliative treatment only |
$ 35.00 |
| D2971 |
Additional procedures to construct new crown under existing partial denture framework |
$65.00 |
| D2980 |
Crown repair, by report |
$ 50.00 |
