| Restorative
(Fillings) |
Member Pays |
| ADA Code |
Procedure |
| 2110 |
Amalgam-one
surface (primarychild) |
10 |
| 2120 |
Amalgam-two
surfaces (primary-child) |
15 |
| 2130 |
Amalgam-three
surfaces (primary-child) |
20 |
| 2131 |
Amalgam-four
or more surfaces
(primary-child) |
25 |
| 2140 |
Amalgam-one
surface (permanent) |
10 |
| 2150 |
Amalgam-two
surfaces (permanent) |
15 |
| 2160 |
Amalgam-three
surfaces (permanent) |
20 |
| 2161 |
Amalgam-four
or more surfaces (permanent) |
25 |
| 2330 |
Resin-one
surface, anterior |
10 |
| 2331 |
Resin-two
surfaces, anterior |
15 |
| 2332 |
Resin-three
surfaces, anterior |
20 |
| 2335 |
Resin-four
or more surfaces or
involving incisal angle
(tooth reconstruction
including incisal edge),
anterior |
60 |
| 2336 |
Composite
resin crown, anterior
(primary-child) |
60 |
| 2380 |
Resin-one
surface, posterior
(primary-child) |
25 |
| 2381 |
Resin-two
surfaces, posterior
(primary-child) |
30 |
| 2382 |
Resin-three
surfaces, posterior
(primary-child) |
35 |
| 2385 |
Resin-one
surface, posterior
(permanent) |
50 |
| 2386 |
Resin-two
surfaces, posterior
(permanent) |
60 |
| 2387 |
Resin-three
or more surfaces, posterior
(permanent) |
75 |
| 2940 |
Sedative
filling |
10 |
| 2950 |
Core
buildup including any pins |
70 |
| 2951 |
Pin
retention (per tooth, in
addition to restoration) |
10 |
| 2952 |
Cast
post and core in addition to
crown |
70 |
| 2954 |
Prefabricated
post and core in addition to
crown |
70 |
| 2960 |
Labial
veneer (laminate) (chairside) |
195 |
| 2961 |
Labial
veneer (resin laminate)
(laboratory) |
235 |
| 2962 |
Labial
veneer (porcelain laminate)
(laboratory) |
300 |
