Dentist Restorative Services

Restorative Services include dental fillings using composite, amalgam and others.

Amalgam Restorations (Including Polishing)
D2140	Amalgam; one surface, primary or permanent	No	Primary teeth: Once per tooth, per year, per provider1 (tooth letters A-T and AS-TS only). Permanent teeth: Once per tooth, per three years, per provider1 (tooth numbers 1-32 and 51-82 only).
D2150	two surfaces, primary or permanent	No	Primary teeth: Once per tooth, per year, per provider1 (tooth letters A-T and AS-TS only). Permanent teeth: Once per tooth, per three years, per provider1 (tooth numbers 1-32 and 51-82 only).
D2160	three surfaces, primary or permanent	No	Primary teeth: Once per tooth, per year, per provider1 (tooth letters A-T and AS-TS only). Permanent teeth: Once per tooth, per three years, per provider1 (tooth numbers 1-32 and 51-82 only).
D2161	four or more surfaces, primary or permanent	No	Primary teeth: Once per tooth, per year, per provider1 (tooth letters A-T and AS-TS only). Permanent teeth: Once per tooth, per three years, per provider1 (tooth numbers 1-32 and 51-82 only).

Resin-Based Composite Restorations – Direct
D2330	Resin-based composite; one surface, anterior	No	Primary teeth: Once per tooth, per year, per provider.1 Permanent teeth: Once per tooth, per three years, per provider.1 Allowed for Class I and Class V only (tooth numbers 6-11, 22-27, C-H, M-R, 56-61, 72-77, CS-HS, and MS-RS only).
D2331	two surfaces, anterior	No	Primary teeth: Once per tooth, per year, per provider.1 Permanent teeth: Once per tooth, per three years, per provider.1 Allowed for Class III only (tooth numbers 6-11, 22-27, C-H, M-R, 56-61, 72-77, CS-HS, and MS-RS only).
D2332	three surfaces, anterior	No	Primary teeth: Once per tooth, per year, per provider.1 Permanent teeth: Once per tooth, per three years, per provider.1 Allowed for Class III and Class IV only (tooth numbers 6-11, 22-27, C-H, M-R, 56-61, 72-77, CS-HS, and MS-RS only).
D2335	four or more surfaces or involving incisal angle (anterior)	No	Primary teeth: Once per tooth, per year, per provider.1 Permanent teeth: Once per tooth, per three years, per provider.1 Allowed for Class IV only (tooth numbers 6-11, 22-27, C-H, M-R, 56-61, 72-77, CS-HS, and MS-RS only). Must include incisal angle. Four surface resins may be billed under D2332, unless an incisal angle is included.
D2390	Resin-based composite crown, anterior	No	Primary teeth: Once per year, per tooth (tooth letters D-G, DS-GS only). Permanent teeth: Once per five years, per tooth (tooth numbers 6-11, 22-27, 56-61, 72-77 only.) Limitation can be exceeded with narrative for children1, and with PA for adults greater than age 20.2
D2391	Resin-based composite – one surface, posterior	No	Primary teeth: Once per year, per provider, per tooth1 (tooth letters A, B, I, J, K, L, S, T, AS, BS, IS, JS, KS, LS, SS, and TS only). Permanent teeth: Once per three years, per provider, per tooth1 (tooth numbers 1-5, 12-21, 28-32, 51-55, 62-71, and 78-82 only).
D2392	Resin-based composite – two surfaces, posterior	No	Primary teeth: Once per year, per provider, per tooth1 (tooth letters A, B, I, J, K, L, S, T, AS, BS, IS, JS, KS, LS, SS, and TS only). Permanent teeth: Once per three years, per provider, per tooth1 (tooth numbers 1-5, 12-21, 28-32, 51-55, 62-71, and 78-82 only).
D2393	Resin-based composite – three surfaces, posterior	No	Primary teeth: Once per year, per provider, per tooth1 (tooth letters A, B, I, J, K, L, S, T, AS, BS, IS, JS, KS, LS, SS, and TS only). Permanent teeth: Once per three years, per provider, per tooth1 (tooth numbers 1-5, 12-21, 28-32, 51-55, 62-71, and 78-82 only).
D2394	Resin-based composite – four or more surfaces, posterior	No	Primary teeth: Once per year, per provider, per tooth1 (tooth letters A, B, I, J, K, L, S, T, AS, BS, IS, JS, KS, LS, SS, and TS only). Permanent teeth: Once per three years, per provider, per tooth1 (tooth numbers 1-5, 12-21, 28-32, 51-55, 62-71, and 78-82 only).
Crowns – Single Restorations Only
D2791	Crown – full cast predominantly base metal	No	Once per year, per primary tooth; once per five years, per permanent tooth2 (tooth numbers 1-32, A-T, 51-82, and AS-TS.) Reimbursement is limited to the rate of code D2933. Upgraded crown. No dentist is obligated to complete this type of crown.

Other Restorative Services
D2910	Recement inlay, onlay or partial coverage restoration	No	Tooth numbers 1-32, 51-82 only.
D2915	Recement cast or prefabricated post and core	No	Tooth numbers 1-32, A-T, 51-82, AS-TS.
D2920	Recement crown	No	Tooth numbers 1-32, A-T, 51-82, AS-TS.
D2930	Prefabricated stainless steel crown; primary tooth	No	Once per year, per tooth (tooth letters, A-T and AS-TS only).2
D2931	permanent tooth	No	Once per five years, per tooth (tooth numbers 1-32 and 51-82 only).
D2932	Prefabricated resin crown	No	Primary teeth: Once per year, per tooth (tooth letters D-G and DS-GS only). Permanent teeth: Once per five years, per tooth (tooth numbers 6-11, 22-27, 56-61, and 72-77 only.) Limitation can be exceeded with narrative for children1, and with PA for adults older than age 20.2
D2933	Prefabricated stainless steel crown with resin window	No	Primary teeth: Once per year, per tooth (tooth letters D-G, DS-GS only). Permanent teeth: Once per five years, per tooth (tooth numbers 6-11 and 56-61 only.) Limitation can be exceeded with narrative for children1, and with PA for adults older than age 20.2
D2934	Prefabricated esthetic coated stainless steel crown – primary tooth	No	Once per year, per tooth. Allowable age less than 21. Tooth letters D-G and DS-GS only.
D2940	Sedative filling	No	Not allowed with pulpotomies, permanent restorations, or endodontic procedures (tooth numbers 1-32, A-T, 51-82, and AS-TS).
D2951	Pin retention – per tooth, in addition to restoration	No	Once per three years, per tooth (tooth numbers 1-32 and 51-82 only).1
D2952	Post and core in addition to crown, indirectly fabricated	No	Once per tooth, per lifetime, per provider. Tooth numbers 2-15, 18-31, 52-65, and 68-81 only. Cannot be billed with D2954.
D2954	Prefabricated post and core in addition to crown	No	Once per tooth, per lifetime, per provider. Tooth numbers 2-15, 18-31, 52-65, and 68-81 only. Cannot be billed with D2952.
D2971	Additional procedures to construct new crown under existing partial denture framework	No	Tooth numbers 2-15 and 18-31 only.
D2999	Unspecified restorative procedure, by report	Yes	HealthCheck “Other Service.” Use this code for single-unit crown. Allowable for members ages 0-20.