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. |