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19.15.5 Restorative Services
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Procedure Code
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Limitations
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Maximum Fee
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Amalgam Restorations (Including Polishing)
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D2140*
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Reimburse primary TIDs A-T at $61.98; reimburse permanent TIDs 1-5, 12-21, and 28-32 at $65.72. A 1-20, PXR
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$65.72
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D2150*
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Reimburse primary TIDs A-T at $82.90; reimburse permanent TIDs 1-5, 12-21, and 28-32 at $87.46. A 1-20, PXR
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$87.46
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D2160*
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Reimburse primary TIDs A-T at $90.01; reimburse permanent TIDs 1-5, 12-21, and 28-32 at $111.42. A 1-20, PXR
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$111.42
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D2161*
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Reimburse primary TIDs A-T at $52.69; reimburse permanent TIDs 1-5, 12-21, and 28-32 at $60.04. A 1-20, PXR
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$60.04
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Resin-Based Composite Restorations-Direct
All fees for resin restorations on primary teeth are limited to $170.38, which is the fee for a stainless steel crown (exception: D2335). All fees for resin restorations on permanent teeth are limited to a total of $110.20 for posterior teeth and $170.38 for anterior teeth. Resin restoration includes composites or glass ionomer.
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D2330*
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TID C-H, M-R, #6-11, #22-27. A 1-20, PXR
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$79.34
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D2331*
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TID C-H, M-R, #6-11, #22-27. A 1-20, PXR
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$105.14
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D2332*
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TID C-H, M-R, #6-11, #22-27. A 1-20, PXR
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$137.28
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D2335*
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TID C-H, M-R, #6-11, #22-27. A 1-20, PXR
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$170.38
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D2390*
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Reimburse primary anterior TIDs C-H, M-R at $76.98; reimburse permanent anterior TIDs 6-11, 22-27 at $150.00. A 1-20, PXR
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$150.00
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D2391*
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Reimburse primary posterior TIDs A, B, I, J, K, L, S, T at $76.98; reimburse permanent posterior TIDs 1-5, 12-21, 28-32 at $84.08. A 1-20, PXR
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$84.08
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D2392*
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Reimburse primary posterior TIDs A, B, I, J, K, L, S, T at $98.98; reimburse permanent posterior TIDs 1-5, 12-21, 28-32 at $110.20. A 1-20, PXR
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$110.20
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D2393*
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Reimburse primary posterior TIDs A, B, I, J, K, L, S, T at $87.11; reimburse permanent posterior TIDs 1-5, 12-21, 28-32 at $101.18. A 1-20, PXR
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$101.18
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D2394*
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Reimburse primary posterior TIDs A, B, I, J, K, L, S, T at $64.62; reimburse permanent posterior TIDs 1-5, 12-21, 28-32 at $75.06. A 1-20, PXR
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$75.06
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Gold Foil Restorations (Permanent Teeth only)
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D2410
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A 13-20, N, PPXR, CCP
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$75.00
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D2420
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A 13-20, N, PPXR, CCP
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$125.00
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D2430
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A 13-20, N, PPXR, CCP
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$125.00
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Inlay/Onlay Restorations (Permanent Teeth only)
For procedure codes D2510 through D2664 inlay/onlay (permanent teeth only), porcelain is allowed on all teeth. Prior authorization is required for any combination of inlays/onlays or permanent crowns that exceed the limit of four inlays/onlays or permanent crowns.
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D2510
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A 13-20, N, PPXR, CCP
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$181.25
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D2520
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A 13-20, N, PPXR, CCP
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$264.00
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D2530
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A 13-20, N, PPXR, CCP
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$264.00
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D2542
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Same as D2520. A 13-20, N, PPXR, CCP
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$264.00
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D2543
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2544
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2610
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2620
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2630
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2642
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2643
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2644
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2650
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2651
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2652
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2662
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2663
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2664
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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Crowns-Single Restorations Only
For procedure codes D2710 through D2794, single crown restorations (permanent teeth only) the following limitations apply:
• Procedure code D2920 is payable to the same THSteps dental provider that performed the original cementation of the crown.
•Porcelain is allowed on all teeth.
•Prior authorization is required for any combination of inlays/onlays or permanent crowns that exceed the limit of four inlays/onlays or permanent crowns.
•Stainless steel crowns and permanent all-metal cast crowns are not reimbursed on anterior permanent teeth (6-11, 22-27).
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D2710
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2720
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2721
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2722
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2740
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All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2750*
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All materials accepted. A 13-20, N, PPXR, CCP
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$528.00
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D2751*
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All materials accepted. A 13-20, N, PPXR
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$528.00
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D2752
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All materials accepted. A 13-20, N, PPXR, CCP
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$528.00
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D2780
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A 13-20, N, PPXR, CCP
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$264.00
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D2781
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A 13-20, N, PPXR, CCP
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$264.00
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D2782
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A 13-20, N, PPXR, CCP
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$264.00
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D2783
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Anterior teeth only (#6-11 and #22-27).
A 13-20, N, PPXR, CCP
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$264.00
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D2790
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Posterior teeth only (#1-5; #12-21; and #28-32). All materials accepted. A 13-20, N, PPXR, CCP
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$528.00
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D2791*
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Posterior teeth only (#1-5; #12-21; and #28-32). All materials accepted. A 13-20, N, PPXR
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$264.00
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D2792*
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Posterior teeth only (#1-5; #12-21; and #28-32). All materials accepted. A 13-20, N, PPXR, CCP
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$264.00
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D2794
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A 13-20, N, PPXR, CCP
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$264.00
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D2799
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Denied as global fee to any crown placed.
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NC
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D2915
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A 4-20
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$18.75
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Other Restorative Services
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D2910
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A 13-20, PXR
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$18.75
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D2920
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A 1-20, PXR
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$20.00
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D2930*
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A 1-20, PXR
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$156.06
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D2931*
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A 1-20, PXR
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$162.50
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D2932*
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A 1-20, PXR ($68.75 per primary tooth)
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$68.75
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D2933*
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Limited to anterior primary teeth only (TID C-H, M-R).
A 1-20, N, CCP, PXR
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$156.06
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D2934*
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Limited to anterior primary teeth only (TID C-H, M-R).
A 1-20, N, CCP, PXR
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$156.06
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D2940*
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Not allowed on the same date as permanent restoration.
A 1-20, PXR
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$36.58
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D2950*
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Not allowed on primary teeth.
A 4-20, N, CCP, PXR
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$45.00
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D2951
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Not payable with crowns or D2950. Not allowed on primary teeth.
A 4-20, PXR
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$12.50
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D2952
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Not payable with D2950. Not allowed on primary teeth.
A 13-20, PXR
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$87.50
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D2953
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Not allowed on primary teeth.
A 13-20
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$43.75
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D2954*
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Not payable with codes D2952 or D3950 on the same TID by the same provider. Not allowed on primary teeth.
A 13-20, N, CCP, PXR
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$75.00
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D2955
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Not allowed on primary teeth.
A 4-20, CCP, PXR
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$75.00
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D2957
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Not allowed on primary teeth.
A 13-20, PXR, CCP
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$37.50
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D2960
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A 13-20, N, PPXR, CCP
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$112.50
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D2961
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A 13-20, N, PPXR, CCP
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$181.25
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D2962
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A 13-20, N, PPXR, CCP
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$212.50
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D2980
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A 13-20, PXR (permanent teeth only)
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$50.00
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D2999
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A 1-20, N, CCP, PXR
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Manually priced
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