Dental Codes Schedule of Benefits Procedure Code
Description
D2392
Resin- based composite -two surfaces, posterior
D2394
Resin- based composite - four or more surfaces, posterior
D2393 D2543 D2544 D2643 D2644 D2740 D2750 D2751 D2752 D2780 D2783 D2790 D2930 D2931 D2932 D2933 D2940 D2950 D2951 D2954 D3110 D3310 D3320 D3330 D3346 D3347 D3348 D3410 D3421 D3425 D3430
Resin- based composite -three surfaces, posterior Onlay - metallic - three surfaces
Onlay - metallic - four or more surfaces
Onlay - porcelain/ceramic - three surfaces
Onlay - porcelain/ceramic - four or more surfaces Crown - porcelain/ceramic substrate
Crown - porcelain fused to high noble metal
Crown - porcelain fused to predominately base metal Crown - porcelain fused to noble metal Crown - 3/4 cast high noble metal Crown - 3/4 porcelain/ceramic
Crown - full cast high noble metal
Prefabricatated stainless steel crown - primary tooth
Prefabricatated stainless steel crown - permanent tooth Prefabricated resin crown
Prefabricated stainless steel crown with resin window Sedative filling
Core buildup, including any pins
Pin retention - per tooth, in addition to restoration
Maximum Benefits $148 $184 $220 $375 $440 $375 $440 $453 $423 $410 $414 $406 $410 $410 $148 $222 $221 $222 $70 $95 $38
Prefabricated post and core in addition to crown
$127
Root canal - Anterior (excluding final restoration)
$489
Root canal - Molar (excluding final restoration)
$695
Pulp cap - direct (excluding final restoration)
Root canal - Bicuspid (excluding final restoration) Retreatment of previous root canal therapy - anterior
Retreatment of previous root canal therapy - bicuspid Retreatment of previous root canal therapy - molar Apicoectomy/periradicular surgery - anterior
Apicoectomy/periradicular surgery - bicuspid (first root) Apicoectomy/periradicular surgery - molar(first root) Retrograde filling - per root
$43
$566 $592 $674 $814 $435 $480 $520 $116
D4210
Gingivectomy or gingivoplasty - four or more contiguous
$358
D4211
Gingivectomy or gingivoplasty - one to three contiguous
$113
D4249
teeth or bounded teeth spaces per quadrant teeth or bounded teeth spaces per quadrant Clinical crown lengthening - hard tissue
$455
D4260
Osseous surgery (including flap entry and closure) four or
$672
D4261
Osseous surgery (including flap entry and closure) one to
$511
Free soft tissue graft procedure (including donor site surgery)
$632
D4271
more contigous teeth or bounded teeth spaces per quadrant three contigous teeth or bounded teeth spaces per quadrant
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