New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 56 - MANUAL FOR DENTAL SERVICES
Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS)
Section 10:56-3.4 - D2000-D2999 RESTORATIVE

Universal Citation: NJ Admin Code 10:56-3.4

Current through Register Vol. 56, No. 18, September 16, 2024

(a) Amalgam restorations (including polishing):

Maximum Fee
HCPCSAllowance
INDCodeModProcedure DescriptionS$NS
D2110Amalgam--One Surface, Primary32.0030.00
D2120Amalgam--Two Surfaces, Primary38.0035.50
D2130Amalgam--Three Surfaces, Primary44.0041.00
D2131Amalgam--Four or More Surfaces,51.0046.50
Primary
D2140Amalgam--One Surface, Permanent32.0030.00
D2150Amalgam--Two Surfaces, Permanent38.0035.50
D2160Amalgam--Three Surfaces, Permanent44.0041.00
D2161Amalgam--Four or More Surfaces,51.0046.50
Permanent

(b) Filled or Unfilled Resin Restorations:

1. Proximal restorations in anterior teeth are normally considered to be single surface restorations. When access to a proximal cavity is gained by involvement of a second surface, reimbursement will be permitted for only one surface. A two or three surface proximal restoration will be reimbursed only when the facial and/or lingual margin(s) of the restoration extends beyond the proximal one-third of the facial and/or lingual surface(s).

2. Reimbursement will include acid etch where appropriate.

D2330Resin-based composite--One35.5033.00
Surface, anterior
D2331Resin-based composite--Two42.5039.00
Surfaces, anterior
D2332Resin-based composite--Three49.5045.00
Surfaces, anterior
D2335Resin-based composite--Four or59.5054.00
more Surfaces or involving incisal
angle (anterior)
D2336Resin-based composite crown,40.0035.00
anterior--primary
D2337Resin-based composite crown,40.0035.00
anterior--permanent
D2380Resin-based composite--One32.0030.00
surface, posterior--primary
D2381Resin-based--Two surfaces,38.0035.00
posterior--primary
D2382Resin-based composite--three or44.0041.00
more surfaces, posterior--primary

For permanent teeth only:

D2385Resin-based composite--One32.0030.00
surface, posterior--permanent
D2386Resin-based composite--two38.0035.50
surfaces, posterior--permanent
D2387Resin-based composite--three44.0041.00
surfaces, posterior--permanent
D2388Resin-based composite--four or44.0041.00
more surfaces, posterior--permanent

NOTE: Code to be used for three or more surfaces.

(c) Gold Foil Restorations:

1. Primarily for use in Dental Colleges.

D2410Gold Foil--One Surface9.008.00
D2420Gold Foil--Two Surfaces18.0016.00
D2430Gold Foil--Three Surfaces27.0024.00

NOTE: Code to be used for three or more surfaces.

(d) Inlay Restorations:

1. Primarily for use in dental colleges.

D2510Inlay--Metallic--One Surface31.0027.00
D2520Inlay--Metallic--Two Surfaces56.0049.00
D2530Inlay--Metallic--Three or more75.0065.00
Surfaces

NOTE: Code to be used for three or more surfaces.

D2542Onlay--Metallic--Two Surfaces79.0069.00
D2543Onlay--Metallic--Three Surfaces98.0085.00

(e) Crowns--single restoration only:

1. There is only one fee for each type of crown Use the type of alloy most appropriate for the patient's needs.

2. The Noble Metal Classification System has been adopted as a more precise method of reporting various alloys used in dentistry. The alloys are defined on the basis of the percentage of noble metal content.

HighPredominantly
NobleNobleBase
ClassificationAlloyAlloyAlloy
Weight %Au., Pd. and/orAu., Pd. and/orAu., Pd. and/or
Pt. >60% (withPt. >25%Pt. </=25%
at least 40% Au)

3. Codes to be used for crowns, single restoration only:

D2710Crown Resin (Laboratory)98.0085.00

NOTE: Laboratory processed.

D2720Crown--Resin with High Noble Metal161.00140.00

NOTE: Acrylic veneer.

D2721Crown--Resin with Predominantly161.00140.00
Base Metal

NOTE: Acrylic veneer.

D2722Crown--Resin with Noble Metal161.00140.00

NOTE: Acrylic veneer.

D2750Crown--Porcelain Fused to High279.00253.00
Noble Metal
D2751Crown--Porcelain Fused to279.00253.00
Predominantly Base Metal
D2752Crown--Porcelain Fused to Noble279.00253.00
Metal
D2790Crown--Full Cast High Noble Metal161.00140.00
D2791Crown--Full Cast Predominantly161.00140.00
Base Metal
D2792Crown--Full Cast Noble Metal161.00140.00

(f) Other restorative services:

D2910Recement Inlay7.006.00
D2920Recement Crown7.006.00
D2930Prefabricated Stainless Steel76.0070.00
Crown--Primary Tooth

NOTE: Reimbursable only for deciduous teeth.

D2931Prefabricated Stainless Steel76.0070.00
Crown--Permanent Tooth

NOTE: Reimbursable only for permanent posterior teeth up to and including 17 years of age.

D2932Prefabricated Resin Crown40.0035.00

NOTE: For example, Polycarbonate--Reimbursable only for primary and permanent anterior teeth up to and including 15 years of age.

D2933Prefabricated Stainless Steel135.50124.00
Crown with Resin window
D2940Sedative Filling10.009.00
D2950Core Buildup including any Pins49.0045.00

NOTE 1: And/or post.

NOTE 2: Core of composite or amalgam.

D2951Pin Retention--Per Tooth, In6.005.00
Addition to Restoration

NOTE 1: Per pin.

NOTE 2: Maximum reimbursable--three pins.

NOTE 3: Not in conjunction with Procedure Code D3950 and D3950 22.

D2952Cast Post and Core In Addition to75.0068.00
Crown

NOTE 1: Post and core fabricated (cast) and cemented as a separate unit from crown.

NOTE 2: Preparatory to crown restoration only.

NOTE 3: Not in conjunction with Procedure Code D3950 and D3950 22.

D2954Prefabricated Post and Core In49.0045.00
Addition to Crown

NOTE 1: Preparatory to crown restoration only.

NOTE 2: Not in conjunction with Procedure Code D3950 and D3950 22.

D2970Temporary Crown (Fractured Tooth)29.0025.00

NOTE: A preformed artificial crown which is fitted over a damaged tooth as an immediate protective device in tooth injury.

*D2980Crown Repair, By ReportBRBR
*D2999Unspecified Restorative Procedure,BRBR
By Report

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