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
Current through Register Vol. 56, No. 18, September 16, 2024
(a) Amalgam restorations (including polishing):
Maximum Fee | ||||||
HCPCS | Allowance | |||||
IND | Code | Mod | Procedure Description | S | $ | NS |
D2110 | Amalgam--One Surface, Primary | 32.00 | 30.00 | |||
D2120 | Amalgam--Two Surfaces, Primary | 38.00 | 35.50 | |||
D2130 | Amalgam--Three Surfaces, Primary | 44.00 | 41.00 | |||
D2131 | Amalgam--Four or More Surfaces, | 51.00 | 46.50 | |||
Primary | ||||||
D2140 | Amalgam--One Surface, Permanent | 32.00 | 30.00 | |||
D2150 | Amalgam--Two Surfaces, Permanent | 38.00 | 35.50 | |||
D2160 | Amalgam--Three Surfaces, Permanent | 44.00 | 41.00 | |||
D2161 | Amalgam--Four or More Surfaces, | 51.00 | 46.50 | |||
Permanent |
(b) Filled or Unfilled Resin Restorations:
D2330 | Resin-based composite--One | 35.50 | 33.00 |
Surface, anterior | |||
D2331 | Resin-based composite--Two | 42.50 | 39.00 |
Surfaces, anterior | |||
D2332 | Resin-based composite--Three | 49.50 | 45.00 |
Surfaces, anterior | |||
D2335 | Resin-based composite--Four or | 59.50 | 54.00 |
more Surfaces or involving incisal | |||
angle (anterior) | |||
D2336 | Resin-based composite crown, | 40.00 | 35.00 |
anterior--primary | |||
D2337 | Resin-based composite crown, | 40.00 | 35.00 |
anterior--permanent | |||
D2380 | Resin-based composite--One | 32.00 | 30.00 |
surface, posterior--primary | |||
D2381 | Resin-based--Two surfaces, | 38.00 | 35.00 |
posterior--primary | |||
D2382 | Resin-based composite--three or | 44.00 | 41.00 |
more surfaces, posterior--primary |
For permanent teeth only:
D2385 | Resin-based composite--One | 32.00 | 30.00 |
surface, posterior--permanent | |||
D2386 | Resin-based composite--two | 38.00 | 35.50 |
surfaces, posterior--permanent | |||
D2387 | Resin-based composite--three | 44.00 | 41.00 |
surfaces, posterior--permanent | |||
D2388 | Resin-based composite--four or | 44.00 | 41.00 |
more surfaces, posterior--permanent |
NOTE: Code to be used for three or more surfaces.
(c) Gold Foil Restorations:
D2410 | Gold Foil--One Surface | 9.00 | 8.00 |
D2420 | Gold Foil--Two Surfaces | 18.00 | 16.00 |
D2430 | Gold Foil--Three Surfaces | 27.00 | 24.00 |
NOTE: Code to be used for three or more surfaces.
(d) Inlay Restorations:
D2510 | Inlay--Metallic--One Surface | 31.00 | 27.00 |
D2520 | Inlay--Metallic--Two Surfaces | 56.00 | 49.00 |
D2530 | Inlay--Metallic--Three or more | 75.00 | 65.00 |
Surfaces |
NOTE: Code to be used for three or more surfaces.
D2542 | Onlay--Metallic--Two Surfaces | 79.00 | 69.00 |
D2543 | Onlay--Metallic--Three Surfaces | 98.00 | 85.00 |
(e) Crowns--single restoration only:
High | Predominantly | ||
Noble | Noble | Base | |
Classification | Alloy | Alloy | Alloy |
Weight % | Au., Pd. and/or | Au., Pd. and/or | Au., Pd. and/or |
Pt. >60% (with | Pt. >25% | Pt. </=25% | |
at least 40% Au) |
D2710 | Crown Resin (Laboratory) | 98.00 | 85.00 |
NOTE: Laboratory processed.
D2720 | Crown--Resin with High Noble Metal | 161.00 | 140.00 |
NOTE: Acrylic veneer.
D2721 | Crown--Resin with Predominantly | 161.00 | 140.00 |
Base Metal |
NOTE: Acrylic veneer.
D2722 | Crown--Resin with Noble Metal | 161.00 | 140.00 |
NOTE: Acrylic veneer.
D2750 | Crown--Porcelain Fused to High | 279.00 | 253.00 |
Noble Metal | |||
D2751 | Crown--Porcelain Fused to | 279.00 | 253.00 |
Predominantly Base Metal | |||
D2752 | Crown--Porcelain Fused to Noble | 279.00 | 253.00 |
Metal | |||
D2790 | Crown--Full Cast High Noble Metal | 161.00 | 140.00 |
D2791 | Crown--Full Cast Predominantly | 161.00 | 140.00 |
Base Metal | |||
D2792 | Crown--Full Cast Noble Metal | 161.00 | 140.00 |
(f) Other restorative services:
D2910 | Recement Inlay | 7.00 | 6.00 |
D2920 | Recement Crown | 7.00 | 6.00 |
D2930 | Prefabricated Stainless Steel | 76.00 | 70.00 |
Crown--Primary Tooth |
NOTE: Reimbursable only for deciduous teeth.
D2931 | Prefabricated Stainless Steel | 76.00 | 70.00 |
Crown--Permanent Tooth |
NOTE: Reimbursable only for permanent posterior teeth up to and including 17 years of age.
D2932 | Prefabricated Resin Crown | 40.00 | 35.00 |
NOTE: For example, Polycarbonate--Reimbursable only for primary and permanent anterior teeth up to and including 15 years of age.
D2933 | Prefabricated Stainless Steel | 135.50 | 124.00 |
Crown with Resin window | |||
D2940 | Sedative Filling | 10.00 | 9.00 |
D2950 | Core Buildup including any Pins | 49.00 | 45.00 |
NOTE 1: And/or post.
NOTE 2: Core of composite or amalgam.
D2951 | Pin Retention--Per Tooth, In | 6.00 | 5.00 |
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.
D2952 | Cast Post and Core In Addition to | 75.00 | 68.00 |
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.
D2954 | Prefabricated Post and Core In | 49.00 | 45.00 |
Addition to Crown |
NOTE 1: Preparatory to crown restoration only.
NOTE 2: Not in conjunction with Procedure Code D3950 and D3950 22.
D2970 | Temporary Crown (Fractured Tooth) | 29.00 | 25.00 |
NOTE: A preformed artificial crown which is fitted over a damaged tooth as an immediate protective device in tooth injury.
* | D2980 | Crown Repair, By Report | BR | BR |
* | D2999 | Unspecified Restorative Procedure, | BR | BR |
By Report |