Procedure Description Copayment Notes D1520 Space maintainer - removable, unilateral – per quadrant 20 D1526 Space maintainer - removable, bilateral, maxillary 30 D1527 Space maintainer - removable, bilateral, mandibular 30 D1551 Re-cement or re-bond bilateral space maintainer – maxillary 10 D1552 Re-cement or re-bond bilateral space maintainer – mandibular 10 D1553 Re-cement or re-bond unilateral space maintainer – per quadrant 10 D1556 Removal of fixed unilateral space maintainer – per quadrant 10 D1557 Removal of fixed bilateral space maintainer – maxillary 10 D1558 Removal of fixed bilateral space maintainer – mandibular 10 D2000 – D2335 III. Minor Restorative D2140 Amalgam - one surface, primary or permanent 10 D2150 Amalgam - two surfaces, primary or permanent 10 D2160 Amalgam - three surfaces, primary or permanent 10 D2161 Amalgam - four or more surfaces, primary or permanent 10 D2330 Resin-based composite - one surface, anterior 15 D2331 Resin-based composite - two surfaces, anterior 15 D2332 Resin-based composite - three surfaces, anterior 15 D2335 Resin-based composite - four or more surfaces (anterior) 15 D2390 Resin-based composite crown anterior 50 D2391 Resin-based composite - one surface, posterior 50 D2392 Resin-based composite - two surfaces, posterior 50 D2393 Resin-based composite - three surface, posterior 50 D2394 Resin-based composite - four or more surfaces, posterior 50 D2510 – D2999 IV. Major Restorative D2510 Inlay - metallic - one surface 115 D2520 Inlay - metallic - two surfaces 115 D2530 Inlay - metallic - three surfaces 115 D2543 Onlay - metallic - three surfaces 125 D2544 Onlay metallic - four or more surfaces 125 D2642 Onlay - porcelain/ceramic - two surfaces 125 D2643 Onlay - porcelain/ceramic - three surfaces 125 D2644 Onlay - porcelain/ceramic - four or more surfaces 125 D2740 Crown - porcelain/ceramic 155 D2750 Crown - porcelain fused to high noble metal 175 D2751 Crown - porcelain fused to predominantly base metal 125 D2752 Crown - porcelain fused to noble metal 150 D2753 Crown - porcelain fused to titanium or titanium alloy 175 D2790 Crown - full cast high noble metal 175 D2791 Crown - full cast predominantly base metal 125 D2792 Crown - full cast noble metal 150 D2794 Crown – titanium/titanium alloy 175 D2799 Interim crown 125 Recement or rebond inlay, onlay, veneer or partial coverage D2910 restorations 0 2024-01-03100-BB 8 DCL 20240101