D2950 Core Buildup, Including Any Pins when required YES YES NO NO $150.00 D2951 Pin Retention - Per in Addition to Restoration YES YES NO NO $19.00 D2952 Post & Core in Addition to Crown, Indirectly Fabricated NO NO Not Covered D2953 Each Additional Indirectly Fabricated Post - Same Tooth NO NO Not Covered D2954 Prefabricated Post & Core in Addition to YES YES NO NO Permanent tooth only $95.00 Covered Service Prior Authorization Additional Limits Max Proc. Description Age/ICF-IID required Allow Code under age 21 age 21 & under age age 21 & & all over when 21 & all over allowed ICF-IID when residents* under residents allowed 25.04 under 25.04 D2955 Post Removal NO NO Not Covered Each Additional Prefabricated Post-Same Tooth, Use YES YES NO NO Permanent tooth only $47.50 with D2954 Labial Veneer (resin laminate)-Chairside NO NO Not Covered D2961 Labial Veneer (resin laminate)-Laboratory NO NO Not Covered Labial Veneer (porcelain laminate)-Laboratory NO NO Not Covered Temporary Crown (Fractured Tooth) YES YES NO NO $40.00 D2971 Additional Procedures to Construct New under NO NO Not Covered Existing Partial Denture Framework Coping NO NO Not Covered D2980 Crown Repair Necessitated By Restorative Material YES Yes NO NO $34.00 Failure D2981 Inlay Repair Necessitated By Restorative Material NO NO Not Covered Failure D2982 Repair Necessitated By Restorative Material NO NO Not Covered Failure Veneer Repair Necessitated By Restorative Material NO NO Not Covered Failure D2990 Resin Infiltration of Incipient Smooth Surface Lesions NO NO Not Covered
D2950 Core Buildup, Including Any Pins when required YES YES NO NO $150.00 D2951 Pin Retention - Per in Addition to Restoration YES YES NO NO $19.00 D2952 Post & Core in Addition to Crown, Indirectly Fabricated NO NO Not Covered D2953 Each Additional Indirectly Fabricated Post - Same Tooth NO NO Not Covered D2954 Prefabricated Post & Core in Addition to YES YES NO NO Permanent tooth only $95.00 Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow under age 21 & all residents* age 21 & over when allowed under 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D2955 Post Removal NO NO Not Covered Each Additional Prefabricated Post-Same Tooth, Use with D2954 YES YES NO NO Permanent tooth only $47.50 Labial Veneer (resin laminate)-Chairside NO NO Not Covered D2961 Labial Veneer (resin laminate)-Laboratory NO NO Not Covered Labial Veneer (porcelain laminate)-Laboratory NO NO Not Covered Temporary Crown (Fractured Tooth) YES YES NO NO $40.00 D2971 Additional Procedures to Construct New under Existing Partial Denture Framework NO NO Not Covered Coping NO NO Not Covered D2980 Crown Repair Necessitated By Restorative Material Failure YES Yes NO NO $34.00 D2981 Inlay Repair Necessitated By Restorative Material Failure NO NO Not Covered D2982 Repair Necessitated By Restorative Material Failure NO NO Not Covered Veneer Repair Necessitated By Restorative Material Failure NO NO Not Covered D2990 Resin Infiltration of Incipient Smooth Surface Lesions NO NO Not Covered
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