Page 30 - Demo

Restorative %u2014 Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners, and acid etch procedures. %u2014 When there are more than six crowns in the same treatment plan, a covered person may be charged an additional $125 per crown, beyond the 6th unit. %u2014 Replacement of crowns, inlays, and onlays requires the existing restoration to be 5+ years old.Silver (Amalgam) Restorations %u2014 Primary/Permanent Teeth: D2140 Amalgam %u2014 one surface, primary or permanent $45D2150 Amalgam %u2014 two surfaces, primary or permanent $50D2160 Amalgam %u2014 three surfaces, primary or permanent $70D2161 Amalgam %u2014 four or more surfaces, primary or permanent $85Resin (White) Restoration %u2014 Anterior/Posterior Teeth:D2330 Resin-based composite %u2014 one surface, anterior $50D2331 Resin-based composite %u2014 two surfaces, anterior $55D2332 Resin-based composite %u2014 three surfaces, anterior $70D2335 Resin-based composite %u2014 four or more surfaces or involving incisal angle (anterior) $90D2390 Resin-based composite crown, anterior $120D2391 Resin-based composite %u2014 one surface, posterior $60D2392 Resin-based composite %u2014 two surfaces, posterior $90D2393 Resin-based composite %u2014 three surfaces, posterior $115D2394 Resin-based composite %u2014 four or more surfaces, posterior $130Inlay or Onlay MetallicD2510 Inlay %u2014 metallic %u2014 one surface $220D2520 Inlay %u2014 metallic %u2014 two surfaces $320D2530 Inlay %u2014 metallic %u2014 three or more surfaces $440D2542 Onlay %u2014 metallic %u2014 two surfaces $360D2543 Onlay %u2014 metallic %u2014 three surfaces $500D2544 Onlay %u2014 metallic %u2014 four or more surfaces $540Inlay or Onlay Porcelain/CeramicD2610 Inlay %u2014 porcelain/ceramic %u2014 one surface $400D2620 Inlay %u2014 porcelain/ceramic %u2014 two surfaces $450D2630 Inlay %u2014 porcelain/ceramic %u2014 three or more surfaces $480D2642 Onlay %u2014 porcelain/ceramic %u2014 two surfaces $500D2643 Onlay %u2014 porcelain/ceramic %u2014 three surfaces $520D2644 Onlay %u2014 porcelain/ceramic %u2014 four or more surfaces $535Inlay or Onlay Resin-Based CompositeD2650 Inlay %u2014 resin-based composite %u2014 one surface $360D2651 Inlay %u2014 resin-based composite %u2014 two surfaces $430D2652 Inlay %u2014 resin-based composite %u2014 three or more surfaces $450D2662 Onlay %u2014 resin-based composite %u2014 two surfaces $450D2663 Onlay %u2014 resin-based composite %u2014 three surfaces $465D2664 Onlay %u2014 resin-based composite %u2014 four or more surfaces $515CrownsLimitations may apply. Refer to your Benefit Plan Summary booklet.D2710 Crown %u2014 resin-based composite (indirect) $480D2712 Crown %u2014 %u00be resin-based composite (indirect) $510D2720 Crown %u2014 resin with high noble metal* $500D2721 Crown %u2014 resin with predominantly base metal $450D2722 Crown %u2014 resin with noble metal* $450D2740 Crown %u2014 porcelain/ceramic substrate $585D2750 Crown %u2014 porcelain fused to high noble metal* $525D2751 Crown %u2014 porcelain fused to predominantly base metal $470D2752 Crown %u2014 porcelain fused to noble metal* $510D2780 Crown %u2014 %u00be cast high noble metal* $540D2781 Crown %u2014 %u00be cast predominantly base metal $510D2782 Crown %u2014 %u00be cast noble metal* $525D2783 Crown %u2014 %u00be porcelain/ceramic $530D2790 Crown %u2014 full cast high noble metal* $535D2791 Crown %u2014 full cast predominantly base metal $465D2792 Crown %u2014 full cast noble metal* $515D2794 Crown %u2014 titanium $525D2910 Re-cement or re-bond inlay, onlay, veneer, or partial coverage restoration $35D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core $35D2920 Re-cement or re-bond crown $40D2921 Reattachment of tooth fragment, incisal edge, or cusp (anterior) $110D2929 Prefabricated porcelain/ceramic crown %u2014 primary tooth %u2014 anterior $135D2930 Prefabricated stainless steel crown %u2014 primary tooth $125D2931 Prefabricated stainless steel crown %u2014 permanent tooth $135(Continued next page)302