My Benefits



	Emergency Services Specialist Services Benefits, Limitations and Exclusions Renewal, Cancellation and Termination of Benefits Extension of Benefits Entire Contract Schedule A Description of Benefits and Copayments Schedule B Limitations and Exclusions

SCHEDULE A
DESCRIPTION OF BENEFITS AND COPAYMENTS

D2000-D2999 III. Restorative - When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." *

Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures.

Code	Description	Enrollee Pays
D2140	Amalgam - one surface, primary or permanent	$ 27
D2150	Amalgam - two surfaces, primary or permanent	$ 32
D2160	Amalgam - three surfaces, primary or permanent	$ 37
D2161	Amalgam - four or more surfaces, primary or permanent	$ 50
D2330	Resin-based composite - one surface, anterior (tooth colored)	$ 55
D2331	Resin-based composite - two surfaces, anterior (tooth colored)	$ 65
D2332	Resin-based composite - three surfaces, anterior (tooth colored)	$ 75
D2335	Resin-based composite - four or more surfaces or involving incisal angle (anterior) (tooth colored)	$ 85
D2390	Resin-based composite crown, anterior	$ 85
D2391	Resin-based composite - one surface, posterior (tooth colored)	$ 75
D2392	Resin-based composite - two surfaces, posterior (tooth colored)	$ 80
D2393	Resin-based composite - three surfaces, posterior (tooth colored)	$ 85
D2394	Resin-based composite - four or more surfaces, posterior (tooth colored)	$ 95
D2510	Inlay - metallic - one surface ^{1, 2}	$260
D2520	Inlay - metallic - two surfaces ^{1, 3}	$270
D2530	Inlay - metallic - three or more surfaces ^{1, 3}	$280
D2542	Onlay - metallic - two surfaces ^{1, 3}	$270
D2543	Onlay - metallic - three surfaces ^{1, 3}	$290
D2544	Onlay - metallic - four or more surfaces ^{1, 3}	$300
D2610	Inlay - porcelain/ceramic - one surface ^{1, 3}	$360
D2620	Inlay - porcelain/ceramic - two surfaces ^{1, 3}	$370
D2630	Inlay - porcelain/ceramic - three or more surfaces ^{1, 3}	$380
D2642	Onlay - porcelain/ceramic - two surfaces ^{1, 3}	$370
D2643	Onlay - porcelain/ceramic - three surfaces ^{1, 3}	$390
D2644	Onlay - porcelain/ceramic - four or more surfaces ^{1, 3}	$400
D2650	Inlay - resin-based composite - one surface (tooth colored) ^{1, 3}	$260
D2651	Inlay - resin-based composite - two surfaces (tooth colored) ^{1, 3}	$270
D2652	Inlay - resin-based composite - three or more surfaces (tooth colored) ^{1, 3}	$280
D2662	Onlay - resin-based composite - two surfaces (tooth colored) ^{1, 3}	$270
D2663	Onlay - resin-based composite - three surfaces (tooth colored) ^{1, 3}	$280
D2664	Onlay - resin-based composite - four or more surfaces (tooth colored) ^{1, 3}	$300
D2710	Crown - resin - based composite (indirect) ^{1, 3}	$125
D2712	Crown - ¾ resin-based composite (indirect) ^{1, 3}	$125
D2720	Crown - resin with high noble metal ^{1, 3}	$425
D2721	Crown - resin with predominantly base metal ^{1, 3}	$325
D2722	Crown - resin with noble metal ^{1, 3}	$325
D2740	Crown - porcelain/ceramic substrate ^{1, 3}	$425
D2750	Crown - porcelain fused to high noble metal ^{1, 3}	$425
D2751	Crown - porcelain fused to predominantly base metal ^{1, 3}	$325
D2752	Crown - porcelain fused to noble metal ^{1, 3}	$325
D2780	Crown - ¾ cast high noble metal ¹	$425
D2781	Crown - ¾ cast predominantly base metal ¹	$325
D2782	Crown - ¾ cast noble metal ¹	$325
D2790	Crown - full cast high noble metal ¹	$425
D2791	Crown - full cast predominantly base metal ¹	$325
D2792	Crown - full cast noble metal ¹	$325
D2794	Crown-titanium ¹	$425
D2910	Recement inlay, onlay or partial coverage restoration	$ 20
D2915	Recement cast or prefabricated post and core	$20
D2920	Recement crown	$ 20
D2931	Prefabricated stainless steel crown - permanent tooth	$ 80
D2940	Sedative filling	$ 20
D2950	Core buildup, including any pins	$ 50
D2951	Pin retention - per tooth, in addition to restoration	$ 25
D2952	Post and core in addition to crown, indirectly fabricated – includes canal preparation ²	$ 95
D2953	Each additional indirectly fabricated post – same tooth – includes canal preparation ²	$ 50
D2954	Prefabricated post and core in addition to crown - base metal post; includes canal reparation	$ 70
D2957	Each additional prefabricated post - same tooth - base metal post; includes canal preparation	$ 45
D2970	Temporary crown (fractured tooth) -palliative treatment only	$ 35
D2971	Additional procedures to construct new crown under existing partial denture framework	$ 65
D2980	Crown repair, by report	$ 50

* If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Copayment. Listed, referable procedures that are not available in the contract facility or that require a Dentist to provide specialized services may be provided by a contracted oral surgeon, endodontist, or periodontist at 75 percent of the Contract Specialist's "filed fees." Specialist services are only available in areas where there is a DeltaCare USA Contract Specialist, and upon referral by the assigned Contract Dentist.