My Benefits



	Emergency Services Specialist Services Benefits, Limitations and Exclusions Cancellation and Termination 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

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	$ 26
D2150	Amalgam - two surfaces, primary or permanent	$ 36
D2160	Amalgam - three surfaces, primary or permanent	$ 44
D2161	Amalgam - four or more surfaces, primary or permanent	$ 52
D2330	Resin-based composite - one surface, anterior	$ 35
D2331	Resin-based composite - two surfaces, anterior	$ 45
D2332	Resin-based composite - three surfaces, anterior	$ 55
D2335	Resin-based composite - four or more surfaces or involving incisal angle (anterior)	$ 65
D2390	Resin-based composite crown, anterior	$ 65
D2391	Resin-based composite - one surface, posterior	$ 65
D2392	Resin-based composite - two surfaces, posterior	$ 75
D2393	Resin-based composite - three surfaces, posterior	$ 90
D2394	Resin-based composite - four or more surfaces, posterior	$100
D2510	Inlay - metallic - one surface ^{1, 2}	$240
D2520	Inlay - metallic - two surfaces ^{1, 2}	$260
D2530	Inlay - metallic - three or more surfaces ^{1, 2}	$280
D2542	Onlay - metallic - two surfaces ^{1, 2}	$245
D2543	Onlay - metallic - three surfaces ^{1, 2}	$265
D2544	Onlay - metallic - four or more surfaces ^{1, 2}	$285
D2610	Inlay - porcelain/ceramic - one surface ¹	$320
D2620	Inlay - porcelain/ceramic - two surfaces ¹	$340
D2630	Inlay - porcelain/ceramic - three or more surfaces ¹	$355
D2642	Onlay - porcelain/ceramic - two surfaces ¹	$355
D2643	Onlay - porcelain/ceramic - three surfaces ¹	$375
D2644	Onlay - porcelain/ceramic - four or more surfaces ¹	$400
D2650	Inlay - resin-based composite - one surface ¹	$210
D2651	Inlay - resin-based composite - two surfaces ¹	$250
D2652	Inlay - resin-based composite - three or more surfaces ¹	$280
D2662	Onlay - resin-based composite - two surfaces ¹	$290
D2663	Onlay - resin-based composite - three surfaces ¹	$305
D2664	Onlay - resin-based composite - four or more surfaces ¹	$335
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}	$395
D2721	Crown - resin with predominantly base metal ^{1, 3}	$295
D2722	Crown - resin with noble metal ^{1, 3}	$295
D2740	Crown - porcelain/ceramic substrate ^{1, 3}	$395
D2750	Crown - porcelain fused to high noble metal ^{1, 3}	$395
D2751	Crown - porcelain fused to predominantly base metal ^{1, 3}	$295
D2752	Crown - porcelain fused to noble metal ^{1, 3}	$295
D2780	Crown - ¾ cast high noble metal ¹	$395
D2781	Crown - ¾ cast predominantly base metal ¹	$295
D2782	Crown - ¾ cast noble metal ¹	$295
D2790	Crown - full cast high noble metal ¹	$395
D2791	Crown - full cast predominantly base metal ¹	$295
D2792	Crown - full cast noble metal ¹	$295
D2794	Crown - titanium ¹	$395
D2910	Recement inlay, onlay or partial coverage restoration	$ 15
D2915	Recement cast or prefabricated post and core	$ 15
D2920	Recement crown	$ 15
D2930	Prefabricated stainless steel crown - primary tooth	$ 65
D2931	Prefabricated stainless steel crown - permanent tooth	$ 65
D2932	Prefabricated resin crown - anterior primary tooth	$ 65
D2933	Prefabricated stainless steel crown with resin window - anterior primary tooth	$ 75
D2940	Sedative filling	$ 15
D2950	Core buildup, including any pins	$ 50
D2951	Pin retention - per tooth, in addition to restoration	$ 15
D2952	Post and core in addition to crown, indirectly fabricated – includes canal preparation ²	$ 90
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 preparation	$ 85
D2957	Each additional prefabricated post - same tooth - base metal post; includes canal preparation	$ 45
D2970	Temporary crown (fractured tooth) - palliative treatment only	$ 20
D2971	Additional procedures to construct new crown under existing partial denture framework	$ 59
D2980	Crown repair, by report	$ 45