My Benefits



	Definitions Emergency Dental Services Specialized Services Benefits, Limitations and Exclusions Renewal, Cancellation and Termination of Benefits Grace Period Reinstatement Description of Benefits and Copayments (Schedule A) Limitations and Exclusions (Schedule B)

SCHEDULE OF BENEFITS AND COPAYMENTS

D2000-D2999 III. Restorative - When referable services are provided by a Contract Specialty Care Dentist, 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)	$ 70
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 ^{2, 3}	$ 240
D2520	Inlay - metallic - two surfaces ^{2, 3}	$ 260
D2530	Inlay - metallic - three or more surfaces ^{2, 3}	$ 280
D2542	Onlay - metallic - two surfaces ^{2, 3}	$ 270
D2543	Onlay - metallic - three surfaces ^{2, 3}	$ 290
D2544	Onlay - metallic - four or more surfaces ^{2, 3}	$ 300
D2610	Inlay - porcelain/ceramic - one surface ^{3, 4}	$ 320
D2620	Inlay - porcelain/ceramic - two surfaces ^{3, 4}	$ 340
D2630	Inlay - porcelain/ceramic - three or more surfaces ^{3, 4}	$ 355
D2642	Onlay - porcelain/ceramic - two surfaces ^{3, 4}	$ 355
D2643	Onlay - porcelain/ceramic - three surfaces ^{3, 4}	$ 375
D2644	Onlay - porcelain/ceramic - four or more surfaces ^{3, 4}	$ 400
D2650	Inlay - resin-based composite - one surface (tooth colored) ^{3, 4}	$ 240
D2651	Inlay - resin-based composite - two surfaces (tooth colored) ^{3, 4}	$ 260
D2652	Inlay - resin-based composite - three or more surfaces (tooth colored) ^{3, 4}	$ 280
D2662	Onlay - resin-based composite - two surfaces (tooth colored) ^{3, 4}	$ 270
D2663	Onlay - resin-based composite - three surfaces (tooth colored) ^{3, 4}	$ 280
D2664	Onlay - resin-based composite - four or more surfaces (tooth colored) ^{3, 4}	$ 300
D2710	Crown - resin-based composite (indirect) ^{3, 4}	$ 125
D2712	Crown - ¾ resin-based composite (indirect) ^{3, 4}	$ 125
D2720	Crown - resin with high noble metal ^{3, 4}	$ 410
D2721	Crown - resin with predominantly base metal ^{3, 4}	$ 310
D2722	Crown - resin with noble metal ^{3, 4}	$ 310
D2740	Crown - porcelain/ceramic substrate ^{3, 4}	$ 410
D2750	Crown - porcelain fused to high noble metal ^{3, 4}	$ 410
D2751	Crown - porcelain fused to predominantly base metal ^{3, 4}	$ 310
D2752	Crown - porcelain fused to noble metal ³	$ 310
D2780	Crown - ¾ cast high noble metal ³	$ 410
D2781	Crown - ¾ cast predominantly base metal ³	$ 310
D2782	Crown - ¾ cast noble metal ³	$ 310
D2790	Crown - full cast high noble metal ³	$ 410
D2791	Crown - full cast predominantly base metal ³	$ 310
D2792	Crown - full cast noble metal ³	$ 310
D2794	Crown - titanium	$ 410
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	$ 65
D2940	Sedative filling	$ 20
D2950	Core buildup, including any pins	$ 50
D2951	Pin retention - per tooth, in addition to restoration ²	$ 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	$ 30
D2954	Prefabricated post and core in addition to crown - base metal post; includes canal preparation	$ 70
D2957	Each additional prefabricated post - same tooth - base metal post; includes canal preparation	$ 20
D2970	Temporary crown (fractured tooth) -palliative treatment only	$ 35
D2971	Additional procedures to construct new crown under existing partial denture framework	$ 62
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 Specialty Care Dentist's"filed fees." Specialized Services are only available upon referral by the assigned Contract Dentist.