•Out-of-Network: $75 deductible; you pay 80% of the plan allowance for covered services as defined by the
plan, subject to plan maximums and any difference between our allowance and the billed amount.
Major Restorative Services
D2410 Gold Foil – one surface – Limit 1 every 24 months - An alternate benefit will be provided
D2420 Gold Foil – two surfaces – Limit 1 every 24 months - An alternate benefit will be provided
D2430 Gold Foil – three surfaces – Limit 1 every 24 months - An alternate benefit will be provided
D2510 Inlay - metallic - one surface - Limit 1 per tooth every 60 months - An alternate benefit will be provided
D2520 Inlay - metallic - two surfaces -Limit 1 per tooth every 60 months - An alternate benefit will be provided
D2530 Inlay - metallic - three surfaces - Limit 1 per tooth every 60 months - An alternate benefit will be provided
D2542 Onlay - metallic - two surfaces - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2543 Onlay - metallic - three surfaces - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2544 Onlay - metallic - four or more surfaces - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2642 Onlay-porcelain/ceramic - two surfaces - Limit 1 per tooth every 60 months
D2643 Onlay-porcelain/ceramic - three surfaces - Limit 1 per tooth every 60 months
D2644 Onlay porcelain/ceramic - four or more surfaces - Limit 1 per tooth every 60 months
D2650 Inlay - resin-based composite - one surface, lab proc - Limit 1 every 60 months - An alternate benefit will be provided
D2651 Inlay - resin-based composite - two surfaces, lab proc - Limit 1 every 60 months - An alternate benefit will be provided
D2652 Inlay - resin-based composite - three surfaces, lab proc - Limit 1 every 60 months - An alternate benefit will be provided
D2662 Onlay - resin-based composite - two surfaces, lab proc - Limit 1 every 60 months
D2663 Onlay - resin-based composite - three surfaces, lab proc - Limit 1 per tooth every 60 months
D2664 Onlay - resin-based composite - four or more surfaces, lab proc - Limit 1 per tooth every 60 months
D2710 Crown - resin-based composite, lab proc - Limit 1 every 60 months
D2712 Crown - 3/4 resin-based composite, lab proc - Limit 1 per tooth every 60 months
D2720 Crown - resin with high noble metal - Limit 1 per tooth every 60 months
D2721 Crown - resin with predominantly base metal - Limit 1 per tooth every 60 months
D2722 Crown - resin with noble metal - Limit 1 per tooth every 60 months
D2740 Crown - porcelain/ceramic - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2750 Crown - porcelain fused to high noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2751 Crown - porcelain fused to predominately base metal - Limit 1 per tooth every 60 months, including crowns, bridges,
prosthetics
D2752 Crown - porcelain fused to noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2753 Crown - porcelain fused to titanium and titanium alloys- Limit 1 per tooth every 60 months, including crowns, bridges,
prosthetics
D2780 Crown - 3/4 cast high noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2781 Crown - 3/4 cast predominately base metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2782 Crown - 3/4 cast noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2783 Crown - 3/4 porcelain/ceramic - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics. Denied if done
on an anterior tooth.
D2790 Crown - full cast high noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2791 Crown - full cast predominately base metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2792 Crown - full cast noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2794 Crown - titanium and titanium alloys - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2932 Crown prefabricated resin – Limit 1 per tooth every 60 months for patients up to age 15, including crowns, bridges,
prosthetics
D2933 Crown prefabricated stainless steel crown/resin window - Limit 1 per tooth every 60 months for patients up to age of 15 -
alternate benefit will be provided
Major Restorative Services - continued on next page
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