Page 4 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D1551 Re-cement or re-bond bilateral space maintainer – maxillary $15 D1552 Re-cement or re-bond bilateral space maintainer – mandibular $15 D1553 Re-cement or re-bond unilateral space maintainer – per quadrant $15 D1556 Removal of fixed unilateral space maintainer – per quadrant $15 D1557 Removal of fixed bilateral space maintainer – maxillary $15 D1558 Removal of fixed bilateral space maintainer – mandibular $15 D1575 Distal shoe space maintainer – fixed, unilateral – per quadrant Fabrication and delivery of fixed appliance extending subgingivally and distally to guide the eruption of the first permanent molar. Does not include ongoing follow-up or adjustments, or replacement appliance, once the tooth had erupted $25 Restorative Treatment D2140 Amalgam – one surface, primary or permanent $0 D2150 Amalgam – two surfaces, primary or permanent $0 D2160 Amalgam – three surfaces, primary or permanent $0 D2161 Amalgam – four or more surfaces, primary or permanent $0 D2330 Resin-based composite – one surface, anterior $0 D2331 Resin-based composite – two surfaces, anterior $0 D2332 Resin-based composite – three surfaces, anterior $0 D2335 Resin-based composite – four or more surfaces (anterior) $0 D2390 Resin-based composite crown, anterior $30 D2391 Resin-based composite – one surface, posterior $30 D2392 Resin-based composite – two surfaces, posterior $45 D2393 Resin-based composite – three surfaces, posterior $65 D2394 Resin-based composite – four or more surfaces, posterior $65 Crowns • An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble or titanium metal. There is a $75 Co-Payment per molar, for the use of porcelain. • Cases involving seven (7) or more Crowns, implants and/or fixed Bridge units in the same treatment plan require an additional $125 Co-Payment per unit in addition to the specified Co-Payment for each Crown, implant or Bridge unit. D2510 Inlay – metallic – one surface $225 D2520 Inlay – metallic – two surfaces $235 D2530 Inlay – metallic – three or more surfaces $245 D2542 Onlay – metallic – two surfaces $245 D2543 Onlay – metallic – three surfaces $260 D2544 Onlay – metallic – four or more surfaces $270 D2610 Inlay – porcelain/ceramic – one surface $245 D2620 Inlay – porcelain/ceramic – two surfaces $245 D2630 Inlay – porcelain/ceramic – three or more surfaces $245 D2642 Onlay – porcelain/ceramic – two surfaces $245 D2643 Onlay – porcelain/ceramic – three surfaces $245 D2644 Onlay – porcelain/ceramic – four or more surfaces $245 D2650 Inlay – resin-based composite – one surface $245 D2651 Inlay – resin-based composite – two surfaces $245 D2652 Inlay – resin-based composite – three or more surfaces $245 D2662 Onlay – resin-based composite – two surfaces $245