GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 4 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D2651 Inlay – resin-based composite – two surfaces $100 D2652 Inlay – resin-based composite – three or more surfaces $100 D2662 Onlay – resin-based composite – two surfaces $100 D2663 Onlay – resin-based composite – three surfaces $100 D2664 Onlay – resin-based composite – four or more surfaces $100 D2710 Crown – resin-based composite (indirect) $100 D2712 Crown – ¾ resin-based composite (indirect) $100 D2720 Crown – resin with high noble metal $100 D2721 Crown – resin with predominantly base metal $100 D2722 Crown – resin with noble metal $100 D2740 Crown – porcelain/ceramic $225 D2750 Crown – porcelain fused to high noble metal $100 D2751 Crown – porcelain fused to predominantly base metal $100 D2752 Crown – porcelain fused to noble metal $100 D2753 Crown – porcelain fused to titanium and titanium alloys $100 D2780 Crown – ¾ cast high noble metal $100 D2781 Crown – ¾ cast predominantly base metal $100 D2782 Crown – ¾ cast noble metal $100 D2783 Crown – ¾ porcelain/ceramic $100 D2790 Crown – full cast high noble metal $100 D2791 Crown – full cast predominantly base metal $100 D2792 Crown – full cast noble metal $100 D2794 Crown – titanium and titanium alloys $100 D2799 Interim crown – further treatment or completion of diagnosis necessary prior to final impression. Further treatment or completion of diagnosis necessary prior to final impression. Not to be used as a temporary crown for a routine prosthetic restoration. $0 D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration $0 D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core $0 D2920 Re-cement or re-bond crown $0 D2928 Prefabricated porcelain/ceramic crown – permanent tooth $113 D2930 Prefabricated stainless steel crown – primary tooth $0 D2931 Prefabricated stainless steel crown – permanent tooth $0 D2932 Prefabricated resin crown $0 D2933 Prefabricated stainless steel crown with resin window $0 D2940 Protective restoration $0 D2941 Interim therapeutic restoration - primary dentition $0 D2950 Core buildup, including any pins when required $15 D2951 Pin retention – per tooth, in addition to restoration $10 D2952 Post and core in addition to crown, indirectly fabricated $40 D2953 Each additional indirectly fabricated post – same tooth $40 D2954 Prefabricated post and core in addition to crown $40 D2955 Post removal $10 D2957 Each additional prefabricated post – same tooth $25 D2960 Labial veneer (resin laminate) – chairside $250 D2961 Labial veneer (resin laminate) – laboratory $300 D2962 Labial veneer (porcelain laminate) – laboratory $350