GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 3 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D1516 Space maintainer – fixed – bilateral, maxillary $0 D1517 Space maintainer – fixed – bilateral, mandibular $0 D1520 Space maintainer – removable, unilateral – per quadrant $0 D1526 Space maintainer – removable – bilateral, maxillary $0 D1527 Space maintainer – removable – bilateral, mandibular $0 D1551 Re-cement or re-bond bilateral space maintainer – maxillary $5 D1552 Re-cement or re-bond bilateral space maintainer – mandibular $5 D1553 Re-cement or re-bond unilateral space maintainer – per quadrant $5 D1556 Removal of fixed unilateral space maintainer – per quadrant $5 D1557 Removal of fixed bilateral space maintainer – maxillary $5 D1558 Removal of fixed bilateral space maintainer – mandibular $5 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 $0 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 $20 D2391 Resin-based composite – one surface, posterior $25 D2392 Resin-based composite – two surfaces, posterior $30 D2393 Resin-based composite – three surfaces, posterior $35 D2394 Resin-based composite – four or more surfaces, posterior $40 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 crown/bridge unit in addition to regular co-payments for porcelain on molars. • Cases involving seven (7) or more crowns and/or fixed bridge units in the same treatment plan require an additional $125 co-payment per unit in addition to co-payment for each crown/bridge unit. D2510 Inlay – metallic – one surface $100 D2520 Inlay – metallic – two surfaces $100 D2530 Inlay – metallic – three or more surfaces $100 D2542 Onlay – metallic – two surfaces $100 D2543 Onlay – metallic – three surfaces $100 D2544 Onlay – metallic – four or more surfaces $100 D2610 Inlay – porcelain/ceramic – one surface $100 D2620 Inlay – porcelain/ceramic – two surfaces $100 D2630 Inlay – porcelain/ceramic – three or more surfaces $100 D2642 Onlay – porcelain/ceramic – two surfaces $100 D2643 Onlay – porcelain/ceramic – three surfaces $100 D2644 Onlay – porcelain/ceramic – four or more surfaces $100 D2650 Inlay – resin-based composite – one surface $100