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SCHEDULE OF BENEFITS (Continued) <br />0041-D•SOB <br />25C-41 <br />2 <br />Your and Your <br />Dependent's <br />Code <br />Service <br />Co -Payment <br />Preventive Services <br />Procedures identified with an asterisk (`) are limited to twice a year, unless <br />medically necessary. <br />D1110 <br />Prophylaxis — adult' <br />$0 <br />D1120 <br />Prophylaxis — child' <br />$0 <br />D1206 <br />Topical application of fluoride varnish' <br />$0 <br />D1208 <br />Topical application of fluoride — excluding varnish <br />$0 <br />D1330 <br />Oral hygiene instructions <br />$0 <br />D1351 <br />Sealant — per tooth <br />$0 <br />D1510 <br />Space maintainer — fixed — unilateral <br />$0 <br />D1515 <br />Space maintainer — fixed — bilateral <br />$0 <br />D1520 <br />Space maintainer— removable — unilateral <br />$0 <br />D1525 <br />Space maintainer — removable — bilateral <br />$0 <br />D1550 <br />Re -cement or re -bond space maintainer <br />$0 <br />D1555 <br />Removal of fixed space maintainer <br />$0 <br />Restorative Treatment <br />D2140 <br />Amalgam — one surface, primary or permanent <br />$0 <br />D2150 <br />Amalgam — two surfaces, primary or permanent <br />$0 <br />D2160 <br />Amalgam — three surfaces, primary or permanent <br />$0 <br />D2161 <br />Amalgam —four or more surfaces, primary or permanent <br />$0 <br />D2330 <br />Resin -based composite — one surface, anterior <br />$0 <br />D2331 <br />Resin -based composite — two surfaces, anterior <br />$0 <br />D2332 <br />Resin -based composite — three surfaces, anterior <br />$0 <br />D2335 <br />Resin -based composite — four or more surfaces or involving incisal angle <br />$0 <br />(anterior) <br />D2390 <br />Resin -based composite crown, anterior <br />$0 <br />Crowns <br />The use of noble or high noble for any procedure will include additional lab <br />fees. <br />$75 fee per crown unit above co -pay for porcelain on molars. <br />D2710 <br />Crown — resin -based composite (indirect) <br />$0 <br />D2712 <br />Crown —3/a resin -based composite (indirect) <br />$0 <br />D2740 <br />Crown — porcelain/ceramic substrate <br />$0 <br />D2750 <br />Crown — porcelain fused to high noble metal <br />$0 <br />D2751 <br />Crown — porcelain fused to predominantly base metal <br />$0 <br />D2752 <br />Crown — porcelain fused to noble metal <br />$0 <br />D2780 <br />Crown - 3/4 cast high noble metal <br />$0 <br />D2781 <br />Crown —3/ cast predominantly base metal <br />$0 <br />D2782 <br />Crown — 3/a cast noble metal <br />$0 <br />D2790 <br />Crown —full cast high noble metal <br />$0 <br />D2791 <br />Crown —full cast predominantly base metal <br />$0 <br />D2792 <br />Crown —full cast noble metal <br />$0 <br />0041-D•SOB <br />25C-41 <br />2 <br />