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SCHEDULE OF BENEFITS (Continued) <br />0041 -13 -SOB <br />25C-41 <br />F <br />The use of noble or high noble for any procedure will include additional lab <br />Your and Your <br />fees. <br />Dependent's <br />Code <br />Service <br />Co -Payment <br />D2710 <br />Preventive Services <br />$0 <br />D2712 <br />Procedures Identified with an asterisk (�) are limited to twice a year, unless <br />$0 <br />D2740 <br />medically necessary. <br />$0 <br />D1110 <br />Prophylaxis — adult" <br />$0 <br />01120 <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 maintalner— fixed — unilateral <br />$0 <br />D1615 <br />Space maintainer — fixed — bilateral <br />$0 <br />D1520 <br />Space malntalner— removable —unilateral <br />$0 <br />D1525 <br />Space maintainer — removable — bilateral <br />$0 <br />D1850 <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 />0041 -13 -SOB <br />25C-41 <br />F <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 —a/a resin -based composite (Indirect) <br />$0 <br />D2740 <br />Crown — porcelaintceramic 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-'/ cast high noble metal <br />$0 <br />D2781 <br />Crown -3/ cast predominantly base metal <br />$0 <br />D2782 <br />Crown —'/a cast noble metdl <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 -13 -SOB <br />25C-41 <br />F <br />