Percentage Payable – 80% of Applicable Fee Guide – Annual Calendar Maximum Payment of $2,500

1. Crowns, including gold and porcelain veneer restorations, when other material is not suitable.
2. Onlays, when the major portion of the clinical crown is decayed, heavily filled, or the cusps are fractured and cannot be restored using basic restorative services.
3. Inlays, when 3 or more surfaces are involved and the tooth cannot be restored using basic restorative materials. If only 1 or 2 tooth surfaces are involved, the inlay will be considered for reimbursement as a restorative service under Basic Services and payment will be determined based on the cost of a comparable amalgam or composite restoration.