Percentage Payable – 80% of Applicable Fee Guide – Annual Calendar Maximum Payment of $2,500
- Crowns, including gold and porcelain veneer restorations, when other material is not suitable.
- 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.
- 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.