Page 15 of 24 MET245_SOB_CA (01/26) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D6611 Retainer onlay – cast high noble metal, three or more surfaces $245 D6612 Retainer onlay – cast predominantly base metal, two surfaces $245 D6613 Retainer onlay – cast predominantly base metal, three or more surfaces $245 D6614 Retainer onlay – cast noble metal, two surfaces $245 D6615 Retainer onlay – cast noble metal, three or more surfaces $245 D6624 Retainer inlay – titanium $245 D6634 Retainer onlay – titanium $245 D6710 Retainer crown – indirect resin based composite $245 D6720 Retainer crown – resin with high noble metal $245 D6721 Retainer crown – resin with predominantly base metal $245 D6722 Retainer crown – resin with noble metal $245 D6740 Retainer crown – porcelain/ceramic $245 D6750 Retainer crown – porcelain fused to high noble metal $245 D6751 Retainer crown – porcelain fused to predominantly base metal $245 D6752 Retainer crown – porcelain fused to noble metal $245 D6753 Retainer crown – porcelain fused to titanium and titanium alloys $245 D6780 Retainer crown – ¾ cast high noble metal $245 D6781 Retainer crown – ¾ cast predominantly base metal $245 D6782 Retainer crown – ¾ cast noble metal $245 D6783 Retainer crown – ¾ porcelain/ceramic $245 D6784 Retainer crown – ¾ titanium and titanium alloys $245 D6790 Retainer crown – full cast high noble metal $245 D6791 Retainer crown – full cast predominantly base metal $245 D6792 Retainer crown – full cast noble metal $245 D6793 Interim pontic. Further treatment or completion of diagnosis necessary prior to final impression. Not to be used as a temporary retainer crown for a routine prosthetic restoration. $70 D6794 Retainer crown – titanium and titanium alloys $245 D6930 Re-cement or re-bond fixed partial denture $0 D6940 Stress breaker $110 D6950 Precision attachment. A pair of components constitutes one precision attachment, that is separate from the prosthesis. $195 D6980 Fixed partial denture repair necessitated by restorative material failure $45 Oral Surgery • Includes routine post operative visits/treatment. • The removal of asymptomatic third molars is not a Covered Service unless pathology (disease) exists. D7111 Extraction, coronal remnants – primary tooth $5 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $5 D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated $30 D7220 Removal of impacted tooth – soft tissue $50 D7230 Removal of impacted tooth – partially bony $65 D7240 Removal of impacted tooth – completely bony $80 D7241 Removal of impacted tooth – completely bony, with unusual surgical complications $100 D7250 Removal of residual tooth roots (cutting procedure) $40