Page 12 of 24 MET245_SOB_CA (01/26) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D6106 Guided tissue regeneration – resorbable barrier, per implant. This procedure does not include flap entry and closure, or, when indicated, wound debridement, osseous contouring, bone replacement grafts, and placement of biologic materials to aid in osseous regeneration. This procedure is used for peri-implant defects and during implant placement. $215 D6107 Guided tissue regeneration – non-resorbable barrier, per implant. This procedure does not include flap entry and closure, or, when indicated, wound debridement, osseous contouring, bone replacement grafts, and placement of biologic materials to aid in osseous regeneration. This procedure is used for peri-implant defects and during implant placement. $255 Implant Supported Prosthetics • An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble or titanium metal. There is a $75 Co-Payment per molar, for the use of porcelain. • Cases involving seven (7) or more Crowns, implants and/or fixed Bridge units in the same treatment plan require an additional $125 Co-Payment per unit in addition to the specified Co-Payment for each Crown, implant or Bridge unit. D6055 Connecting bar – implant supported or abutment supported $345 D6056 Prefabricated abutment – includes modification and placement $245 D6057 Custom fabricated abutment – includes placement $335 D6058 Abutment supported porcelain/ceramic crown $685 D6059 Abutment supported porcelain fused to metal crown (high noble metal) $660 D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) $640 D6061 Abutment supported porcelain fused to metal crown (noble metal) $645 D6062 Abutment supported cast metal crown (high noble metal) $655 D6063 Abutment supported cast metal crown (predominantly base metal) $640 D6064 Abutment supported cast metal crown (noble metal) $720 D6065 Implant supported porcelain/ceramic crown $725 D6066 Implant supported crown - porcelain fused to high noble alloys. A single metal-ceramic crown restoration that is retained, supported and stabilized by an implant $700 D6067 Implant supported crown - high noble alloys. A single metal crown restoration that is retained, supported and stabilized by an implant $725 D6068 Abutment supported retainer for porcelain/ceramic FPD $680 D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) $680 D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) $595 D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) $635 D6072 Abutment supported retainer for cast metal FPD (high noble metal) $625 D6073 Abutment supported retainer for cast metal FPD (predominantly base metal ) $445 D6074 Abutment supported retainer for cast metal FPD (noble metal) $640 D6075 Implant supported retainer for ceramic FPD $720 D6076 Implant supported retainer for FPD - porcelain fused to high noble alloys. A metal- ceramic retainer for a fixed partial denture that gains retention, support and stability from an implant $700 D6077 Implant supported retainer for metal FPD - high noble alloys. A metal retainer for a fixed partial denture that gains retention, support and stability from an implant $510