Page 12 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment 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 D6080 Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prosthesis and abutments $55 D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure $17 D6082 Implant supported crown – porcelain fused to predominantly base alloys $640 D6083 Implant supported crown – porcelain fused to noble alloys $645 D6084 Implant supported crown – porcelain fused to titanium and titanium alloys $650 D6086 Implant supported crown – predominantly base alloys $640 D6087 Implant supported crown – noble alloys $720