Page 13 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D6088 Implant supported crown – titanium and titanium alloys $650 D6089 Accessing and retorquing loose implant screw – per screw $0 D6090 Repair implant supported prosthesis, by report $190 D6091 Replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment $170 D6092 Re-cement or re-bond implant/abutment supported crown $50 D6093 Re-cement or re-bond implant/abutment supported fixed partial denture $70 D6094 Abutment supported crown - titanium and titanium alloys. A single crown restoration that is retained, supported and stabilized by an abutment on an implant $650 D6096 Remove broken implant retaining screw $24 D6097 Abutment supported crown – porcelain fused to titanium and titanium alloys $700 D6098 Implant supported retainer – porcelain fused to predominantly base alloys $595 D6099 Implant supported retainer for FPD – porcelain fused to noble alloys $635 D6110 Implant/abutment supported removable denture for edentulous arch-maxillary $995 D6111 Implant/abutment supported removable denture for edentulous arch-mandibular $995 D6112 Implant/abutment supported removable denture for partially edentulous arch- maxillary $945 D6113 Implant/abutment supported removable denture for partially edentulous arch- mandibular $945 D6114 Implant/abutment supported fixed denture for edentulous arch-maxillary $2,380 D6115 Implant/abutment supported fixed denture for edentulous arch-mandibular $2,380 D6116 Implant/abutment supported fixed denture for partially edentulous arch-maxillary $1,410 D6117 Implant/abutment supported fixed denture for partially edentulous arch-mandibular $1,410 D6120 Implant supported retainer – porcelain fused to titanium and titanium alloys $520 D6121 Implant supported retainer for metal FPD – predominantly base alloys $445 D6122 Implant supported retainer for metal FPD – noble alloys $640 D6123 Implant supported retainer for metal FPD – titanium and titanium alloys $520 D6180 Implant maintenance procedures when a full arch fixed hybrid prosthesis is not removed, including cleansing of prosthesis and abutments. $55 D6191 Semi-precision abutment – placement $335 D6192 Semi-precision attachment – placement $252 D6193 Replacement of an implant screw $24 D6194 Abutment supported retainer crown for FPD – titanium and titanium alloys. A retainer for a fixed partial denture that gains retention, support and stability from an abutment on an implant $520 D6195 Abutment supported retainer – porcelain fused to titanium and titanium alloys $510 D6197 Replacement of restorative material used to close an access opening of a screw- retained implant supported prosthesis, per implant. $30 Crowns/Fixed Bridges - Per Unit • 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. D6205 Pontic – indirect resin based composite $245