Page 14 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D6210 Pontic – cast high noble metal $245 D6211 Pontic – cast predominantly base metal $245 D6212 Pontic – cast noble metal $245 D6214 Pontic – titanium and titanium alloys $245 D6240 Pontic – porcelain fused to high noble metal $245 D6241 Pontic – porcelain fused to predominantly base metal $245 D6242 Pontic – porcelain fused to noble metal $245 D6243 Pontic – porcelain fused to titanium and titanium alloys $245 D6245 Pontic – porcelain/ceramic $265 D6250 Pontic – resin with high noble metal $245 D6251 Pontic – resin with predominantly base metal $245 D6252 Pontic – resin with noble metal $245 D6253 Further treatment or completion of diagnosis necessary prior to final impression. Not to be used as a temporary pontic for a routine prosthetic restoration. $70 D6545 Retainer – cast metal for resin bonded fixed prosthesis $100 D6548 Retainer – porcelain/ceramic for resin bonded fixed prosthesis $100 D6549 Resin retainer – for resin bonded fixed prosthesis $75 D6600 Retainer inlay – porcelain/ceramic, two surfaces $245 D6601 Retainer inlay – porcelain/ceramic, three or more surfaces $245 D6602 Retainer inlay – cast high noble metal, two surfaces $245 D6603 Retainer inlay – cast high noble metal, three or more surfaces $245 D6604 Retainer inlay – cast predominantly base metal, two surfaces $245 D6605 Retainer inlay – cast predominantly base metal, three or more surfaces $245 D6606 Retainer inlay – cast noble metal, two surfaces $245 D6607 Retainer inlay – cast noble metal, three or more surfaces $245 D6608 Retainer onlay – porcelain/ceramic, two surfaces $245 D6609 Retainer onlay – porcelain/ceramic, three or more surfaces $245 D6610 Retainer onlay – cast high noble metal, two surfaces $245 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