Page 15 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment 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 D7251 Coronectomy – intentional partial tooth removal, impacted teeth only: Intentional partial tooth removal is performed when a neurovascular complication is likely if the entire tooth is removed. $80 D7252 Partial extraction for immediate implant placement Sectioning the root of a tooth vertically, then extracting the palatal portion of the root. The buccal section of the root is retained in order to stablize the buccal plate prior to immediate implant placement. Also known as the Socket Shield Technique. $60 D7260 Oroantral fistula closure $270 D7261 Primary closure of a sinus perforation $275 D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $50 D7280 Exposure of an unerupted tooth $100 D7282 Mobilization of erupted or malpositioned tooth to aid eruption $90 D7283 Placement of an attachment on an unerupted tooth, after its exposure, to aid in its eruption. Report the surgical exposure separately using D7280. $90 D7285 Incisional biopsy of oral tissue – hard (bone, tooth) $150 D7286 Incisional biopsy of oral tissue – soft $60 D7287 Exfoliative cytological sample collection $50