GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 10 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D6602 Retainer inlay – cast high noble metal, two surfaces $100 D6603 Retainer inlay – cast high noble metal, three or more surfaces $100 D6604 Retainer inlay – cast predominantly base metal, two surfaces $100 D6605 Retainer inlay – cast predominantly base metal, three or more surfaces $100 D6606 Retainer inlay – cast noble metal, two surfaces $100 D6607 Retainer inlay – cast noble metal, three or more surfaces $100 D6608 Retainer onlay – porcelain/ceramic, two surfaces $100 D6609 Retainer onlay – porcelain/ceramic, three or more surfaces $100 D6610 Retainer onlay – cast high noble metal, two surfaces $100 D6611 Retainer onlay – cast high noble metal, three or more surfaces $100 D6612 Retainer onlay – cast predominantly base metal, two surfaces $100 D6613 Retainer onlay – cast predominantly base metal, three or more surfaces $100 D6614 Retainer onlay – cast noble metal, two surfaces $100 D6615 Retainer onlay – cast noble metal, three or more surfaces $100 D6710 Retainer crown – indirect resin based composite $100 D6720 Retainer crown – resin with high noble metal $100 D6721 Retainer crown – resin with predominantly base metal $100 D6722 Retainer crown – resin with noble metal $100 D6740 Retainer crown – porcelain/ceramic $100 D6750 Retainer crown – porcelain fused to high noble metal $100 D6751 Retainer crown – porcelain fused to predominantly base metal $100 D6752 Retainer crown – porcelain fused to noble metal $100 D6753 Retainer crown – porcelain fused to titanium and titanium alloys $100 D6780 Retainer crown – ¾ cast high noble metal $100 D6781 Retainer crown – ¾ cast predominantly base metal $100 D6782 Retainer crown – ¾ cast noble metal $100 D6783 Retainer crown – ¾ porcelain/ceramic $100 D6784 Retainer crown – ¾ titanium and titanium alloys $100 D6790 Retainer crown – full cast high noble metal $100 D6791 Retainer crown – full cast predominantly base metal $100 D6792 Retainer crown – full cast noble metal $100 D6794 Retainer crown – titanium and titanium alloys $100 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 benefit unless pathology (disease) exists. D7111 Extraction, coronal remnants – primary tooth $0 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $0 D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated $15 D7220 Removal of impacted tooth – soft tissue $20 D7230 Removal of impacted tooth – partially bony $40 D7240 Removal of impacted tooth – completely bony $75