My Benefits



	Benefits summary Emergency Services Specialist services Benefits, limitations and exclusions Description of benefits and copayments (Schedule A) Limitations of benefits (Schedule B) Benefits that are not covered (Schedule B)

SCHEDULE A
DESCRIPTION OF BENEFITS AND COPAYMENTS

D6200-D6999 IX. Prosthodontics, fixed (each retainer and each pontic constitutes a unit in a fixed partial denture [bridge])

Code	Description	Enrollee Pays
D6210	Pontic - cast high noble metal ⁷	$425
D6211	Pontic - cast predominantly base metal ⁷	$325
D6212	Pontic - cast noble metal ⁷	$325
D6240	Pontic - porcelain fused to high noble metal ^{3, 7}	$425
D6241	Pontic - porcelain fused to predominantly base metal ^{3, 7}	$325
D6242	Pontic - porcelain fused to noble metal ^{3, 7}	$325
D6245	Pontic - porcelain/ceramic ^{3, 7}	$425
D6250	Pontic - resin with high noble metal ^{3, 7}	$425
D6251	Pontic - resin with predominantly base metal ^{3, 7}	$325
D6252	Pontic - resin with noble metal ^{3, 7}	$325
D6600	Inlay - porcelain/ceramic, two surfaces ⁷	$425
D6601	Inlay - porcelain/ceramic, three or more surfaces ⁷	$425
D6602	Inlay - cast high noble metal, two surfaces ^{2, 7}	$270
D6603	Inlay - cast high noble metal, three or more surfaces ^{2, 7}	$280
D6604	Inlay - cast predominantly base metal, two surfaces ⁷	$270
D6605	Inlay - cast predominantly base metal, three or more surfaces ⁷	$280
D6606	Inlay - cast noble metal, two surfaces ⁷	$270
D6607	Inlay - cast noble metal, three or more surfaces ⁷	$280
D6608	Onlay - porcelain/ceramic, two surfaces ⁷	$425
D6609	Onlay - porcelain/ceramic, three or more surfaces ⁷	$425
D6610	Onlay - cast high noble metal, two surfaces ^{2, 7}	$270
D6611	Onlay - cast high noble metal, three or more surfaces ^{2, 7}	$290
D6612	Onlay - cast predominantly base metal, two surfaces ⁷	$270
D6613	Onlay - cast predominantly base metal, three or more surfaces ⁷	$290
D6614	Onlay - cast noble metal, two surfaces ⁷	$270
D6615	Onlay - cast noble metal, three or more surfaces ⁷	$290
D6720	Crown - resin with high noble metal ^{3, 7}	$425
D6721	Crown - resin with predominantly base metal ^{3, 7}	$325
D6722	Crown - resin with noble metal ^{3, 7}	$325
D6740	Crown - porcelain/ceramic ^{3, 7}	$425
D6750	Crown - porcelain fused to high noble metal ^{3, 7}	$425
D6751	Crown - porcelain fused to predominantly base metal ^{3, 7}	$325
D6752	Crown - porcelain fused to noble metal ^{3, 7}	$325
D6780	Crown - ¾ cast high noble metal ⁷	$425
D6781	Crown - ¾ cast predominantly base metal ⁷	$325
D6782	Crown - ¾ cast noble metal ⁷	$325
D6790	Crown - full cast high noble metal ⁷	$425
D6791	Crown - full cast predominantly base metal ⁷	$325
D6792	Crown - full cast noble metal ⁷	$325
D6930	Recement fixed partial denture	$ 30
D6940	Stress breaker ^{2, 7}	$ 50
D6970	Post and core in addition to fixed partial denture retainer, indirectly fabricated – includes canal preparation ²	$ 95
D6972	Prefabricated post and core in addition to fixed partial denture retainer - base metal post; includes canal preparation	$ 85
D6973	Core buildup for retainer, including any pins	$ 50
D6976	Each additional indirectly fabricated post – same tooth – includes canal preparation ²	$ 30
D6977	Each additional prefabricated post - same tooth - base metal post; includes canal preparation	$ 20
D6980	Fixed partial denture repair, by report	$ 50