My Benefits



	Emergency Services Specialist Services Benefits, Limitations and Exclusions Cancellation and Termination of Benefits Entire Contract Schedule A Description of Benefits and Copayments Schedule B Limitations and Exclusions

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 ⁸	$395
D6211	Pontic - cast predominantly base metal ⁸	$295
D6212	Pontic - cast noble metal ⁸	$295
D6240	Pontic - porcelain fused to high noble metal ^{3, 8}	$395
D6241	Pontic - porcelain fused to predominantly base metal ^{3, 8}	$295
D6242	Pontic - porcelain fused to noble metal ^{3, 8}	$295
D6245	Pontic - porcelain/ceramic ^{3, 8}	$395
D6250	Pontic - resin with high noble metal ^{3, 8}	$395
D6251	Pontic - resin with predominantly base metal ^{3, 8}	$295
D6252	Pontic - resin with noble metal ^{3, 8}	$295
D6600	Inlay - porcelain/ceramic, two surfaces ⁸	$340
D6601	Inlay - porcelain/ceramic, three or more surfaces ⁸	$355
D6602	Inlay - cast high noble metal, two surfaces ⁸	$360
D6603	Inlay - cast high noble metal, three or more surfaces ⁸	$380
D6604	Inlay - cast predominantly base metal, two surfaces ⁸	$260
D6605	Inlay - cast predominantly base metal, three or more surfaces ⁸	$280
D6606	Inlay - cast noble metal, two surfaces ⁸	$260
D6607	Inlay - cast noble metal, three or more surfaces ⁸	$280
D6608	Onlay - porcelain/ceramic, two surfaces ⁸	$355
D6609	Onlay - porcelain/ceramic, three or more surfaces ⁸	$375
D6610	Onlay - cast high noble metal, two surfaces ⁸	$345
D6611	Onlay - cast high noble metal, three or more surfaces ⁸	$365
D6612	Onlay - cast predominantly base metal, two surfaces ⁸	$245
D6613	Onlay - cast predominantly base metal, three or more surfaces ⁸	$265
D6614	Onlay - cast noble metal, two surfaces ⁸	$245
D6615	Onlay - cast noble metal, three or more surfaces ⁸	$265
D6720	Crown - resin with high noble metal ^{3, 8}	$395
D6721	Crown - resin with predominantly base metal ^{3, 8}	$295
D6722	Crown - resin with noble metal ^{3, 8}	$295
D6740	Crown - porcelain/ceramic ^{3, 8}	$395
D6750	Crown - porcelain fused to high noble metal ^{3, 8}	$395
D6751	Crown - porcelain fused to predominantly base metal ^{3, 8}	$295
D6752	Crown - porcelain fused to noble metal ^{3, 8}	$295
D6780	Crown - ¾ cast high noble metal ⁸	$395
D6781	Crown - ¾ cast predominantly base metal ⁸	$295
D6782	Crown - ¾ cast noble metal ⁸	$295
D6790	Crown - full cast high noble metal ⁸	$395
D6791	Crown - full cast predominantly base metal ⁸	$295
D6792	Crown - full cast noble metal ⁸	$295
D6930	Recement fixed partial denture	$ 25
D6940	Stress breaker ⁸	$ 45
D6970	Post and core in addition to fixed partial denture retainer, indirectly fabricated – includes canal preparation ²	$ 90
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	$ 50
D6977	Each additional prefabricated post - same tooth - base metal post; includes canal preparation	$ 45
D6980	Fixed partial denture repair, by report	$ 50