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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])

- When a crown and/or pontic exceeds six units in the same treatment plan, an Enrollee may be charged an additional $100.00 per unit, beyond the 6th unit.
- Replacement of a crown, pontic, inlay, onlay or stress breaker requires the existing bridge to be 5+ years old.

Code	Description	Enrollee Pays
D6210	Pontic - cast high noble metal	$440.00
D6211	Pontic - cast predominantly base metal	$340.00
D6212	Pontic - cast noble metal	$425.00
D6240	Pontic - porcelain fused to high noble metal ^{2, 3}	$440.00
D6241	Pontic - porcelain fused to predominantly base metal ²	$340.00
D6242	Pontic - porcelain fused to noble metal ²	$425.00
D6245	Pontic - porcelain/ceramic ³	$575.00
D6250	Pontic - resin with high noble metal ²	$425.00
D6251	Pontic - resin with predominantly base metal ²	$325.00
D6252	Pontic - resin with noble metal ²	$425.00
D6600	Inlay - porcelain/ceramic, two surfaces ²	$385.00
D6601	Inlay - porcelain/ceramic, three or more surfaces ²	$405.00
D6602	Inlay - cast high noble metal, two surfaces	$370.00
D6603	Inlay - cast high noble metal, three or more surfaces	$380.00
D6604	Inlay - cast predominantly base metal, two surfaces	$270.00
D6605	Inlay - cast predominantly base metal, three or more surfaces	$280.00
D6606	Inlay - cast noble metal, two surfaces	$370.00
D6607	Inlay - cast noble metal, three or more surfaces	$380.00
D6608	Onlay - porcelain/ceramic, two surfaces ²	$395.00
D6609	Onlay - porcelain/ceramic, three or more surfaces ²	$415.00
D6610	Onlay - cast high noble metal, two surfaces	$370.00
D6611	Onlay - cast high noble metal, three or more surfaces	$390.00
D6612	Onlay - cast predominantly base metal, two surfaces	$270.00
D6613	Onlay - cast predominantly base metal, three or more surfaces	$290.00
D6614	Onlay - cast noble metal, two surfaces	$370.00
D6615	Onlay - cast noble metal, three or more surfaces	$390.00
D6720	Crown - resin with high noble metal ²	$425.00
D6721	Crown - resin with predominantly base metal ²	$325.00
D6722	Crown - resin with noble metal ²	$425.00
D6740	Crown - porcelain/ceramic ³	$575.00
D6750	Crown - porcelain fused to high noble metal ^{2, 3}	$440.00
D6751	Crown - porcelain fused to predominantly base metal ²	$340.00
D6752	Crown - porcelain fused to noble metal ²	$425.00
D6780	Crown - ¾ cast high noble metal	$440.00
D6781	Crown - ¾ cast predominantly base metal	$340.00
D6782	Crown - ¾ cast noble metal	$425.00
D6783	Crown - ¾ porcelain/ceramic ^{2, 3}	$495.00
D6790	Crown - full cast high noble metal	$440.00
D6791	Crown - full cast predominantly base metal	$340.00
D6792	Crown - full cast noble metal	$425.00
D6930	Recement fixed partial denture	$ 30.00
D6940	Stress breaker	$ 45.00
D6970	Post and core in addition to fixed partial denture retainer, indirectly fabricated – includes canal preparation ¹	$ 95.00
D6972	Prefabricated post and core in addition to fixed partial denture retainer - base metal post; includes canal preparation ¹	$ 75.00
D6973	Core buildup for retainer, including any pins	$ 75.00
D6976	Each additional indirectly fabricated post – same tooth – includes canal preparation ¹	$ 45.00
D6977	Each additional prefabricated post - same tooth - base metal post; includes canal preparation	$ 25.00
D6980	Fixed partial denture repair, by report	$ 75.00