Page 34 - Demo

Implant Supported Prosthetics, ContinuedD6093 Re-cement implant/abutment supported fixed partial denture $53D6094 Abutment supported crown (titanium) $574D6095 Repair implant abutment, by report $289D6194 Abutment supported retainer crown for FPD (titanium) $629Prosthodontics %u2014 Fixed %u2014 each retainer and each pontic constitutes a unit in a fixed partial denture (bridge) %u2014 When a crown and/or pontic exceeds six units in the same treatment plan, a covered person may be charged an additional $125 per unit, beyond the 6th unit. %u2014 Replacement of a crown, pontic, inlay, onlay, or stress breaker requires the existing bridge to be 5+ years old.D6210 Pontic %u2014 cast high noble metal* $490D6211 Pontic %u2014 cast predominantly base metal $450D6212 Pontic %u2014 cast noble metal* $495D6240 Pontic %u2014 porcelain fused to high noble metal* $525D6241 Pontic %u2014 porcelain fused to predominantly base metal $480D6242 Pontic %u2014 porcelain fused to noble metal* $495D6245 Pontic %u2014 porcelain/ceramic $600D6250 Pontic %u2014 resin with high noble metal* $495D6251 Pontic %u2014 resin with predominantly base metal $430D6252 Pontic %u2014 resin with noble metal* $465D6600 Inlay %u2014 porcelain/ceramic, two surfaces $400D6601 Retainer inlay %u2014 porcelain/ceramic, three or more surfaces $440D6602 Retainer inlay %u2014 cast high noble metal, two surfaces* $400D6603 Retainer inlay %u2014 cast high noble metal, three or more surfaces* $415D6604 Retainer inlay %u2014 cast predominantly base metal, two surfaces $375D6605 Retainer inlay %u2014 cast predominantly base metal, three or more surfaces $385D6606 Retainer inlay %u2014 cast noble metal, two surfaces* $380D6607 Retainer inlay %u2014 cast noble metal, three or more surfaces* $430D6608 Retainer onlay %u2014 porcelain/ceramic, two surfaces $495D6609 Retainer onlay %u2014 porcelain/ceramic, three or more surfaces $500D6610 Retainer onlay %u2014 cast high noble metal, two surfaces* $425D6611 Retainer onlay %u2014 cast high noble metal, three or more surfaces* $535D6612 Retainer onlay %u2014 cast predominantly base metal, two surfaces $415D6613 Retainer onlay %u2014 cast predominantly base metal, three or more surfaces $525D6614 Retainer onlay %u2014 cast noble metal, two surfaces* $420D6615 Retainer onlay %u2014 cast noble metal, three or more surfaces* $525D6720 Retainer crown %u2014 resin with high noble metal* $495D6721 Retainer crown %u2014 resin with predominantly base metal $400D6722 Retainer crown %u2014 resin with noble metal* $445D6740 Retainer crown %u2014 porcelain/ceramic $600D6750 Retainer crown %u2014 porcelain fused to high noble metal* $530D6751 Retainer crown %u2014 porcelain fused to predominantly base metal $530D6752 Retainer crown %u2014 porcelain fused to noble metal* $530D6780 Retainer crown %u2014 %u00be cast high noble metal* $585D6781 Retainer crown %u2014 %u00be cast predominantly base metal $500D6782 Retainer crown %u2014 %u00be cast noble metal* $525D6783 Retainer crown %u2014 %u00be porcelain/ceramic $525D6790 Retainer crown %u2014 full cast high noble metal* $575D6791 Retainer crown %u2014 full cast predominantly base metal $510D6792 Retainer crown %u2014 full cast noble metal* $520D6930 Re-cement or re-bond fixed partial denture $60D6940 Stress breaker $145D6980 Fixed partial denture repair necessitated by restorative material failure $125*Note: Base metal is the benefit. Noble and high noble metal (precious), if used, will be charged to the Enrollee at the additional laboratory cost of the high noble metal. This applies to crowns, bridges, cast post and cores, inlays, and onlays. Porcelain on molars is considered optional treatment.Oral and Maxillofacial SurgeryIncludes preoperative and postoperative evaluations and treatment under a local anesthetic.D7111 Extraction, coronal remnants %u2014 primary tooth $50D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $50D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated$120D7220 Removal of impacted tooth %u2014 soft tissue $155D7230 Removal of impacted tooth %u2014 partially bony $235D7240 Removal of impacted tooth %u2014 completely bony $275D7241 Removal of impacted tooth %u2014 completely bony, with unusual surgical complications $290(Continued next page)346