Page 13 of 24 MET245_SOB_CA (01/26) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D6080 Implant maintenance procedures when a full arch fixed hybrid prosthesis is removed and reinserted, including cleansing of prosthesis and abutments. This procedure includes active debriding of the implant(s) and examination of all aspects of the implant system, including the occlusion and stability of the prosthesis. The patient is also instructed in thorough daily cleansing of the implant(s). $55 D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure $17 D6082 Implant supported crown – porcelain fused to predominantly base alloys $640 D6083 Implant supported crown – porcelain fused to noble alloys $645 D6084 Implant supported crown – porcelain fused to titanium and titanium alloys $650 D6086 Implant supported crown – predominantly base alloys $640 D6087 Implant supported crown – noble alloys $720 D6088 Implant supported crown – titanium and titanium alloys $650 D6089 Accessing and retorquing loose implant screw – per screw $0 D6090 Repair implant supported prosthesis, by report $190 D6091 Replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment $170 D6092 Re-cement or re-bond implant/abutment supported crown $50 D6093 Re-cement or re-bond implant/abutment supported fixed partial denture $70 D6094 Abutment supported crown - titanium and titanium alloys. A single crown restoration that is retained, supported and stabilized by an abutment on an implant $650 D6096 Remove broken implant retaining screw $24 D6097 Abutment supported crown – porcelain fused to titanium and titanium alloys $700 D6098 Implant supported retainer – porcelain fused to predominantly base alloys $595 D6099 Implant supported retainer for FPD – porcelain fused to noble alloys $635 D6110 Implant/abutment supported removable denture for edentulous arch-maxillary $995 D6111 Implant/abutment supported removable denture for edentulous arch-mandibular $995 D6112 Implant/abutment supported removable denture for partially edentulous arch- maxillary $945 D6113 Implant/abutment supported removable denture for partially edentulous arch- mandibular $945 D6114 Implant/abutment supported fixed denture for edentulous arch-maxillary $2,380 D6115 Implant/abutment supported fixed denture for edentulous arch-mandibular $2,380 D6116 Implant/abutment supported fixed denture for partially edentulous arch-maxillary $1,410 D6117 Implant/abutment supported fixed denture for partially edentulous arch-mandibular $1,410 D6120 Implant supported retainer – porcelain fused to titanium and titanium alloys $520 D6121 Implant supported retainer for metal FPD – predominantly base alloys $445 D6122 Implant supported retainer for metal FPD – noble alloys $640 D6123 Implant supported retainer for metal FPD – titanium and titanium alloys $520 D6180 Implant maintenance procedures when a full arch fixed hybrid prosthesis is not removed, including cleansing of prosthesis and abutments. $55 D6191 Semi-precision abutment – placement $335 D6192 Semi-precision attachment – placement $252 D6193 Replacement of an implant screw $24