Page 11 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D5760 Reline maxillary partial denture (laboratory) $85 D5761 Reline mandibular partial denture (laboratory) $85 D5765 Soft liner for complete or partial removable denture – indirect $85 D5810 Interim complete denture (maxillary) $230 D5811 Interim complete denture (mandibular) $230 D5820 Interim partial denture (maxillary) $160 D5821 Interim partial denture (mandibular) $170 D5850 Tissue conditioning, maxillary $20 D5851 Tissue conditioning, mandibular $20 D5862 Precision attachment, by report. Each pair of components is one precision attachment. Describe the type of attachment used. $160 D5876 Add metal substructure to acrylic full denture (per arch). Use of metal substructure in removable complete dentures without a framework $82 Implant Services Pre-Surgical Services D6190 Radiographic/surgical implant index, by report $130 Surgical Services D6010 Surgical placement of implant body: endosteal implant $1,005 D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant $770 D6013 Surgical placement of mini implant $1,005 D6040 Surgical placement: eposteal implant $1,860 D6050 Surgical placement: transosteal implant $1,170 D6051 Interim implant abutment placement. A healing cap is not an interim abutment. $123 D6100 Surgical removal of implant body $240 D6101 Debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure $34 D6102 Debridement and osseous contouring of a peri-implant defect or defects surrounding a single implant and includes surface cleaning of the exposed implant surfaces, including flap entry and closure $68 D6103 Bone graft for repair of peri-implant defect – does not include flap entry and closure $100 D6104 Bone graft at time of implant placement $100 D6105 Removal of implant body not requiring bone removal nor flap elevation $240 D6106 Guided tissue regeneration – resorbable barrier, per implant. This procedure does not include flap entry and closure, or, when indicated, wound debridement, osseous contouring, bone replacement grafts, and placement of biologic materials to aid in osseous regeneration. This procedure is used for peri-implant defects and during implant placement. $215 D6107 Guided tissue regeneration – non-resorbable barrier, per implant. This procedure does not include flap entry and closure, or, when indicated, wound debridement, osseous contouring, bone replacement grafts, and placement of biologic materials to aid in osseous regeneration. This procedure is used for peri-implant defects and during implant placement. $255