Page 10 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D5222 Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) Includes limited follow-up care only; does not include future rebasing/relining procedure(s) $400 D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) Includes limited follow-up care only; does not include future rebasing/relining procedure(s) $425 D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) Includes limited follow-up care only; does not include future rebasing/relining procedure(s) $425 D5225 Maxillary partial denture – flexible base (including any clasps, rests and teeth) $425 D5226 Mandibular partial denture – flexible base (including any clasps, rests and teeth) $425 D5227 Immediate maxillary partial denture – flexible base (including any clasps, rests and teeth) $400 D5228 Immediate mandibular partial denture – flexible base (including any clasps, rests and teeth) $400 D5282 Removable unilateral partial denture – one piece cast metal (including clasps and teeth), maxillary $300 D5283 Removable unilateral partial denture – one piece cast metal (including clasps and teeth), mandibular $300 D5284 Removable unilateral partial denture – one piece flexible base (including clasps and teeth) – per quadrant $150 D5286 Removable unilateral partial denture – one piece resin (including clasps and teeth) – per quadrant $150 D5410 Adjust complete denture – maxillary $10 D5411 Adjust complete denture – mandibular $10 D5421 Adjust partial denture – maxillary $10 D5422 Adjust partial denture – mandibular $10 D5511 Repair broken complete denture base, mandibular $35 D5512 Repair broken complete denture base, maxillary $35 D5520 Replace missing or broken teeth – complete denture (each tooth) $35 D5611 Repair resin partial denture base, mandibular $35 D5612 Repair resin partial denture base, maxillary $35 D5621 Repair cast partial framework, mandibular $35 D5622 Repair cast partial framework, maxillary $35 D5630 Repair or replace broken retentive clasping materials – per tooth $35 D5640 Replace broken teeth – per tooth $35 D5650 Add tooth to existing partial denture $35 D5660 Add clasp to existing partial denture – per tooth $35 D5670 Replace all teeth and acrylic on cast metal framework (maxillary) $165 D5671 Replace all teeth and acrylic on cast metal framework (mandibular) $165 D5710 Rebase complete maxillary denture $75 D5711 Rebase complete mandibular denture $75 D5720 Rebase maxillary partial denture $75 D5721 Rebase mandibular partial denture $75 D5725 Rebase hybrid prosthesis $75 D5730 Reline complete maxillary denture (chairside) $65 D5731 Reline complete mandibular denture (chairside) $65 D5740 Reline maxillary partial denture (chairside) $65 D5741 Reline mandibular partial denture (chairside) $65 D5750 Reline complete maxillary denture (laboratory) $85 D5751 Reline complete mandibular denture (laboratory) $85