GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 9 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D5760 Reline maxillary partial denture (laboratory) $40 D5761 Reline mandibular partial denture (laboratory) $40 D5765 Soft liner for complete or partial removable denture – indirect $40 D5810 Interim complete denture (maxillary) $130 D5811 Interim complete denture (mandibular) $130 D5820 Interim partial denture (maxillary) $40 D5821 Interim partial denture (mandibular) $40 D5850 Tissue conditioning, maxillary $10 D5851 Tissue conditioning, mandibular $10 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 $32 D6089 Accessing and retorquing loose implant screw – per screw $0 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 D6197 Replacement of restorative material used to close an access opening of a screw- retained implant supported prosthesis, per implant. $25 Crowns/Fixed Bridges - Per Unit • An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble or titanium metal. There is a $75 co-payment per crown/bridge unit in addition to regular co-payments for porcelain on molars. • Cases involving seven (7) or more crowns and/or fixed bridge units in the same treatment plan require an additional $125 co-payment per unit in addition to co-payment for each crown/bridge unit. D6210 Pontic – cast high noble metal $100 D6211 Pontic – cast predominantly base metal $100 D6212 Pontic – cast noble metal $100 D6214 Pontic – titanium and titanium alloys $100 D6240 Pontic – porcelain fused to high noble metal $100 D6241 Pontic – porcelain fused to predominantly base metal $100 D6242 Pontic – porcelain fused to noble metal $100 D6243 Pontic – porcelain fused to titanium and titanium alloys $100 D6245 Pontic – porcelain/ceramic $120 D6250 Pontic – resin with high noble metal $100 D6251 Pontic – resin with predominantly base metal $100 D6252 Pontic – resin with noble metal $100 D6253 Further treatment or completion of diagnosis necessary prior to final impression. Not to be used as a temporary pontic for a routine prosthetic restoration. $0 D6545 Retainer – cast metal for resin bonded fixed prosthesis $100 D6600 Retainer inlay – porcelain/ceramic, two surfaces $100 D6601 Retainer inlay – porcelain/ceramic, three or more surfaces $100