GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 8 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment 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) $150 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) $150 D5225 Maxillary partial denture – flexible base (including any clasps, rests and teeth) $365 D5226 Mandibular partial denture – flexible base (including any clasps, rests and teeth) $365 D5227 Immediate maxillary partial denture – flexible base (including any clasps, rests and teeth) $110 D5228 Immediate mandibular partial denture – flexible base (including any clasps, rests and teeth) $110 D5282 Removable unilateral partial denture – one piece cast metal (including clasps and teeth), maxillary $150 D5283 Removable unilateral partial denture – one piece cast metal (including clasps and teeth), mandibular $150 D5284 Removable unilateral partial denture – one piece flexible base (including clasps and teeth) – per quadrant $75 D5286 Removable unilateral partial denture – one piece resin (including clasps and teeth) – per quadrant $75 D5410 Adjust complete denture – maxillary $0 D5411 Adjust complete denture – mandibular $0 D5421 Adjust partial denture – maxillary $0 D5422 Adjust partial denture – mandibular $0 D5511 Repair broken complete denture base, mandibular $15 D5512 Repair broken complete denture base, maxillary $15 D5520 Replace missing or broken teeth – complete denture (each tooth) $15 D5611 Repair resin partial denture base, mandibular $15 D5612 Repair resin partial denture base, maxillary $15 D5621 Repair cast partial framework, mandibular $15 D5622 Repair cast partial framework, maxillary $15 D5630 Repair or replace broken retentive clasping materials – per tooth $15 D5640 Replace broken teeth – per tooth $15 D5650 Add tooth to existing partial denture $15 D5660 Add clasp to existing partial denture - per tooth $15 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 $50 D5711 Rebase complete mandibular denture $50 D5720 Rebase maxillary partial denture $50 D5721 Rebase mandibular partial denture $50 D5725 Rebase hybrid prosthesis $50 D5730 Reline complete maxillary denture (chairside) $35 D5731 Reline complete mandibular denture (chairside) $35 D5740 Reline maxillary partial denture (chairside) $35 D5741 Reline mandibular partial denture (chairside) $35 D5750 Reline complete maxillary denture (laboratory) $40 D5751 Reline complete mandibular denture (laboratory) $40