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Prosthodontics %u2014 Removable, ContinuedD5731 Reline complete mandibular denture (chairside) $120D5740 Reline maxillary partial denture (chairside) $120D5741 Reline mandibular partial denture (chairside) $120D5750 Reline complete maxillary denture (laboratory) $195D5751 Reline complete mandibular denture (laboratory) $195D5760 Reline maxillary partial denture (laboratory) $170D5761 Reline mandibular partial denture (laboratory) $170D5820 Interim partial denture (maxillary) %u2014 limited to 1 in any 12 consecutive months $385D5821 Interim partial denture (mandibular) %u2014 limited to 1 in any 12 consecutive months $385D5850 Tissue conditioning, maxillary $85D5851 Tissue conditioning, mandibular $85Implant Services Pre-Surgical ServicesD6190 Radiographic/surgical implant index, by report $189 Surgical ServicesD6010 Surgical placement of implant body: endosteal implant $946D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant $946D6013 Surgical placement of mini implant $568D6040 Surgical placement: eposteal implant $450D6050 Surgical placement: transosteal implant $2,587D6051 Interim abutment $450D6052 Semi-precision attachment abutment $239D6100 Implant removal, by report $235D6101 Debridement of a peri-implant defect and surface cleaning of exposed implant surfaces, including flap entry and closure $164D6102 Debridement and osseous contouring of a periimplant defect; includes surface cleaning of exposed implant surfaces and flap entry and closure$272D6103 Bone graft for repair of peri-implant defect %u2014 not including flap entry and closure or, when indicated, placement of a barrier membrane or biologic materials to aid in osseous regeneration$164D6104 Bone graft at time of implant placement $164 Implant Supported Prosthetics %u2014 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 molar, for the use of porcelain. %u2014 Cases involving 7 or more crowns, implants, and/or fixed bridge units in the same treatment plan require an additional $125 co-payment per unit in addition to the specified co-payment for each crown, implant, or bridge unit.D6053 Implant/abutment supported removable denture for completely endentulous arch $1,200D6054 Implant/abutment supported removable denture for partially endentulous arch $1,200D6055 Connecting bar %u2014 implant supported or abutment supported $948D6056 Prefabricated abutment %u2014 includes modification and placement $329D6057 Custom fabricated abutment %u2014 includes placement $381D6058 Abutment supported porcelain/ceramic crown $559D6059 Abutment supported porcelain fused to metal crown, high noble metal* $598D6060 Abutment supported porcelain fused to metal crown, predominantly base metal $542D6061 Abutment supported porcelain fused to metal crown, noble metal* $576D6062 Abutment supported cast metal crown, high noble metal* $582D6063 Abutment supported cast metal crown, predominantly base metal $542D6064 Abutment supported cast metal crown, noble metal* $569D6065 Implant supported porcelain/ceramic crown $573D6066 Implant supported porcelain fused to metal crown %u2014 titanium, titanium alloy, high noble metal* $648D6067 Implant supported metal crown %u2014 titanium, titanium alloy, high noble metal* $649D6068 Abutment supported retainer for porcelain/ceramic FPD $573D6069 Abutment supported retainer for porcelain fused to metal FPD, high noble metal* $600D6070 Abutment supported retainer for porcelain fused to metal FPD, predominantly base metal $580D6071 Abutment supported retainer for porcelain fused to metal FPD, noble metal* $608D6072 Abutment supported retainer for cast metal FPD, high noble metal* $619D6073 Abutment supported retainer for cast metal FPD, predominantly base metal $539D6074 Abutment supported retainer for cast metal FPD, noble metal* $604D6075 Implant supported retainer for ceramic FPD $573D6076 Implant supported retainer for porcelain fused to metal FPD %u2014 titanium, titanium alloy, or high noble metal* $660D6077 Implant supported retainer for cast metal FPD %u2014 titanium, titanium alloy, or high noble metal* $653D6078 Implant/abutment supported fixed denture for completely edentulous arch $10,260D6079 Implant/abutment supported fixed denture for partially edentulous arch $1,531D6080 Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prosthesis and abutments$206D6090 Repair implant supported prosthesis, by report $122D6091 Replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment$293D6092 Re-cement implant/abutment supported crown $34(Continued next page)335