My Benefits



	Emergency Services Specialist Services Benefits, Limitations and Exclusions Renewal, Cancellation and Termination of Benefits Conversion Entire Contract Outline of Coverage Schedule A Description of Benefits and Copayments Schedule B Limitations and Exclusions

SCHEDULE A
DESCRIPTION OF BENEFITS AND COPAYMENTS

D5000-D5899 VI. Prosthodontics (removable)

Code	Description	Enrollee Pays
D5110	Complete denture - maxillary ^{5, ⁶}	$450
D5120	Complete denture - mandibular ^{5, ⁶}	$450
D5130	Immediate denture - maxillary ^{5, ⁶}	$550
D5140	Immediate denture - mandibular ^{5, ⁶}	$550
D5211	Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) ^{5, ⁶}	$300
D5212	Mandibular partial denture - resin base(including any conventional clasps, rests and teeth) ^{5, ⁶}	$300
D5213	Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) ^{5, 7}	$550
D5214	Mandible partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth ^{5, ⁶}	$550
D5225	Maxillary partial denture - flexible base (including any clasps, rests and teeth) ^{5, ⁶}	$600
D5226	Mandible partial denture - flexible base(including any clasps, rests and teeth) ^{5, ⁶}	$600
D5410	Adjust complete denture - maxillary ⁵	$ 20
D5411	Adjust complete denture - mandibular ⁵	$ 20
D5421	Adjust partial denture - maxillary ⁵	$ 20
D5422	Adjust partial denture - mandibular ⁵	$ 20
D5510	Repair broken complete denture base	$ 50
D5520	Replace missing or broken teeth - complete denture (each tooth)	$ 30
D5610	Repair resin denture base	$ 75
D5620	Repair cast framework	$ 90
D5630	Repair or replace broken clasp	$ 55
D5640	Replace broken teeth - per tooth	$ 30
D5650	Add tooth to existing partial denture	$ 55
D5660	Add clasp to existing partial denture	$ 55
D5710	Rebase complete maxillary denture ⁷	$130
D5711	Rebase complete mandibular denture ^⁷	$130
D5720	Rebase maxillary partial denture ^⁷	$130
D5721	Rebase mandibular partial denture ^⁷	$130
D5730	Reline complete maxillary denture (chairside) ^⁷	$ 50
D5731	Reline complete mandibular denture (chairside) ^⁷	$ 50
D5740	Reline maxillary partial denture (chairside) ^⁷	$ 45
D5741	Reline mandibular partial denture (chairside) ^⁷	$ 45
D5750	Reline complete maxillary denture (laboratory) ^⁷	$150
D5751	Reline complete mandibular denture (laboratory) ^⁷	$150
D5760	Reline maxillary partial denture (laboratory) ^⁷	$150
D5761	Reline mandibular partial denture (laboratory) ^⁷	$150
D5820	Interim partial denture (maxillary) - limited to initial placement of interim partial denture/stayplate to replace extracted anterior teeth during healing ⁵	$ 55
D5821	Interim partial denture (mandibular) - limited to initial placement of interimpartial denture/stayplate to replace extracted anterior teeth during healing ⁵	$ 55
D5850	Tissue conditioning, maxillary ^{5, ⁷}	$ 30
D5851	Tissue conditioning, mandibular ^{5, ⁷}	$ 30