Procedure Description Copayment Notes D5621 Repair cast partial framework, mandibular 45 D5622 Repair cast partial framework, maxillary 45 D5630 Repair or replace broken retentive clasping materials – per tooth 30 D5640 Replace broken teeth - per tooth 10 D5650 Add tooth to existing partial denture 20 D5660 Add clasp to existing partial denture – per tooth 20 D5670 Replace teeth and acrylic on cast metal framework (mandibular) NB D5671 Replace teeth and acrylic on cast metal framework (maxillary) NB D5710 Rebase complete maxillary denture 60 D5711 Rebase complete mandibular denture 60 D5720 Rebase maxillary partial denture 40 D5721 Rebase mandibular partial denture 40 D5725 Rebase hybrid prosthesis 40 D5730 Reline complete maxillary denture (chairside) 40 D5731 Reline complete mandibular denture (chairside) 40 D5740 Reline maxillary partial denture (chairside) 40 D5741 Reline mandibular partial denture (chairside) 40 D5750 Reline complete maxillary denture (laboratory) 50 D5751 Reline complete mandibular denture (laboratory) 50 D5760 Reline maxillary partial denture (laboratory) 50 D5761 Reline mandibular partial denture (laboratory) 50 D5765 Soft liner for complete or partial removable denture – indirect 50 D5850 Tissue conditioning, maxillary 15 D5851 Tissue conditioning, mandibular 15 D5863 Overdenture - complete upper 175 D5864 Overdenture - partial upper 175 D5865 Overdenture - complete lower 175 D5866 Overdenture - partial lower 175 D6000-D6199 VIII. Implant Services Pre-Implant Consultation Fees 25 R Initial Implant Exam or Consultation Detailed and Extensive Oral Evaluation 125 R Implant Fees - Case Rates Single Tooth 2,800 R Two Teeth 5,464 R Three Teeth 7,644 R Full Denture (two implants) 5,120 R Full Denture (three implants) 6,885 R Each additional tooth 2,095 R D6089 Accessing and retorquing loose implant screw - per screw 0 D6200 - D6999 IX. Prosthodontics, Fixed D6210 Pontic - cast high noble metal 175 D6211 Pontic - cast predominantly base metal 125 D6212 Pontic - cast noble metal 150 D6240 Pontic - porcelain fused to high noble metal 175 2024-01-03100-BB 12 DCL 20240101