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SCHEDULE OF BENEFITS (Continued) <br />Removable Prosthodontics <br />• <br />Replacement limit I every 3 years. <br />Your and Your <br />• <br />Denture relines: Twice in one year <br />Dependent's <br />Code <br />Service <br />Co -Payment <br />D4261 <br />Osseous surgery (including elevation of a full thickness flap and closure) — one <br />$0 <br />D5120 <br />to three contiguous teeth or tooth bounded spaces per quadrant <br />$0 <br />D4341 <br />Periodontal scaling and root planing —four or more teeth per quadrant <br />$0 <br />D4342 <br />Periodontal scaling and root planing — one to three teeth per quadrant <br />$0 <br />D4356 <br />Full mouth debridement to enable comprehensive evaluation and diagnosis <br />$0 <br />D4910 <br />Periodontal maintenance <br />$0 <br />Removable Prosthodontics <br />• <br />Replacement limit I every 3 years. <br />• <br />Denture relines: Twice in one year <br />• <br />Includes up to 3 adjustments within 6 monthsof delivery. <br />D5110 <br />Complete denture — maxillary <br />$0 <br />D5120 <br />Complete denture—mandibular <br />$0 <br />D5130 <br />Immediate denture — maxillary <br />$0 <br />D5140 <br />Immediate denture — mandibular <br />$0 <br />D5211 <br />Maxillary partial denture — resin base (including any conventional clasps, rests <br />$0 <br />and teeth) <br />D5212 <br />Mandibular partial denture — resin base (including any conventional clasps, <br />$0 <br />rests and teeth) <br />D5213 <br />Maxillary partial denture— cast metal framework with resin denture bases <br />$0 <br />(including any conventional clasps, rests and teeth) <br />D5214 <br />Mandibular partial denture — cast metal framework with resin denture bases <br />$0 <br />(including any conventional clasps, rests and teeth <br />D5410 <br />Adjust complete denture — maxillary <br />$0 <br />D5411 <br />Adjust complete denture — mandibular <br />$0 <br />D5421 <br />Adjust partial denture — maxillary <br />$0 <br />D5422 <br />Adjust partial denture — mandibular <br />$0 <br />D5510 <br />Repair broken complete denture base <br />$0 <br />D5520 <br />Replace missing or broken teeth — complete denture (each tooth) <br />$0 <br />D5610 <br />Repair resin denture base <br />$0 <br />D5620 <br />Repair cast framework <br />$0 <br />D5630 <br />Repair or replace broken clasp <br />$0 <br />D5640 <br />Replace broken teeth — per tooth <br />$0 <br />D565D <br />Add tooth to existing partial denture <br />$0 <br />D6660 <br />Add clasp to existing partial denture <br />$0 <br />05710 <br />Rebase complete maxillary denture <br />$0 <br />D5711 <br />Rebase complete mandibular denture <br />$0 <br />D5720 <br />Rebase maxillary partial denture <br />$0 <br />D5721 <br />Rebase mandibular partial denture <br />$0 <br />D5730 <br />Reline complete maxillary denture (chairside) <br />$0 <br />D5731 <br />Reline complete mandibular denture (chairside) <br />$0 <br />D5740 <br />Reline maxillary partial denture (chairside) <br />$0 <br />D5741 <br />Reline mandibular partial denture (chairside) <br />$0 <br />D5750 <br />Reline complete maxillary denture (laboratory) <br />$0 <br />0041 -D -SOB <br />25C-43 <br />4 <br />