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SCHEDULE OF BENEFITS (Continued) <br />0041 -D -SOB <br />26C-44 <br />5 <br />Your and Your <br />Dependent's <br />Code <br />Service <br />Co -Payment <br />D5751 <br />Reline complete mandibular denture (laboratory) <br />$0 <br />D5760 <br />Reline maxillary partial denture (laboratory) <br />$0 <br />D5761 <br />Reline mandibular partial denture (laboratory) <br />$0 <br />D5820 <br />Interim partial denture (maxillary) <br />$0 <br />D5821 <br />Interim partial denture (mandibular) <br />$0 <br />D5860 <br />Tissue conditioning, maxillary <br />$0 <br />D5851 <br />Tissue conditioning, mandibular <br />$0 <br />CrownslFixed Bridges - Per Unit <br />The use of noble or high noble fcr any procedure will Include additional lab <br />fees, <br />$75 fee per crown/bridge unit above co -pay for porcelain on molars, <br />D6206 <br />Pontic— Indirect resin based composite <br />$0 <br />06210 <br />Pontic—cast high noble metal <br />$0 <br />D6211 <br />Pontic — cast predominantly bass metal <br />$0 <br />D6212 <br />Pontic—cast noble metal <br />$0 <br />D6214 <br />Pontic — titanium <br />$0 <br />D6240 <br />Pontie — porcelain fused to high noble metal <br />$0 <br />D6241 <br />Pontic— porcelain fused to predominantly base metal <br />$0 <br />06242 <br />Pontic — porcelain fused to noble metal <br />$0 <br />D6250 <br />Pontic — resin with high noble metal <br />$0 <br />D6251 <br />Pontic — resin with predominantly base metal <br />$0 <br />D6252 <br />Pontic — resin with noble metal <br />$0 <br />D5710 <br />Crown — Indirect resin based composite <br />$0 <br />06720 <br />Crown — resin with high noble metal <br />$0 <br />D6721 <br />Crown— resin with predominantly base metal <br />$0 <br />D6722 <br />Crown—resin with noble metal <br />$0 <br />D6760 <br />Crown— porcelain fused to high noble metal <br />$0 <br />D6751 <br />Crown — porcelain fused to predominantly base metal <br />$0 <br />D6762 <br />Crown — porcelain fused to noble metal <br />$0 <br />D6780 <br />Crown - % cast high noble metal <br />$0 <br />D6781 <br />Crown —3/<castpredominantly bass metal <br />$0 <br />D6782 <br />Crown — % cast noble metal <br />$0 <br />D6790 <br />Crown —full cast high noble metal <br />$0 <br />D6791 <br />Crown—full cast predominantly base metal <br />$0 <br />D6792 <br />Crown —full cast noble metal <br />$0 <br />D6794 <br />Crown—titanium <br />$0 <br />D6930 <br />Re -cement or re -bond fixed partial denture <br />$0 <br />Oral Surgery <br />Includes routine post operative visits/treatment. <br />Surgical removal of impacted teeth - (not covered unless pathology [disease] <br />exists). <br />0041 -D -SOB <br />26C-44 <br />5 <br />