CODE SERVICE FREQUENCY BENEFIT DETAILS Other Denture Services D5850 Tissue conditioner applied 2 procedures per Covered after delivery of to inside of upper denture upper denture every immediate upper denture to help gums heal 5 calendar years (D5130, D5221, D5223, D5227) and before fabrication of new upper denture (D5110, D5211, D5213, D5225), not payable after delivery of new upper denture D5851 Tissue conditioner applied 2 procedures per Covered after delivery of to inside of lower denture lower denture every immediate lower denture to help gums heal 5 calendar years (D5140, D5222, D5224, D5228) and before fabrication of new lower denture (D5120, D5212, D5214, D5226), not payable after delivery of new lower denture Bridge (pontics and retainers) D6210 The fake tooth (pontic) of Unlimited 1 pontic code per edentulous D6212 the bridge that replaces space every 5 calendar years D6214 the missing tooth (edentulous space). D6240 Pontics are made of metal, D6242 porcelain, porcelain fused D6243 to metal or titanium. D6245 D6545 The caps (retainers) of the Unlimited 1 retainer code or crown code D6548 bridge that are placed on (see covered crown codes D6740 natural teeth. Retainers above) per tooth every 5 are made of metal, calendar years, not covered for a D6750 porcelain, porcelain fused bridge supported by implants D6752 to metal or titanium. D6753 D6790 D6792 D6794 10