| Code |
Description |
Enrollee Pays |
| D5110 |
Complete denture - maxillary |
$450.00 |
| D5120 |
Complete denture - mandibular |
$450.00 |
| D5130 |
Immediate denture - maxillary |
$550.00 |
| D5140 |
Immediate denture - mandibular |
$550.00 |
| D5211 |
Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) |
$300.00 |
| D5212 |
Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) |
$300.00 |
| D5213 |
Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) |
$550.00 |
| D5214 |
Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) |
$550.00 |
| D5225 |
Maxillary partial denture - flexible base (including any clasps, rests and teeth) |
$600.00 |
| D5226 |
Mandibular partial denture - flexible base (including any clasps, rests and teeth) |
$600.00 |
| D5410 |
Adjust complete denture - maxillary |
$ 20.00 |
| D5411 |
Adjust complete denture - mandibular |
$ 20.00 |
| D5421 |
Adjust partial denture - maxillary |
$ 20.00 |
| D5422 |
Adjust partial denture - mandibular |
$ 20.00 |
| D5510 |
Repair broken complete denture base |
$ 50.00 |
| D5520 |
Replace missing or broken teeth - complete denture (each tooth) |
$ 30.00 |
| D5610 |
Repair resin denture base |
$ 75.00 |
| D5620 |
Repair cast framework |
$ 90.00 |
| D5630 |
Repair or replace broken clasp |
$ 55.00 |
| D5640 |
Replace broken teeth - per tooth |
$ 30.00 |
| D5650 |
Add tooth to existing partial denture |
$ 55.00 |
| D5660 |
Add clasp to existing partial denture |
$ 55.00 |
| D5710 |
Rebase complete maxillary denture |
$130.00 |
| D5711 |
Rebase complete mandibular denture |
$130.00 |
| D5720 |
Rebase maxillary partial denture |
$130.00 |
| D5721 |
Rebase mandibular partial denture |
$130.00 |
| D5730 |
Reline complete maxillary denture (chairside) |
$ 50.00 |
| D5731 |
Reline complete mandibular denture (chairside) |
$ 50.00 |
| D5740 |
Reline maxillary partial denture (chairside) |
$ 45.00 |
| D5741 |
Reline mandibular partial denture (chairside) |
$ 45.00 |
| D5750 |
Reline complete maxillary denture (laboratory) |
$150.00 |
| D5751 |
Reline complete mandibular denture (laboratory) |
$150.00 |
| D5760 |
Reline maxillary partial denture (laboratory) |
$150.00 |
| D5761 |
Reline mandibular partial denture (laboratory) |
$150.00 |
| D5820 |
Interim partial denture (maxillary) - limited to 1 in any 12 consecutive months |
$ 55.00 |
| D5821 |
Interim partial denture (mandibular) - limited to 1 in any 12 consecutive months |
$ 55.00 |
| D5850 |
Tissue conditioning, maxillary |
$ 30.00 |
| D5851 |
Tissue conditioning, mandibular |
$ 30.00 |
