| Prosthetics
(Full & Partial
Dentures) |
Member Pays |
| ADA Code |
Procedure |
| 5110 |
Complete
upper denture |
300 |
| 5120 |
Complete
lower denture |
300 |
| 5130 |
Immediate
upper denture |
350 |
| 5140 |
Immediate
lower denture |
350 |
| 5211 |
Partial
upper-resin base (including
any pins) |
325 |
| 5212 |
Partial
lower-resin base (including
any pins) |
325 |
| 5213 |
Partial
upper -cast metal framework
with resin denture base |
375 |
| 5214 |
Partial
lower-chrome cast framework
with resin denture base |
375 |
| 5410 |
Adjustments-complete
upper |
10 |
| 5411 |
Adjustments-complete
lower |
10 |
| 5421 |
Adjustments-partial
upper |
10 |
| 5422 |
Adjustments-partial
lower |
10 |
| 5710 |
Rebase
complete upper denture
(laboratory) |
80 |
| 5711 |
Rebase
complete lower denture
(laboratory) |
80 |
| 5720 |
Rebase
partial upper denture
(laboratory) |
80 |
| 5721 |
Rebase
partial lower denture
(laboratory) |
80 |
| 5730 |
Reline
complete upper denture
(office) |
50 |
| 5731 |
Reline
complete lower denture
(office) |
50 |
| 5740 |
Reline
partial upper denture
(office) |
50 |
| 5741 |
Reline
partial lower denture
(office) |
50 |
| 5750 |
Reline
complete upper denture
(laboratory) |
80 |
| 5751 |
Reline
complete lower denture
(laboratory) |
80 |
| 5760 |
Reline
partial upper denture
(laboratory) |
80 |
| 5761 |
Reline
partial lower denture
(laboratory) |
80 |
| 5850 |
Tissue
conditioning, upper |
20 |
| 5851 |
Tissue
conditioning, lower |
20 |
