ADA CODE |
|
Procedure |
|
Member Pays |
 |
 |
|
 |
 |
|
|
REMOVABLE PARTIAL AND COMPLETE DENTURES |
|
|
|
|
(Limit replacement to every 5 years) |
|
|
|
D5110 |
|
COMPLETE DENTURE-UPPER |
|
$498 |
D5120 |
|
COMPLETE DENTURE-LOWER |
|
$498 |
D5130 |
|
IMMEDIATE DENTURE-UPPER |
|
$543 |
D5140 |
|
IMMEDIATE DENTURE-LOWER |
|
$543 |
D5211 |
|
UPPER PARTIAL-RESIN BASE with CONVENTIONAL CLASPS - RESTS
&TEETH |
|
$420 |
D5212 |
|
LOWER PARTIAL-RESIN BASE with CONVENTIONAL CLASPS - RESTS
&TEETH |
|
$488 |
D5213 |
|
UPPER PARTIAL-CAST METAL RESIN BASE with CONVENTIONAL
CLASPS |
|
$550 |
D5214 |
|
LOWER PARTIAL-CAST METAL RESIN BASE with CONVENTIONAL
CLASPS |
|
$550 |
D5410 |
|
ADJUST COMPLETE DENTURE-UPPER |
|
$27 |
D5411 |
|
ADJUST COMPLETE DENTURE-LOWER |
|
$27 |
D5421 |
|
ADJUST PARTIAL DENTURE-UPPER |
|
$27 |
D5422 |
|
ADJUST PARTIAL DENTURE-LOWER |
|
$27 |
|
|
|
PROSTHETIC REPAIRS |
|
|
|
D5510 |
|
REPAIR BROKEN COMPLETE DENTURE BASE |
|
$55 |
D5520 |
|
REPLACE MISSING/BROKEN TOOTH - COMPLETE DENTURE-EA TOOTH |
|
$46 |
D5610 |
|
REPAIR RESIN DENTURE BASE |
|
$59 |
D5620 |
|
REPAIR CAST FRAMEWORK |
|
$64 |
D5630 |
|
REPAIR OR REPLACE BROKEN CLASP |
|
$77 |
D5640 |
|
REPLACE BROKEN TEETH-PER TOOTH |
|
$50 |
D5650 |
|
ADDITIONAL TOOTH TO EXISTING PARTIAL DENTURE |
|
$68 |
D5660 |
|
ADD CLASP TO EXISTING PARTIAL DENTURE |
|
$82 |
D5710 |
|
REBASE COMPLETE UPPER DENTURE |
|
$202 |
D5711 |
|
REBASE COMPLETE LOWER DENTURE |
|
$193 |
D5720 |
|
REBASE UPPER PARTIAL DENTURE |
|
$191 |
D5721 |
|
REBASE LOWER PARTIAL DENTURE |
|
$191 |
D5730 |
|
RELINE COMPLETE UPPER DENTURE - CHAIRSIDE |
|
$114 |
D5731 |
|
RELINE COMPLETE LOWER DENTURE - CHAIRSIDE |
|
$114 |
D5740 |
|
RELINE UPPER PARTIAL DENTURE - CHAIRSIDE |
|
$105 |
D5741 |
|
RELINE LOWER PARTIAL DENTURE - CHAIRSIDE |
|
$105 |
D5750 |
|
RELINE COMPLETE UPPER DENTURE (LAB) |
|
$152 |
D5751 |
|
RELINE COMPLETE LOWER DENTURE (LAB) |
|
$152 |
D5760 |
|
RELINE UPPER PARTIAL DENTURE (LAB) |
|
$150 |
D5761 |
|
RELINE LOWER PARTIAL DENTURE (LAB) |
|
$150 |
D5850 |
|
TISSUE CONDITIONING, MAXILLARY |
|
$48 |
D5851 |
|
TISSUE CONDITIONING, MANDIBULAR |
|
$48 |
 |