|
19.15.8 Prosthodontic (Removable) Services
|
Procedure Code
|
Limitations
|
Maximum Fee
|
|
Complete Dentures (Including Routine Post Delivery Care)
|
|
D5110
|
A 3-20, PXR
|
$375.00
|
|
D5120
|
A 3-20, PXR
|
$375.00
|
|
D5130
|
A 13-20, N, PXR, CCP
|
$387.50
|
|
D5140
|
A 13-20, N, PXR, CCP
|
$387.50
|
|
Partial Dentures (Including Routine Post Delivery Care)
|
|
D5211*
|
A 6-20, PXR, MTID
|
$275.00
|
|
D5212*
|
A 6-20, PXR, MTID
|
$275.00
|
|
D5213
|
A 9-20, N, PXR, MTID, CCP
|
$400.00
|
|
D5214
|
A 9-20, N, PXR, MTID, CCP
|
$400.00
|
|
D5281*
|
A 9-20, N, PXR, MTID, CCP
|
$250.00
|
|
Adjustments to Dentures
|
|
D5410
|
A 3-20, PXR
|
$18.75
|
|
D5411
|
A 3-20, PXR
|
$18.75
|
|
D5421
|
A 6-20, PXR
|
$18.75
|
|
D5422
|
A 6-20, PXR
|
$18.75
|
|
Repairs to Complete Dentures
|
|
D5510
|
Cost of repairs cannot exceed replacement costs. A 3-20, PXR
|
$50.00
|
|
D5520
|
Cost of repairs cannot exceed replacement costs. A 3-20, PXR
|
$43.75
|
|
Repairs to Partial Dentures
Cost of repairs cannot exceed replacement costs. A bill for the laboratory portion not to exceed $137.50 must be submitted.
|
|
D5610*
|
A 3-20, PXR
|
$115.00
|
|
D5620
|
A 6-20, PXR
|
$56.25
|
|
D5630*
|
A 6-20, PXR
|
$50.00
|
|
D5640*
|
A 6-20, PXR
|
$43.75
|
|
D5650*
|
A 6-20, PXR
|
$50.00
|
|
D5660*
|
A 6-20, PXR
|
$62.50
|
|
D5670*
|
Will be denied as part of procedure codes D5211, D5213, D5281, and D5640. A 6-20
|
$175.00
|
|
D5671*
|
Will be denied as part of procedure codes D5212, D5214, D5281, and D5640. A 6-20
|
$175.00
|
|
Denture Rebase Procedures
|
|
D5710
|
A 4-20, PXR
|
$137.50
|
|
D5711
|
A 4-20, PXR
|
$137.50
|
|
D5720*
|
A 7-20, PXR
|
$137.50
|
|
D5721*
|
A 7-20, PXR
|
$137.50
|
|
Denture Reline Procedures
Allowed whether or not the denture was obtained through THSteps or ICF-MR dental services if the reline makes the denture serviceable.
|
|
D5730
|
A 4-20, N, PXR, CCP
|
$81.25
|
|
D5731
|
A 4-20, N, PXR, CCP
|
$81.25
|
|
D5740*
|
A 7-20, N, PXR, CCP
|
$75.00
|
|
D5741*
|
A 7-20, N, PXR, CCP
|
$75.00
|
|
D5750
|
A 4-20, PXR
|
$118.75
|
|
D5751
|
A 4-20, PXR
|
$118.75
|
|
D5760*
|
A 7-20, PXR
|
$118.75
|
|
D5761*
|
A 7-20, PXR
|
$118.75
|
|
Interim Prosthesis
|
|
D5810
|
A 3-20, N, PXR, CCP
|
$200.00
|
|
D5811
|
A 3-20, N, PXR, CCP
|
$200.00
|
|
D5820
|
A 3-20, N, PXR, CCP
|
$162.50
|
|
D5821
|
A 3-20, N, PXR, CCP
|
$162.50
|
|
Other Removable Prosthetic Services
|
|
D5850
|
A 3-20, N, PXR, CCP
|
$37.50
|
|
D5851
|
A 3-20, N, PXR, CCP
|
$37.50
|
|
D5860
|
A 4-20, N, PXR, CCP
|
$387.50
|
|
D5861
|
A 4-20, N, PXR, CCP
|
$387.50
|
|
D5862
|
A 4-20, N, PXR, CCP
|
$162.50
|
|
D5867
|
Denied as part of any repair or modification of any removable prosthetic.
|
NC
|
|
D5875
|
Denied as part of any repair or modification of any removable prosthetic.
|
NC
|
|
D5899
|
A 1-20, N, PXR, CCP
|
Manually priced
|
|
Maxillofacial Prosthetics
|
|
D5911
|
A 1-20, N, PXR, CCP
|
$50.00
|
|
D5912
|
A 1-20, N, PXR, CCP
|
$90.00
|
|
D5913
|
A 1-20, N, PXR, CCP
|
$875.00
|
|
D5914
|
A 1-20, N, PXR, CCP
|
$875.00
|
|
D5915
|
A 1-20, N, PXR, CCP
|
$875.00
|
|
D5916
|
A 1-20, N, PXR, CCP
|
$562.50
|
|
D5919
|
A 1-20, N, PXR, CCP
|
$1,125.00
|
|
D5922
|
A 1-20, N, PXR, CCP
|
$140.00
|
|
D5923
|
A 1-20, N, PXR, CCP
|
$337.50
|
|
D5924
|
A 1-20, N, PXR, CCP
|
$437.50
|
|
D5925
|
A 1-20, N, PXR, CCP
|
$375.00
|
|
D5926
|
A 1-20, N, PXR, CCP
|
$450.00
|
|
D5927
|
A 1-20, N, PXR, CCP
|
$450.00
|
|
D5928
|
A 1-20, N, PXR, CCP
|
$450.00
|
|
D5929
|
A 1-20, N, PXR, CCP
|
$900.00
|
|
D5931
|
A 1-20, N, PXR, CCP
|
$375.00
|
|
D5932
|
A 1-20, N, PXR, CCP
|
$1,300.00
|
|
D5933
|
A 1-20, N, PXR, CCP
|
$281.25
|
|
D5934
|
A 1-20, N, PXR, CCP
|
$562.50
|
|
D5935
|
A 1-20, N, PXR, CCP
|
$562.50
|
|
D5936
|
A 1-20, N, PXR, CCP
|
$625.00
|
|
D5937
|
A 1-20, N, PXR, CCP
|
$262.50
|
|
D5951
|
Ortho only-requires prior authorization. A Birth-20, N, PXR
|
$140.00
|
|
D5952
|
Ortho only-requires prior authorization. A Birth-20, N, PXR
|
$843.75
|
|
D5953
|
Ortho only-requires prior authorization. A 13-20, N, PXR
|
$843.75
|
|
D5954
|
Ortho only-requires prior authorization. A Birth-20, N, PXR
|
$443.75
|
|
D5955
|
Ortho only-requires prior authorization. A Birth-20, N, PXR
|
$225.00
|
|
D5958
|
Ortho only-requires prior authorization. A Birth-20, N, PXR
|
$225.00
|
|
D5959
|
Ortho only-requires prior authorization. A Birth-20, N, PXR
|
$100.00
|
|
D5960
|
Ortho only-requires prior authorization. A Birth-20, N, PXR
|
$100.00
|
|
D5982
|
A 1-20, N, PXR, CCP
|
$112.50
|
|
D5983
|
A 1-20, N, PXR, CCP
|
$162.50
|
|
D5984
|
A 1-20, N, PXR, CCP
|
$162.50
|
|
D5985
|
A 1-20, N, PXR, CCP
|
$162.50
|
|
D5986
|
A 1-20, N, PXR, CCP
|
$50.00
|
|
D5987
|
A 1-20, N, PXR, CCP
|
$131.25
|
|
D5988
|
A 1-20, N, PXR
|
$112.50
|
|
D5999
|
A 1-20, N, PXR, CCP
|
Manually priced
|
|
|
|
|
