D5730 Reline Complete Maxillary Denture (chairside) Yes Yes No No Refer to Chapter II, 25.03. $78.00 Denturists may also use this code. D5731 Reline Complete Mandibular Denture (chairside) Yes Yes No No Refer to Chapter II, 25.03. $78.00 Denturists may also use this code. D5740 Reline Maxillary Partial Denture (chairside) No No Not Covered D5741 Reline Mandibular Partial Denture (chairside) No No Not Covered Covered Service Prior Authorization Additional Limits Max Proc. Description Age/ICF-IID required Allow Code age 21 age 21 & under age age 21 & & all over when 21 & all over allowed ICF-IID when residents* under residents allowed 25.04 under 25.04 D5750 Reline Complete Maxillary Denture (laboratory) Yes Yes No No Refer to Chapter II, 25.03. $150.00 Denturists may also use this code. D5751 Reline Complete Mandibular Denture (laboratory) Yes Yes No No Refer to Chapter II, 25.03. $150.00 Denturists may also use this code. D5760 Reline Maxillary Partial Denture (laboratory) No No Not Covered D5761 Reline Mandibular Partial Denture (laboratory) No No Not Covered INTERIM PROSTHESIS D5810 Interim Complete Denture (maxillary) No No Not Covered D5811 Interim Complete Denture (mandibular) No No Not Covered D5820 Interim Partial Denture (maxillary) No No Not Covered Interim Partial Denture (mandibular) No No Not Covered OTHER REMOVABLE PROSTHETIC SERVICES
D5730 Reline Complete Maxillary Denture (chairside) Yes Yes No No Refer to Chapter II, 25.03. Denturists may also use this code. $78.00 D5731 Reline Complete Mandibular Denture (chairside) Yes Yes No No Refer to Chapter II, 25.03. Denturists may also use this code. $78.00 D5740 Reline Maxillary Partial Denture (chairside) No No Not Covered D5741 Reline Mandibular Partial Denture (chairside) No No Not Covered Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow age 21 & all residents* age 21 & over when allowed under 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D5750 Reline Complete Maxillary Denture (laboratory) Yes Yes No No Refer to Chapter II, 25.03. Denturists may also use this code. $150.00 D5751 Reline Complete Mandibular Denture (laboratory) Yes Yes No No Refer to Chapter II, 25.03. Denturists may also use this code. $150.00 D5760 Reline Maxillary Partial Denture (laboratory) No No Not Covered D5761 Reline Mandibular Partial Denture (laboratory) No No Not Covered INTERIM PROSTHESIS D5810 Interim Complete Denture (maxillary) No No Not Covered D5811 Interim Complete Denture (mandibular) No No Not Covered D5820 Interim Partial Denture (maxillary) No No Not Covered Interim Partial Denture (mandibular) No No Not Covered OTHER REMOVABLE PROSTHETIC SERVICES
c3s025.docx