D5211 Maxillary Partial Denture-Resin Base (including any Yes YES Yes YES Every 5 years. Denturists may $280.00 conventional clasps, rests and teeth) also use this code. D5212 Mandibular Partial Denture-Resin Base (including any Yes YES Yes YES Every 5 years. Denturists may $280.00 conventional clasps, rests and teeth) also use this code. D5213 Maxillary Partial Denture-Cast Framework with Yes YES Yes YES Every 5 years. Denturists may $423.00 Resin Denture Bases (including any conventional clasps, also use this code. rests and teeth) 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* 25.04 residents allowed under 25.04 D5214 Mandibular Partial Denture-Cast Metal Framework with Yes YES Yes YES 5 years. Denturists may $423.00 Resin Denture Bases (including any conventional clasps, also use this code. and teeth) D5225 Maxillary Partial Denture-Flexible Base (including any NO NO Not Covered clasps, rests and teeth) D5226 Mandibular Partial Denture-Flexible Base (including any NO NO Not Covered clasps, rests and teeth) D5281 Removable Unilateral Partial Denture - One Piece Case No No Not Covered Metal (including clasps and teeth) ADJUSTMENTS TO DENTURES D5410 Adjust Complete Denture - Maxillary Yes Yes No No Denturists may also use this $26.00 code
D5211 Maxillary Partial Denture-Resin Base (including any conventional clasps, rests and teeth) Yes YES Yes YES Every 5 years. Denturists may also use this code. $280.00 D5212 Mandibular Partial Denture-Resin Base (including any conventional clasps, rests and teeth) Yes YES Yes YES Every 5 years. Denturists may also use this code. $280.00 D5213 Maxillary Partial Denture-Cast Framework with Resin Denture Bases (including any conventional clasps, rests and teeth) Yes YES Yes YES Every 5 years. Denturists may also use this code. $423.00 Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow age 21 & all residents* age 21 & over when allowed 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D5214 Mandibular Partial Denture-Cast Metal Framework with Resin Denture Bases (including any conventional clasps, and teeth) Yes YES Yes YES 5 years. Denturists may also use this code. $423.00 D5225 Maxillary Partial Denture-Flexible Base (including any clasps, rests and teeth) NO NO Not Covered D5226 Mandibular Partial Denture-Flexible Base (including any clasps, rests and teeth) NO NO Not Covered D5281 Removable Unilateral Partial Denture - One Piece Case Metal (including clasps and teeth) No No Not Covered ADJUSTMENTS TO DENTURES D5410 Adjust Complete Denture - Maxillary Yes Yes No No Denturists may also use this code $26.00
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