OTHER PERIODONTAL SERVICES Periodontal Maintenance Yes NO YES $39.00 Unscheduled Dressing Change (by someone than Yes No No $27.00 treating dentist or their staff) D4999 Unspecified Periodontal Procedure, by Report Yes Yes Yes Yes By Report VI. PROSTHODONTICS, REMOVABLE COMPLETE DENTURES (INCLUDING ROUTINE POST DELIVERY CARE) Covered Service Prior Authorization Additional Limits Max Proc. Description Age/ICF-IID required Allow Code under 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 D5110 Complete Denture - Maxillary Yes Yes Yes Yes Every 5 years, Denturists may $393.00 also use this code D5120 Complete Denture - Mandibular Yes Yes Yes Yes Every 5 years, Denturists may $393.00 also use this code D5130 Immediate Denture - Maxillary Yes Yes Yes Yes Every 5 years, Denturists may $423.00 also use code D5140 Immediate Denture - Mandibular Yes Yes Yes Yes Every 5 years, Denturists may $423.00 also use this code PARTIAL DENTURES (INCLUDING ROUTINE POST-DELIVERY CARE)
OTHER PERIODONTAL SERVICES Periodontal Maintenance Yes NO YES $39.00 Unscheduled Dressing Change (by someone than treating dentist or their staff) Yes No No $27.00 D4999 Unspecified Periodontal Procedure, by Report Yes Yes Yes Yes By Report VI. PROSTHODONTICS, REMOVABLE COMPLETE DENTURES (INCLUDING ROUTINE POST DELIVERY CARE) Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow under 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 D5110 Complete Denture - Maxillary Yes Yes Yes Yes Every 5 years, Denturists may also use this code $393.00 D5120 Complete Denture - Mandibular Yes Yes Yes Yes Every 5 years, Denturists may also use this code $393.00 D5130 Immediate Denture - Maxillary Yes Yes Yes Yes Every 5 years, Denturists may also use code $423.00 D5140 Immediate Denture - Mandibular Yes Yes Yes Yes Every 5 years, Denturists may also use this code $423.00 PARTIAL DENTURES (INCLUDING ROUTINE POST-DELIVERY CARE)
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