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Effective Date:

Approval Date: 91

D5630 Repair or replace broken clasp D5640 Replace broken teeth - per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture D5710 Rebase complete maxillary denture - Limited to 1 in a 36-month period 6 months after the initial installation D5720 Rebase maxillary partial denture - Limited to 1 in a 36-month period 6 months after the initial installation D5721 Rebase mandibular partial denture - Limited to 1 in a 36-month period 6 months after the initial installation D5730 Reline complete maxillary denture (chairside) - Limited to 1 in a 36-month period 6 months after the initial installation D5731 Reline complete mandibular denture (chairside) - Limited to 1 in a 36-month period 6 months after the initial installation D5740 Reline maxillary partial denture (chairside) - Limited to 1in a 36-month period 6 months after the initial installation D5741 Reline mandibular partial denture (chairside) - Limited to 1 in a 36-month period 6 months after the initial installation D5750 Reline complete maxillary denture (laboratory) - Limited to 1 in a 36-month period 6 months after the initial installation D5751 Reline complete mandibular denture (laboratory) - Limited to 1 in a 36-month period 6 months after the initial installation D5760 Reline maxillary partial denture (laboratory) - Limited to 1 in a 36-month period 6 months after the initial installation D5761 Reline mandibular partial denture (laboratory) Rebase/Reline - Limited to 1 in a 36-month period 6 months after the initial installation. D5850 Tissue conditioning (maxillary) D5851 Tissue conditioning (mandibular) D6930 Recement fixed partial denture D6980 Fixed partial denture repair, by report Oral Surgery D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth – partially bony D7240 Removal of impacted tooth - completely bony D7241 Removal of impacted tooth - completely bony with unusual surgical complications D7250 Surgical removal of residual tooth roots (cutting procedure) D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth D7280 Surgical access of an unerupted tooth D7310 Alveoloplasty in conjunction with extractions/quadrant D7311 Alveoloplasty in conjunction with extractions-1-3 teeth or tooth spaces/quadrant D7320 Alveoloplasty not in conjunction with extractions - per quadrant D7321 Alveoloplasty not in conjunction with extractions-1-3 three teeth or tooth spaces/quadrant D7471 Removal of exostosis D7510 Incision and drainage of abscess - intraoral soft tissue D7910 Suture of recent small wounds up to 5 cm D7971 Excision of pericoronal gingiva