Page 93

Effective Date:

Approval Date: 93

D4211 Gingivectomy or gingivoplasty – one to three teeth D4240 Gingival flap procedure, four or more teeth – Limited to 1 every 36 months D4249 Clinical crown lengthening-hard tissue D4260 Osseous surgery (including flap entry and closure), four or more contiguous teeth or bounded teeth spaces per quadrant – Limited to 1 every 36 months D4270 Pedicle soft tissue graft procedure D4271 Free soft tissue graft procedure (including donor site surgery) D4273 Subepithelial connective tissue graft procedures (including donor site surgery) D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis – Limited to 1 per lifetime Prosthodontic Services D5110 Complete denture - maxillary – Limited to 1 every 60 months D5120 Complete denture - mandibular – Limited to 1 every 60 months D5130 Immediate denture - maxillary – Limited to 1 every 60 months D5140 Immediate denture - mandibular – Limited to 1 every 60 months D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) – Limited to 1 every 60 months D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) – Limited to 1 every 60 months D5213 Maxillary partial denture - cast metal framework with resin denture base (including any conventional clasps, rests and teeth)– Limited to 1 every 60 months D5214 Mandibular partial denture - cast metal framework with resin denture base (including any conventional clasps, restsand teeth) – Limited to 1 every 60 months D5281 Removable unilateral partial denture-one piece cast metal (including clasps and teeth) – Limited to 1 every 60 months D6241 Pontic - porcelain fused to predominately base metal – Limited to 1 every 60 months D6242 Pontic - porcelain fused to noble metal – Limited to 1 every 60 months D6245 Pontic - porcelain/ceramic – Limited to 1 every 60 months D6519 Inlay/onlay – porcelain/ceramic – Limited to 1 every 60 months D6520 Inlay – metallic – two surfaces – Limited to 1 every 60 months D6530 Inlay – metallic – three or more surfaces 1 every 60 months D6543 Onlay – metallic – three surfaces 1 every 60 months D6544 Onlay – metallic – four or more surfaces 1 every 60 months D6545 Retainer - cast metal for resin bonded fixed prosthesis -1 every 60 months D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis -1 every 60 months D6740 Crown - porcelain/ceramic -1 every 60 months D6750 Crown - porcelain fused to high noble metal - 1 every 60 months D6751 Crown - porcelain fused to predominately base metal - 1 every 60 months D6752 Crown - porcelain fused to noble metal - 1 every 60 months D6780 Crown - 3/4 cast high noble metal - 1 every 60 months D6781 Crown - 3/4 cast predominately base metal - 1 every 60 months D6782 Crown - 3/4 cast noble metal - 1 every 60 months D6783 Crown - 3/4 porcelain/ceramic - 1 every 60 months D6790 Crown - full cast high noble metal - 1 every 60 months D6791 Crown - full cast predominately base metal - 1 every 60 months D6792 Crown - full cast noble metal - 1 every 60 months D6973 Core buildup for retainer, including any pins - 1 every 60 months D9940 Occlusal guard, by report - 1 in 12 months for patients 13 and older