PERSONAL AND DEPENDENT DENTAL CARE COVERAGE

PERSONAL AND DEPENDENT DENTAL CARE COVERAGE TA BLE OF DENT A L PROCEDURES The following list of dental procedures for which benefits are payable unde...
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PERSONAL AND DEPENDENT DENTAL CARE COVERAGE TA BLE OF DENT A L PROCEDURES

The following list of dental procedures for which benefits are payable under this section is based upon the Current Dental Terminology, (CDT-4), copyrighted 2002, American Dental Association. No benefits are payable for a procedure that is not listed. For procedures which reference a Benefit Period, see the Schedule of Benefits for the definition of Benefit Period. To determine Covered Expenses for each procedure refer to the PAYMENT BASIS column. BR means By Report. UCR means usual, customary and reasonable. Please read the section DENTAL EXPENSE BENEFITS and "Limitations" for additional coverage information. TYPE I PREVENTIVE PROCEDURES PROC. NO.

0120 0150 0180

PA Y M ENT BA SIS

Periodic oral exam. Comprehensive oral evaluation - new or established patient. Comprehensive periodontal evaluation - new or established patient.

UCR UCR UCR

Two evaluations will be allow ed in a Benefit Period. A 0 120, 0150, or 0180 counts toward this maximum allowance. 0150 and 0180 will be limited to once per provider.

0210 0330

Entire denture series, including bitewings. Panoramic film.

UCR UCR

0210 or 0330: One of these procedures will be allowed in a 3-year period.*

0220 0230 0240 0250 0260 0270 0272 0274 0277

Periapical radiograph - first film. Additional periapical film, each. Intraoral, occlusal film. Extraoral, first film. Extraoral, each additional film. Bitewing, single film. Bitewings - two films. Bitewings - four films. Vertical bitewings - 7 to 8 films.

UCR UCR UCR UCR UCR UCR UCR UCR UCR

Bitew ing films are limited to 2 allowances in a Benefit Period. A 0270 , 0272, 027 4, or 027 7 counts tow ard this maximum allowance. In addition, 0277 w ill be limited to once in a 3-year period.*

1110 1120

Prophylaxis - adult. Prophylaxis - child. Prophylaxis (cleaning) will be allowed twice in a Benefit Period. A 1110, 112 0 or 120 1 counts toward this maximum allowance. Periodontal maintenance may be substituted for a cleaning (see requirements under Type I(B) section). An adult prophylaxis is considered for individuals age 14 and over. A child prophylaxis is considered for individuals age 1 3 and under.

*The frequency is measured forward from the last covered date of service for the procedure.

UCR UCR

PROC. NO.

1201 1203

PA Y M ENT BA SIS

Topical fluoride and prophylaxis. Topical fluoride (reported as a separate code) in conjunction with prophylaxis - child.

UCR UCR

1201 or 1203: Coverage for fluoride treatment is limited to persons age 1 8 and under and to one treatment in a Benefit Period.

1510 1515 1520 1525

Space maintainer - fixed - unilateral. Space maintainer - fixed - bilateral. Space maintainer - removable - unilateral. Space maintainer - removable - bilateral.

UCR UCR UCR UCR

1510-1525: Coverage is limited to space maintenance for unerupted teeth, following extraction of primary teeth. Allow ance includes all adjustments within 6 months after installation.

1550 8210 8220

Recement space maintainer. Removable appliance therapy. Fixed appliance therapy. 8210-8 220: Coverage is limited to the correction of thumb-sucking.

UCR UCR UCR

TYPE II BASIC PROCEDURES PROC. NO.

PA Y M ENT BA SIS

MISCELLANEOUS PROCEDURES. 0140 0170

Limited oral evaluation - problem focused. Re-evaluation - limited, problem focused (established patient; not post-operative visit).

UCR UCR

0140 and 017 0: Coverage is limited to accidental injury only. If not due to an accident, will be considered as a 0120 and count toward this maximum allowance.

0472 0473 0474

Accession of tissue, gross examination, preparation and transmission of written report. Accession of tissue, gross and microscopic examination, preparation and transmission of written report. Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report. 0472-0474: Coverage biopsy/excision.

1351

is

limited

to

one

examination

UCR UCR UCR

per

Sealant - per tooth.

UCR

1351: Coverage is limited to treatment of the occlusal surface of permanent molar teeth once during a 3-year period for persons age 16 and under.*

2910 2920 6930 4355

Recement inlay. Recement crown. Recement fixed partial denture. Full mouth debridement to enable comprehensive evaluation and diagnosis.

UCR UCR UCR UCR

4355: Coverage is limited to once during a 5-year period.*

4910

Periodontal maintenance.

UCR

4910: This procedure is available in place of an eligible routine prophylaxis (1110-1120) as listed above. Coverage is contingent upon evidence of full mouth active periodontal therapy and limited to 2 allowances in a Benefit Period (a 1110, 1120 or 1201 counts tow ard this maximum allowance). Benefits will not be available if performed on the same date as other periodontal services.

5510 5520 5610

Repair broken complete denture base. Replace missing or broken teeth - complete denture (each tooth). Repair resin denture base - partial denture.

*The frequency is measured forward from the last covered date of service for the procedure.

UCR UCR UCR

PROC. NO.

5620 5630 5640 5730 5731 5740 5741 5750 5751 5760 5761

PA Y M ENT BA SIS

Repair cast framework - partial denture. Repair or replace broken clasp - partial denture. Replace broken teeth (per tooth) - partial denture. Reline complete maxillary denture (chairside). Reline complete mandibular denture (chairside). Reline maxillary partial denture (chairside). Reline mandibular partial denture (chairside). Reline complete maxillary denture (laboratory). Reline complete mandibular denture (laboratory). Reline maxillary partial denture (laboratory). Reline mandibular partial denture (laboratory).

UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR

5730-5761: Coverage for relines is limited to service dates more than 6 months after installation.

9110

Palliative (emergency) treatment of dental pain - minor procedure.

UCR

9110: Not covered in conjunction with other procedures, except diagnostic x-ray films.

9310

Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment).

UCR

9310: Coverage is limited to one allow ance per provider.

9440

Office visit after regularly scheduled hours.

UCR

9440: Payment will be made on basis of services rendered or visit, whichever is greater.

9930

Treatment of complications (post-surgical) - unusual circumstances, by report.

UCR

RESTORATIVE (Excluding inlays, crowns). 2140 2150 2160 2161 2330 2331 2332 2335 2391 2392 2393 2394

Amalgam - one surface, primary or permanent. Amalgam - two surfaces, primary or permanent. Amalgam - three surfaces, primary or permanent. Amalgam - four or more surfaces, primary or permanent. Resin-based composite - one surface, anterior. Resin-based composite - two surfaces, anterior. Resin-based composite - three surfaces, anterior. Resin-based composite - four or more surfaces or involving incisal angle, anterior. Resin-based composite - one surface, posterior. Resin-based composite - two surfaces, posterior. Resin-based composite - three surfaces, posterior. Resin-based composite - four or more surfaces, posterior. 2391-2 394: Coverage is limited to permanent bicuspid teeth.

UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR

TYPE II BASIC PROCEDURES (Cont inued) PROC. NO.

2390 2930 2931 2932

PA Y M ENT BA SIS

Resin-based composite crown, anterior. Prefabricated stainless steel crown - primary tooth. Stainless steel crown - permanent tooth. Prefabricated resin crown.

UCR UCR UCR UCR

2390, 2930-2 932: Coverage is limited to persons age 18 and under. Please refer to type III procedures to coverage for persons 19 and older.

2951

Pin retention, per tooth, in addition to restoration.

UCR

ENDODONTICS. 3220

3221 3230 3240 3310 3320 3330 3332 3333

Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament. Limited to treatment of primary teeth. Pulpal debridement, primary and permanent teeth. Pulpal therapy (resorbable filling) - anterior, primary tooth. Pulpal therapy (resorbable filling) - posterior, primary tooth. Root canal, anterior (excluding final restoration). Root canal, bicuspid (excluding final restoration). Root canal, molar (excluding final restoration). Incomplete endodontic therapy; inoperable or fractured tooth. Internal root repair of perforation defects.

UCR

UCR UCR UCR UCR UCR UCR UCR UCR

3310-3333: Coverage is limited to permanent teeth. Allowance includes intraoperative films and cultures but excludes final restoration.

3346 3347 3348

Retreatment of previous root canal therapy - anterior. Retreatment of previous root canal therapy - bicuspid. Retreatment of previous root canal therapy - molar.

UCR UCR UCR

3346-3348: Coverage is limited to permanent teeth and to service dates more than 12 months after root canal therapy or a previous retreatment. Allowance includes intraoperative films and cultures but excludes final restoration.

3351 3352 3353 3410 3421 3425 3426 3430 3450 3920

Apexification/recalcification - initial visit. Apexification/recalcification - interim medication replacement. Apexification/recalcification - final visit. Apicoectomy/periradicular surgery - anterior. Apicoectomy/periradicular surgery - bicuspid (first root). Apicoectomy/periradicular surgery - molar (first root). Apicoectomy/periradicular surgery - (each additional root). Retrograde filling - per root. Root amputation - per root. Hemisection (including any root removal), not including root canal therapy.

UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR

PROC. NO.

PA Y M ENT BA SIS

PERIODONTICS. Surgical Procedures (including postoperative visits). 4210 4211 4240 4241 4260 4261 4263 4264 4265 4270 4271 4273 4274 4275 4276

Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant. Gingivectomy or gingivoplasty - one to three teeth, per quadrant. Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant. Gingival flap procedure, including root planing - one to three teeth, per quadrant. Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant. Osseous surgery (including flap entry and closure) one to three teeth, per quadrant. Bone replacement graft - first site in quadrant. Bone replacement graft - each additional site in quadrant. Biologic materials to aid in soft and osseous tissue regeneration. Pedicle soft tissue graft procedure. Free soft tissue graft procedure (including donor site surgery). Subepithelial connective tissue graft procedures. Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area). Soft tissue allograft. Combined connective tissue and double pedicle graft.

UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR

4210-4276: Each procedure is eligible for consideration once in a 3-year period. Coverage is limited to treatment of periodontal disease.*

Non-surgical Periodontal Procedures. 4341 4342

Periodontal scaling and root planing - four or more contiguous teeth or bounded teeth spaces per quadrant. Periodontal scaling and root planing, one to three teeth, per quadrant.

UCR UCR

4341-4342: Each procedure is eligible for consideration once in a 2year period.*

4381

Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth. 4381: A scaling and planing (4341) must be performed betw een six weeks and two years prior to treatment. A maximum of two sites per quadrant will be considered and the frequency is limited to once in any 2-year period.*

*The frequency is measured forward from the last covered date of service for the procedure.

UCR

TYPE II BASIC PROCEDURES (Cont inued) PROC. NO.

9951 9952

PA Y M ENT BA SIS

Occlusal adjustment, limited. Occlusal adjustment, complete.

UCR UCR

9951-9952: Coverage is limited to adjustment performed in conjunction with treatment of periodontal disease.

ORAL SURGERY. 7111 7140 7210 7220 7230 7240 7241 7250 7260 7261 7270 7272 7280 7281 7282 7285 7286 7287 7310 7320 7340 7350 7410 7411 7412 7413 7414 7415 7440 7441

Coronal remnants - deciduous tooth. Extraction, erupted tooth or exposed root (elevation and/or forceps removal). Surgical removal of erupted tooth. Surgical removal of impacted tooth - soft tissue. Surgical removal of impacted tooth - partially bony. Surgical removal of impacted tooth - completely bony. Removal of impacted tooth completely bony, with unusual surgical complications, by report. Surgical removal of residual tooth roots (cutting procedure). Oral antral fistula closure. Primary closure of a sinus perforation. Tooth re-implantation and/or stabilization of accidentally evulsed or displaced tooth. Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization). Surgical access of an unerupted tooth. Surgical exposure of impacted or unerupted tooth to aid eruption. Mobilization of erupted or malpositioned tooth to aid eruption. Biopsy of oral tissue - hard. Biopsy of oral tissue - soft. Cytology sample collection. Alveoloplasty in conjunction with extractions-per quadrant. Alveoloplasty not in conjunction with extractions-per quadrant. Vestibuloplasty - ridge extension (secondary epithelialization). Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue). Excision of benign lesion up to 1.25 cm. Excision of benign lesion greater than 1.25 cm. Excision of benign lesion, complicated. Excision of malignant lesion up to 1.25 cm. Excision of malignant lesion greater than 1.25 cm. Excision of malignant lesion, complicated. Excision of malignant tumor-lesion diameter up to 1.25 cm. Excision of malignant tumor-lesion diameter greater than 1.25 cm.

UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR

PROC. NO.

7450 7451 7460 7461 7465 7471 7472 7473

PA Y M ENT BA SIS

Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm. Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm. Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm. Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm. Destruction of lesion(s) by physical or chemical method, by report. Removal of lateral exostosis - (maxilla or mandible). Removal of torus palatinus. Removal of torus mandibularis.

UCR UCR UCR UCR UCR UCR UCR UCR

7471-7 473: A maximum of 5 allow ances will be considered.

7485 7510 7520 7530 7540 7550 7560 7910 7911 7912 7960 7970 7972 7980 7983

Surgical reduction of osseous tuberosity. Incision and drainage of abscess - intraoral soft tissue. Incision and drainage of abscess - extraoral soft tissue. Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue. Removal of reaction-producing foreign bodies musculoskeletal system. Partial ostectomy/sequestrectomy for removal of non-vital bone. Maxillary sinusotomy for removal of tooth fragment or foreign body. Suture of recent small wounds - up to 5 cm. Complicated suture - up to 5 cm. Complicated suture - greater than 5 cm. Frenulectomy (frenectomy or frenotomy)-separate procedure. Excision of hyperplastic tissue - per arch. Surgical reduction of fibrous tuberosity. Sialolithotomy. Closure of salivary fistula.

UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR

ANESTHESIA. 9220 9221 9241 9242

Deep sedation/general anesthesia - first 30 minutes. Deep sedation/general anesthesia - each additional 15 minutes. Intravenous conscious sedation/analgesia - first 30 minutes. Intravenous conscious sedation/analgesia - each additional 15 minutes. 9220-9242: Coverage is not available without a cutting procedure. Verification of the dentist’ s anesthesia permit and a copy of the anesthesia report is required. A maximum of tw o additional units (92 21 or 9242) w ill be considered.

UCR UCR UCR UCR

TYPE III PROCEDURES PROC. NO.

PA Y M ENT BA SIS

RESTORATIVE - Inlays and Crowns. 2510 2520 2530 2610 2620 2630 2650 2651 2652

Inlay - metallic - one surface. Inlay - metallic - two surfaces. Inlay - metallic - three or more surfaces. Inlay - porcelain/ceramic - one surface. Inlay - porcelain/ceramic - two surfaces. Inlay - porcelain/ceramic - three or more surfaces. Inlay - composite/resin - one surface. Inlay - composite/resin - two surfaces. Inlay - composite/resin - three or more surfaces.

UCR UCR UCR UCR UCR UCR UCR UCR UCR

2610-2630 and 2650-2652: Coverage is limited to permanent bicuspid teeth.

2390 2543 2544 2642 2643 2644 2662 2663 2664 2710 2720 2721 2722 2740 2750 2751 2752 2780 2781 2782 2783 2790 2791 2792 2930 2931 2932

Resin-based composite crown, anterior. Onlay - metallic - three surfaces. Onlay - metallic - four or more surfaces. Onlay - porcelain/ceramic - two surfaces. Onlay - porcelain/ceramic - three surfaces. Onlay - porcelain/ceramic - four or more surfaces. Onlay - composite/resin - two surfaces. Onlay - composite/resin - three surfaces. Onlay - composite/resin - four or more surfaces. Crown - resin (indirect). Crown - resin with high noble metal. Crown - resin with predominantly base metal. Crown - resin with noble metal. Crown - porcelain/ceramic substrate. Crown - porcelain fused to high noble metal. Crown - porcelain fused to predominantly base metal. Crown - porcelain fused to noble metal. Crown - 3/4 cast high noble metal. Crown - 3/4 cast predominantly base metal. Crown - 3/4 cast noble metal. Crown - 3/4 porcelain/ceramic. Crown - full cast high noble metal. Crown - full cast predominantly base metal. Crown - full cast noble metal. Prefabricated stainless steel crown - primary tooth. Prefabricated stainless steel crown - permanent tooth. (Adults - age 19 and over). Prefabricated resin crown. 2390-2932: These procedures are limited to necessary placement resulting from decay or traumatic injury. Benefits for high noble metal procedures will be determined at the allowance of a cast metal. All procedures are subject to consultant review.

UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR

PROC. NO.

2950 2952 2954 2980 4249

PA Y M ENT BA SIS

Core build-up, including any pins. Cast post and core - in addition to crown. Prefabricated post and core - in addition to crown. Crown repair, by report. Clinical crown lengthening, hard tissue.

UCR UCR UCR UCR UCR

PROSTHODONTICS - FIXED. Pontics. 6210 6211 6212 6240 6241 6242 6245 6250 6251 6252

Cast high noble metal. Cast predominantly base metal. Cast noble metal. Porcelain fused to high noble metal. Porcelain fused to predominantly base metal. Porcelain fused to noble metal. Porcelain/ceramic. Resin with high noble metal. Resin with predominantly base metal. Resin with noble metal.

UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR

Implant Supported. 6058 6059 6060 6061 6062 6063 6064 6065 6066 6067 6068 6069 6070 6071 6072 6073 6074 6075

Abutment supported porcelain/ceramic crown. Abutment supported porcelain fused to metal crown (high noble metal). Abutment supported porcelain fused to metal crown (predominantly base metal). Abutment supported porcelain fused to metal crown (noble metal). Abutment supported cast metal crown (high noble metal). Abutment supported cast metal crown (predominantly base metal). Abutment supported cast metal crown (noble metal). Implant supported porcelain/ceramic crown. Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal). Implant supported metal crown (titanium, titanium alloy, high noble metal). Abutment supported retainer of porcelain/ceramic FPD. Abutment supported retainer for porcelain fused to metal FPD (high noble metal). Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal). Abutment supported retainer for porcelain fused to metal FPD (noble metal). Abutment supported retainer for cast metal FPD (high noble metal). Abutment supported retainer for cast metal FPD (predominantly base metal). Abutment supported retainer for cast metal FPD (noble metal). Implant supported retainer for ceramic FPD.

UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR

TYPE III PROCEDURES (Cont inued) PROC. NO.

6076 6077

PA Y M ENT BA SIS

Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal). Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal).

UCR UCR

6058-6077: Although implants are not a covered benefit, these procedures can qualify for benefits. Coverage is subject to the replacement and extraction provisions as defined under the limitations section of this contract.

Retainers (Abutments). 6545 6548 6600 6601 6602 6603 6604 6605 6606 6607 6608 6609 6610 6611 6612 6613 6614 6615 6720 6721 6722 6740 6750 6751 6752 6780 6781 6782 6783 6790 6791 6792 6940 6970

Retainer - cast metal for resin bonded fixed prosthesis. Retainer - porcelain/ceramic for resin bonded fixed prosthesis. Inlay - porcelain/ceramic, two surfaces. Inlay - porcelain/ceramic, three or more surfaces. Inlay - cast precious metal, two surfaces. Inlay - cast precious metal, three or more surfaces. Inlay - cast predominantly base metal, two surfaces. Inlay - cast predominantly base metal, three or more surfaces. Inlay - cast semi-precious metal, two surfaces. Inlay - cast semi-precious metal, three or more surfaces. Onlay - porcelain/ceramic, two surfaces. Onlay - porcelain/ceramic, three or more surfaces. Onlay - cast precious metal, two surfaces. Onlay - cast precious metal, three or more surfaces. Onlay - cast predominantly base metal, two surfaces. Onlay - cast predominantly base metal, three or more surfaces. Onlay - cast semi-precious metal, two surfaces. Onlay - cast semi-precious metal, three or more surfaces. Crown - resin with precious metal. Crown - resin with predominantly base metal. Crown - resin with semi-precious metal. Crown - porcelain/ceramic. Crown - porcelain fused to precious metal. Crown - porcelain fused to predominantly base metal. Crown - porcelain fused to semi-precious metal. Crown - 3/4 cast precious metal. Crown - 3/4 cast predominantly base metal. Crown - 3/4 cast semi-precious metal. Crown - 3/4 porcelain/ceramic. Crown - full cast precious metal. Crown - full cast predominantly base metal. Crown - full cast semi-precious metal. Stress breaker. Cast post and core in addition to fixed partial denture retainer.

UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR

PROC. NO.

6971 6972 6980

PA Y M ENT BA SIS

Cast post as part of fixed partial denture retainer. Prefabricated post and core in addition to fixed partial denture retainer. Fixed partial denture repair, by report.

UCR UCR UCR

PROSTHODONTICS - REMOVABLE. 5110 5120 5130 5140 5211 5212 5213 5214 5281

Complete denture - maxillary. Complete denture - mandibular. Immediate denture - maxillary. Immediate denture - mandibular. Maxillary partial denture - resin base. Mandibular partial denture - resin base. Maxillary partial denture-cast metal framework with resin denture bases. Mandibular partial denture-cast metal framework with resin denture bases. Removable unilateral partial denture - one piece cast metal.

UCR UCR UCR UCR UCR UCR UCR UCR UCR

5110-5281: Allow ances for partial and complete dentures include adjustments within 6 months after installation. Precision attachments, implants, overdentures, specialized techniques and charact erizat ions are considered optional and the additional expense for these shall be borne by the patient. All partial allowances include conventional clasps, rests and teeth.

5410 5411 5421 5422

Adjust complete denture - maxillary. Adjust complete denture - mandibular. Adjust partial denture - maxillary. Adjust partial denture - mandibular.

UCR UCR UCR UCR

5410-5422: Coverage is limited to an adjustment with a date of service more than 6 months after installation.

5650 5660 5670 5671

Add tooth to existing partial denture. Add clasp to existing partial denture. Replace all teeth and acrylic on cast metal framework (maxillary). Replace all teeth and acrylic on cast metal framework (mandibular).

UCR UCR UCR UCR

5670-5671: Prosthetic replacement limitation applies. See Limitations section.

5710 5711 5720 5721 5810 5811 5820 5821 5850 5851

Rebase complete maxillary denture. Rebase complete mandibular denture. Rebase maxillary partial denture. Rebase mandibular partial denture. Interim complete denture (maxillary). Interim complete denture (mandibular). Interim partial denture (maxillary). Interim partial denture (mandibular). Tissue conditioning - maxillary. Tissue conditioning - mandibular.

UCR UCR UCR UCR UCR UCR UCR UCR UCR UCR