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§ 10:56-3.7 D5000-D5899 PROSTHODONTICS (REMOVABLE)
(a) Complete dentures (including six months post delivery care):




Maximum Fee




HCPCS







Allowance

IND

Code

Mod

Procedure Description

S

$

NS

*

D5110




Complete Denture--Maxillary

334.00




302.00

NOTE: Including denture I.D.

*

D5120




Complete Denture--Mandibular

342.00




311.00

NOTE: Including denture I.D.

(b) Immediate complete dentures (six months post delivery care and placement of ID is included in fee):

1. Reimbursement also includes necessary rebases and/or relines for the six months following insertion.

2. In order to qualify for immediate denture reimbursement, the denture must involve the immediate replacement of anterior teeth which may include first premolars (teeth numbers 5 through 12 and 21 through 28 only). Second premolars and molars must not be included among the qualifying teeth. The date of insertion of a denture and the extractions must carry an identical date of service. List tooth code(s) of teeth involved.



*

D5130




Immediate Denture--Maxillary

365.00




332.00

NOTE 1: Replacing 1 through 4 teeth

*

D5130

22

Immediate Denture--Maxillary

392.00




353.00

NOTE 1: Replacing 5 through 8 teeth

*

D5140




Immediate Denture--Mandibular

372.00




338.00

NOTE 1: Replacing 1 through 4 teeth

*

D5140

22

Immediate Denture--Mandibular

400.00




363.00

NOTE 1: Replacing 5 through 8 teeth

(c) Partial dentures (including six month post delivery care):



*

D5211




Maxillary Partial Denture--Resin

275.00




250.00










Base (Including any conventional



















clasps, rests and teeth)










*

D5211

52

Maxillary Partial Denture--Resin

186.00




173.00










Base (Including teeth--no clasps)










*

D5212




Mandibular Partial Denture--Resin

275.00




250.00










Base (Including any conventional



















clasps, rests and teeth)










*

D5212

52

Mandibular Partial Denture--Resin

186.00




173.00










Base (Including teeth--no clasps)










*

D5213




Maxillary Partial Denture--Cast

361.00




328.00










Metal Framework with Resin Denture



















Bases (Including any conventional



















clasps, rests and teeth)










*

D5214




Mandibular Partial Denture--Cast

342.00




311.00










Metal Framework with Resin Denture



















Bases (Including any conventional



















clasps, rests and teeth)










(d) Immediate replacement of anterior teeth in conjunction with partial dentures (codes D5211 through D5214 only) in addition to denture, maximum six teeth (Teeth numbers 6 through 11 and 22 through 27 only).

1. Immediate partial dentures--Reimbursement also includes necessary rebases and/or relines for the six months following insertion.



*

Y2505




Immediate Replacement of Anterior

11.00




10.00










Teeth--Per Tooth










NOTE: List tooth code(s) of tooth being replaced.

(e) Adjustments to dentures--other than dentist providing denture or after the required period of post delivery care.






D5410




Adjust Complete Denture--Maxillary

10.00




9.00




D5411




Adjust Complete Denture--Mandibular

10.00




9.00




D5421




Adjust Partial Denture--Maxillary

10.00




9.00




D5422




Adjust Partial Denture--Mandibular

10.00




9.00

(f) Repairs to complete dentures:

1. Repair Broken Complete Denture Base:

i. Includes replacing teeth on denture




D5510

YU

Repair Broken Complete Denture Base

49.50




45.00

NOTE: Maxillary--Upper




D5510

YL

Repair Broken Complete Denture Base

49.50




45.00

NOTE: Mandibular--Lower.




D5520




Replace Missing or Broken

15.00




15.00










Teeth--Complete Denture (Each



















Tooth)










NOTE 1: Code may be used in addition to codes D5510 YU or YL above.

NOTE 2: List tooth codes of teeth being replaced.

(g) Repairs to partial denture:




D5610

YU

Repair Resin Denture Base

49.50




45.00

NOTE: Maxillary.




D5610

YL

Repair Resin Denture Base

49.50




45.00

NOTE: Mandibular.




D5620




Repair Cast Framework

33.00




30.00

NOTE 1: Welding in addition to repair procedure(s), limit two welds per denture.

NOTE 2: May be used in conjunction with other repair procedures or as a separate repair procedure.






D5630

YU

Repair or Replace Broken Clasp

76.50




72.00

NOTE 1: Maxillary.

NOTE 2: Maximum two.






D5630

YL

Repair or Replace Broken Clasp

76.50




72.00

NOTE 1: Mandibular.

NOTE 2: Maximum two.






D5640




Replace Broken Teeth--Per Tooth

15.00




15.00

NOTE 1: Code D5640 may be used in addition to partial denture repair procedure(s), D5610 YU or YL above.




D5650




Add Tooth to Existing Partial

66.00




60.00










Denture










NOTE 1: To replace extracted tooth. (List tooth code being replaced).

NOTE 2: For additional replacements beyond the first tooth, use code D5640. List tooth (teeth) being replaced.






D5660

YU

Add Clasp to Existing Partial

76.50




72.00










Denture










NOTE 1: Maxillary--First Clasp.

NOTE 2: List tooth code being clasped.

NOTE 3: Maximum two.




D5660

YL

Add Clasp to Existing Partial

76.50




72.00










Denture










NOTE 1: Mandibular--First Clasp.

NOTE 2: List tooth being clasped.

NOTE 3: Maximum two.

(h) Denture rebase procedures:






D5710




Rebase Complete Maxillary Denture

132.00




120.00




D5711




Rebase Complete Mandibular Denture

132.00




120.00




D5720




Rebase Maxillary Partial Denture

124.00




113.00




D5721




Rebase Mandibular Partial Denture

124.00




113.00

(i) Denture relining procedures:




D5730




Reline Complete Maxillary Denture

29.00




26.00










(Chairside)













D5731




Reline Complete Mandibular Denture

29.00




26.00










(Chairside)













D5740




Reline Maxillary Partial Denture

29.00




26.00










(Chairside)













D5741




Reline Mandibular Partial Denture

29.00




26.00










(Chairside)













D5750




Reline Complete Maxillary Denture

99.00




90.00










(Laboratory)













D5751




Reline Complete Mandibular Denture

99.00




90.00










(Laboratory)













D5760




Reline Maxillary Partial Denture

91.00




83.00










(Laboratory)













D5761




Reline Mandibular Partial Denture

91.00




83.00










(Laboratory)










(j) Other removable prosthetic services:




D5860




Overdenture--complete

342.00




311.00




D5862




Precision attachment

150.00




150.00




D5867




Replacement of replaceable part of

75.00




75.00










semi-precision or precision



















attachment (male or female



















component)










*

D5899




Unspecified Removable

BR




BR










Prosthodontic Procedure, By Report










41 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES



SUBCHAPTER 3. HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS)
N.J.A.C. 10:56-3.8 (2014)
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