Procedure Description Copayment Notes Full Mouth debridement, once every 12months and diagnosis on D4355 subsequent visit. 25 Localized delivery of antimicrobial agents via a controlled release D4381 vehicle into diseased crevicular tissue, per tooth 0 R D4910 Periodontal maintenance following active therapy 35 D5000 - D5899 VII. Prosthodontics, removable D5110 Complete denture, maxillary 140 D5120 Complete denture, mandibular 140 D5130 Immediate denture, maxillary 140 D5140 Immediate denture, mandibular 140 Maxillary partial denture – resin base (including retentive/clasping D5211 materials, rests, and teeth) 140 GAP Mandibular partial denture - resin base resin base (including D5212 retentive/clasping materials, rests, and teeth) 140 GAP Maxillary partial denture - cast metal framework with resin denture bases (including any retentive/clasping materials, rests D5213 and teeth) 140 Mandibular partial denture - cast metal framework with resin denture bases (including any retentive/clasping materials, rests D5214 and teeth) 140 Immediate maxillary partial denture – resin base (including any D5221 retentive/clasping materials, rests and teeth) 140 Immediate mandibular partial denture – resin base (including any D5222 retentive/clasping materials, rests and teeth) 140 Immediate maxillary partial denture – cast metal framework with resin denture bases (including any retentive/clasping materials, D5223 rests and teeth) 140 Immediate mandibular partial denture – cast metal framework with resin denture bases (including any retentive/clasping D5224 materials, rests and teeth) 140 Maxillary partial denture - flexible base (including D5225 retentive/clasping materials, rests, and teeth) 140 Mandibular partial denture - flexible base (including D5226 retentive/clasping materials, rests, and teeth) 140 Immediate maxillary partial denture - flexible base (including any D5227 clasps, rests and teeth) 140 Immediate mandibular partial denture - flexible base (including D5228 any clasps, rests and teeth) 140 Removable unilateral partial denture – one piece flexible base (including retentive/clasping materials, rests, and teeth) – per D5284 quadrant NB Removable unilateral partial denture – one piece resin (including D5286 retentive/clasping materials, rests, and teeth) – per quadrant NB D5410 Adjust complete denture – maxillary 0 D5411 Adjust complete denture – mandibular 0 D5421 Adjust partial denture – maxillary 0 D5422 Adjust partial denture – mandibular 0 D5512 Repair broken complete denture base, maxillary 15 D5520 Replace missing or broken teeth - complete denture 15 D5612 Repair resin partial denture base, maxillary 15 2024-01-03100-BB 11 DCL 20240101