Page 7 of 24 MET245_SOB_CA (01/26) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D3421 Apicoectomy – premolar (first root) $95 D3425 Apicoectomy – molar (first root) $95 D3426 Apicoectomy (each additional root) $60 D3428 Bone graft in conjunction with periradicular surgery - per tooth, single site $180 D3429 Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site $95 D3430 Retrograde filling – per root $60 D3431 Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery $95 D3432 Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery $215 D3450 Root amputation – per root $95 D3460 Endodontic endosseous implant $555 D3471 Surgical repair of root resorption – anterior $72 D3472 Surgical repair of root resorption – premolar $72 D3473 Surgical repair of root resorption – molar $72 D3501 Surgical exposure of root surface without apicoectomy or repair of root resorption – anterior $54 D3502 Surgical exposure of root surface without apicoectomy or repair of root resorption – premolar $54 D3503 Surgical exposure of root surface without apicoectomy or repair of root resorption – molar $54 D3910 Surgical procedure for isolation of tooth with rubber dam $0 D3920 Hemisection (including any root removal) , not including root canal therapy $90 D3921 Decoronation or submergence of an erupted tooth $41 D3950 Canal preparation and fitting of preformed dowel or post $15 Periodontics • Periodontal charting for planning treatment of periodontal disease is included as part of overall diagnosis and treatment. No additional charge will apply to You or Your Dependent or Us. D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant $110 D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant $83 D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth $25 D4240 Gingival flap procedure, including root planing – four or more contiguous teeth or tooth bound spaces per quadrant: A soft tissue flap is reflected or resected to allow debridement of the root surface and the removal of granulation tissue. Osseous recontouring is not accomplished in conjunction with this procedure. May include open flap curettage, reverse bevel flap surgery, modified Kirkland flap procedure, and modified Widman surgery. This procedure is performed in the presence of moderate to deep probing depths, loss of attachment, need to maintain esthetics, need for increased access to the root surface and alveolar bone, or to determine the presence of a cracked tooth or fractured root. Other procedures may be required concurrent to D4240 and should be reported separately using their own unique codes. $150