Page 17 of 24 MET245_SOB_CA (01/26) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D7511 Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage of multiple fascial spaces) $35 D7520 Incision and drainage of abscess – extraoral soft tissue $35 D7521 Incision and drainage of abscess – extraoral soft tissue – complicated (includes drainage of multiple fascial spaces) $35 D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone $125 D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body $505 D7910 Suture of recent small wounds up to 5 cm $25 D7921 Collection and application of autologous blood concentrate product $95 D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla – autogenous or nonautogenous, by report $600 D7951 Sinus augmentation with bone or bone substitutes via a lateral open approach $825 D7952 Sinus augmentation via a vertical approach $825 D7953 Bone replacement graft for ridge preservation – per site $100 D7961 Buccal / labial frenectomy (frenulectomy) $50 D7962 lingual frenectomy (frenulectomy) $50 D7963 Frenuloplasty $50 D7970 Excision of hyperplastic tissue – per arch $55 D7971 Excision of pericoronal gingiva $40 D7972 Surgical reduction of fibrous tuberosity $125 Orthodontics • Benefits cover twenty-four (24) months of usual & customary Orthodontic treatment and an additional twenty four (24) months of retention. • Comprehensive Orthodontic benefits include all phases of treatment and fixed/removable appliances. D8010 Limited orthodontic treatment of the primary dentition $1,000 D8020 Limited orthodontic treatment of the transitional dentition $1,000 D8030 Limited orthodontic treatment of the adolescent dentition $1,000 D8040 Limited orthodontic treatment of the adult dentition $1,000 D8070 Comprehensive orthodontic treatment of the transitional dentition $1,850 D8080 Comprehensive orthodontic treatment of the adolescent dentition $1,850 D8090 Comprehensive orthodontic treatment of the adult dentition $1,850 D8091 Comprehensive orthodontic treatment with orthognatic surgery Treatment of cranofacial syndromes or orthopedic discrepancies that require multiple phases of orthodontic treatment including monitoring growth and development between active phases of treatment $1,850 D8660 Pre-orthodontic treatment examination to monitor growth and development $35 D8670 Periodic orthodontic treatment visit $35 D8671 Periodic orthodontic treatment associated with orthognatic surgery $35 D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) $300 D8681 Removable orthodontic retainer adjustment $0 D8698 Re-cement or re-bond fixed retainer – maxillary $0 D8699 Re-cement or re-bond fixed retainer – mandibular $0 D8701 Repair of fixed retainer, includes reattachment – maxillary $0