Page 9 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D4274 Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) $100 D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft $380 D4276 Combined connective tissue and pedicle graft, per tooth. Advanced gingival recession often cannot be corrected with a single procedure. Combined tissue grafting procedures are needed to achieve the desired outcome. $75 D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant or edentulous tooth position in graft $245 D4278 Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant or edentulous tooth position in same graft site $123 D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) – each additional contiguous tooth, implant or edentulous tooth position in same graft site $38 D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site $190 D4322 Splint - intracoronal; natural teeth or prosthetic crowns $95 D4323 Splint - extracoronal; natural teeth or prosthetic crowns $85 D4341 Periodontal scaling and root planing – four or more teeth per quadrant $50 D4342 Periodontal scaling and root planing – one to three teeth per quadrant $38 D4346 Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation $0 D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit. $50 D4381 Localized delivery of antimicrobial agents via controlled release vehicle into diseased crevicular tissue, per tooth $65 D4910 Periodontal maintenance $40 D4920 Unscheduled dressing change (by someone other than treating dentist or their staff) $0 • Additional periodontal maintenance procedures (beyond 2 per 12 months) $55 Removable Prosthodontics • Delivery of removable and fixed Prosthodontics includes up to 3 adjustments within 6 months of delivery date of service. D5110 Complete denture – maxillary $325 D5120 Complete denture – mandibular $325 D5130 Immediate denture – maxillary $350 D5140 Immediate denture – mandibular $350 D5211 Maxillary partial denture – resin base (including, retentive/clasping materials, rests, and teeth) $400 D5212 Mandibular partial denture – resin base (including, retentive/clasping materials, rests, and teeth) $400 D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) $425 D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) $425 D5221 Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) Includes limited follow-up care only; does not include future rebasing/relining procedure(s) $400