Page 16 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D7288 Brush biopsy – transepithelial sample collection $50 D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report $40 D7310 Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant $40 D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant $15 D7320 Alveoloplasty not in conjunction with extractions – four or more teeth or tooth spaces, per quadrant $60 D7321 Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant $25 D7340 Vestibuloplasty – ridge extension (secondary epithelialization) $370 D7350 Vestibuloplasty – ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) $990 D7450 Removal of benign odontogenic cyst or tumor – lesion diameter up to 1.25 cm $130 D7451 Removal of benign odontogenic cyst or tumor – lesion diameter greater than 1.25 cm $335 D7471 Removal of lateral exostosis (maxilla or mandible) $80 D7472 Removal of torus palatinus $60 D7473 Removal of torus mandibularis $60 D7485 Reduction of osseous tuberosity $60 D7510 Incision and drainage of abscess – intraoral soft tissue $35 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