GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 7 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D4270 Pedicle soft tissue graft procedure $195 D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft $75 D4274 Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) $70 D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft $265 D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant or edentulous tooth position in graft $195 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 $98 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 $133 D4322 Splint - intracoronal; natural teeth or prosthetic crowns $85 D4323 Splint - extracoronal; natural teeth or prosthetic crowns $75 D4341 Periodontal scaling and root planing – four or more teeth per quadrant $25 D4342 Periodontal scaling and root planing – one to three teeth per quadrant $19 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. $15 D4381 Localized delivery of antimicrobial agents via controlled release vehicle into diseased crevicular tissue, per tooth $60 D4910 Periodontal maintenance $15 • Additional periodontal maintenance procedures (beyond 2 per 12 months) $40 • Periodontal charting for planning treatment of periodontal disease $0 • Periodontal hygiene instruction $0 Removable Prosthodontics • Includes up to 3 adjustments within 6 months of delivery. D5110 Complete denture - maxillary $125 D5120 Complete denture - mandibular $125 D5130 Immediate denture - maxillary $125 D5140 Immediate denture – mandibular $125 D5211 Maxillary partial denture – resin base (including, retentive/clasping materials, rests, and teeth) $110 D5212 Mandibular partial denture – resin base (including, retentive/clasping materials, rests, and teeth) $110 D5213 Maxillary partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) $150 D5214 Mandibular partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) $150 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) $110 D5222 Immediate mandibular 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) $110