GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 11 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D7241 Removal of impacted tooth – completely bony, with unusual surgical complications $90 D7250 Removal of residual tooth roots (cutting procedure) $5 D7251 Coronectomy – intentional partial tooth removal, impacted teeth only: Intentional partial tooth removal is performed when a neurovascular complication is likely if the entire tooth is removed. $75 D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $15 D7280 Exposure of an unerupted tooth $15 D7282 Mobilization of erupted or malpositioned tooth to aid eruption $15 D7283 Placement of an attachment on an unerupted tooth, after its exposure, to aid in its eruption. Report the surgical exposure separately using D7280. $15 D7285 Incisional biopsy of oral tissue – hard (bone, tooth) $0 D7286 Incisional biopsy of oral tissue – soft $0 D7287 Exfoliative cytological sample collection $50 D7288 Brush biopsy – transepithelial sample collection $50 D7310 Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant $0 D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant $0 D7320 Alveoloplasty not in conjunction with extractions – four or more teeth or tooth spaces, per quadrant $0 D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant $0 D7471 Removal of lateral exostosis (maxilla or mandible) $80 D7472 Removal of torus palatinus $15 D7473 Removal of torus mandibularis $15 D7485 Reduction of osseous tuberosity $60 D7510 Incision and drainage of abscess – intraoral soft tissue $15 D7511 Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage of multiple fascial spaces) $15 D7520 Incision and drainage of abscess – extraoral soft tissue $15 D7521 Incision and drainage of abscess – extraoral soft tissue – complicated (includes drainage of multiple fascial spaces) $15 D7910 Suture of recent small wounds up to 5 cm $15 D7961 Buccal / labial frenectomy (frenulectomy) $0 D7962 lingual frenectomy (frenulectomy) $0 D7963 Frenuloplasty $0 D7970 Excision of hyperplastic tissue – per arch $55 D7971 Excision of pericoronal gingiva $35 Orthodontics • Benefits cover 24 months of usual & customary orthodontic treatment and 24 months of retention. • Comprehensive orthodontic benefits include all phases of treatment and fixed/removable appliances. D8010 Limited orthodontic treatment of the primary dentition $725 D8020 Limited orthodontic treatment of the transitional dentition $725 D8030 Limited orthodontic treatment of the adolescent dentition $725 D8040 Limited orthodontic treatment of the adult dentition $725 D8070 Comprehensive orthodontic treatment of the transitional dentition $1,450