Periodontal Services
Standard
Option
Copay
Amount
High
Option
Copay
Amount
D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or bounded teeth spaces,
per quadrant
$351
$205
D4211 Gingivectomy or gingivoplasty – one to three teeth, per quadrant
$120
$70
D4212 Gingivectomy or gingivoplasty – with restorative procedures, per tooth
$40
$30
D4240 Gingival flap procedure, including root planing, four of more contiguous teeth or bounded
teeth spaces per quadrant
$373
$257
D4241 Gingival flap procedure, including root planing – one to three teeth per quadrant
$234
$74
D4249 Clinical crown lengthening-hard tissue
$531
$341
D4260 Osseous surgery (including flap entry and closure), four or more contiguous teeth or
bounded teeth spaces per quadrant
$632
$422
D4261 Osseous surgery (including flap entry and closure), one to three contiguous teeth or
bounded teeth spaces per quadrant
$531
$282
D4268 Surgical revision procedure, per tooth
$522
$258
D4270 Pedicle soft tissue graft procedure
$592
$381
D4273 Subepithelial connective tissue graft procedures (including donor site surgery)
$738
$474
D4275 Soft tissue allograft
$613
$394
D4276 Combined connective tissue and double pedicle graft, per tooth
$672
$432
D4277 Free soft tissue graft procedure, first tooth or edentulous tooth position in a graft
$654
$420
D4278 Free soft tissue graft procedure, each additional contiguous tooth or edentulous tooth
position in a graft site
$100
$80
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis
$95
$64
D4381 Localized delivery of antimicrobial agents
$25
$7
Prosthodontic Services
Standard
Option
Copay
Amount
High
Option
Copay
Amount
D5110 Complete denture – maxillary
$702
$455
D5120 Complete denture – mandibular
$702
$455
D5130 Immediate denture – maxillary
$758
$511
D5140 Immediate denture – mandibular
$758
$511
D5211 Maxillary partial denture – resin base (including any conventional clasps, rests and teeth)
$477
$306
D5212 Mandibular partial denture – resin base (including any conventional clasps, rests and
teeth)
$477
$306
D5213 Maxillary partial denture – cast metal framework with resin denture base (including any
conventional clasps, rests and teeth)
$802
$549
D5214 Mandibular partial denture – cast metal framework with resin denture base (including any
conventional clasps, rests and teeth)
$802
$549
D5281 Removable unilateral partial denture – one piece cast metal (including clasps and teeth)
$428
$281
D6010 Endosteal implant – surgical placement
$1292
$830
D6011 Second stage implant surgery
$200
$200
Prosthodontic Services - continued on next page
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2018
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Prosthodontic Services (cont.)
Standard
Option
Copay
Amount
High
Option
Copay
Amount
D6013 Surgical placement of mini implant
$431
$277
D6055 Connecting bar – implant supported or abutment supported
$1213
$780
D6056 Prefabricated abutment – includes modification and placement
$343
$220
D6057 Custom fabricated abutment - includes
modification and placement
$491
$315
D6058 Abutment supported porcelain/ceramic crown
$851
$547
D6059 Abutment supported porcelain fused to metal crown – high
noble metal
$846
$544
D6060 Abutment supported porcelain fused to metal crown – predominantly based metal
$754
$485
D6061 Abutment supported porcelain fused to metal crown – noble metal
$796
$512
D6062 Abutment supported cast metal crown – high noble metal
$834
$536
D6063 Abutment supported cast metal crown – predominantly based metal
$742
$477
D6064 Abutment supported cast metal crown – noble metal
$776
$499
D6065 Implant supported porcelain/ceramic crown
$891
$572
D6066 Implant supported porcelain fused to metal crown – titanium, titanium allow, high noble
metal
$895
$575
D6067 Implant supported metal crown – titanium, titanium alloy, high noble metal
$865
$556
D6068 Abutment supported retainer for porcelain/ceramic FPD
$788
$507
D6069 Abutment supported retainer for porcelain fused to metal FPD – high noble metal
$843
$542
D6070 Abutment supported retainer for porcelain fused to metal FPD – predominantly base metal
$695
$447
D6071 Abutment supported retainer for porcelain fused to metal FPD – noble metal
$704
$453
D6072 Abutment supported retainer for cast metal FPD – high noble metal
$788
$507
D6073 Abutment supported retainer for cast metal FPD – predominantly base metal
$749
$481
D6074 Abutment supported retainer for cast metal FPD – noble metal
$758
$487
D6075 Implant supported retainer for ceramic FPD
$874
$562
D6076 Implant supported retainer for porcelain fused to metal FPD – titanium, titanium alloy, or
high noble metal
$823
$529
D6077 Implant supported retainer for cast metal FPD – titanium, titanium alloy, or high noble
metal
$872
$560
D6080 Implant maintenance procedures
$61
$39
D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant
including cleaning of the implant surfaces, without flap entry and closure
$71
$23
D6090 Repair implant prosthesis
$362
$233
D6091 Replacement of semi-precision or precision attachment
$34
$22
D6094 Abutment supported crown – titanium
$553
$355
D6095 Repair implant abutment
$391
$251
D6100 Implant removal
$241
$155
D6194 Abutment supported retainer crown for FPD – titanium
$741
$476
D6210 Pontic – cast high noble metal
$543
$366
D6211 Pontic – cast predominately base metal
$543
$366
Prosthodontic Services - continued on next page
21
2018
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