| Code |
Description |
Enrollee Pays |
| D7111 |
Extraction, coronal remnants - deciduous tooth |
$ 40.00 |
| D7111 |
Extraction, coronal remnants - deciduous tooth (each additional) |
$ 35.00 |
| D7140 |
Extraction, erupted tooth or exposed root (elevation and/or forceps removal) |
$ 40.00 |
| D7140 |
Extraction, erupted tooth or exposed root (elevation and/or forceps removal) (each additional) |
$ 35.00 |
| D7210 |
Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth |
$ 70.00 |
| D7220 |
Removal of impacted tooth - soft tissue |
$100.00 |
| D7230 |
Removal of impacted tooth - partially bony |
$190.00 |
| D7240 |
Removal of impacted tooth - completely bony |
$210.00 |
| D7241 |
Removal of impacted tooth - completely bony, with unusual surgical complications |
$230.00 |
| D7250 |
Surgical removal of residual tooth roots (cutting procedure) |
$ 75.00 |
| D7286 |
Biopsy of oral tissue - soft - does not include pathology laboratory procedures |
$100.00 |
| D7310 |
Alveoloplasty in conjunction with extractions, four or more teeth or tooth spaces - per quadrant |
$150.00 |
| D7311 |
Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant |
$150.00 |
| D7320 |
Alveoloplasty not in conjunction with extractions,
four or more teeth or tooth spaces
- per quadrant |
$200.00 |
| D7321 |
Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant |
$200.00 |
| D7471 |
Removal of lateral exostosis (maxilla or mandible) |
$150.00 |
| D7472 |
Removal of torus palatinus |
$150.00 |
| D7473 |
Removal of torus mandibularis |
$150.00 |
| D7510 |
Incision and drainage of abscess - intraoral soft tissue |
$35.00 |
| D7960 |
Frenulectomy (frenectomy or frenotomy) - separate procedure |
$160.00 |
