| Code |
Description |
Enrollee Pays |
| D4210 |
Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant |
$260 |
| D4211 |
Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant |
$ 50 |
| D4240 |
Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant |
$350 |
| D4241 |
Gingival flap procedure, including root planing - one to three contiguous teeth or bounded teeth spaces per quadrant |
$350 |
| D4260 |
Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant |
$550 |
| D4261 |
Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces per quadrant |
$650 |
| D4341 |
Periodontal scaling and root planing - four or more teeth per quadrant - limited to 4 quadrants during any 12 consecutive months |
$ 80 |
| D4342 |
Periodontal scaling and root planing - one to three teeth per quadrant - limited to 4 quadrants during any 12 consecutive months |
$ 80 |
| D4355 |
Full mouth debridement to enable comprehensive evaluation and diagnosis - limited to 1 treatment in any 12 consecutive months |
$80 |
| D4910 |
Periodontal maintenance - limited to 1 treatment each 6 month period |
$ 50 |
