Procedure Description Copayment Notes D6241 Pontic - porcelain fused to predominantly base metal 125 D6242 Pontic - porcelain fused to noble metal 150 D6243 Pontic - porcelain fused to titanium or titanium alloys NB D6251 Pontic - resin with predominantly base metal 150 D6252 Pontic - resin with noble metal 150 D6750 Crown - porcelain fused to high noble metal 175 D6751 Crown - porcelain fused to predominantly base metal 125 D6752 Crown - porcelain fused to noble metal 150 D6753 Retainer crown - porcelain fused to titanium or titanium alloys NB D6780 Crown - 3/4 cast high noble metal 175 D6784 Retainer crown ¾ - titanium and titanium alloys NB D6790 Crown - full cast high noble metal 175 D6791 Crown - full cast predominantly base metal 120 D6792 Crown - full cast noble metal 150 D6930 Re-cement or rebond fixed partial denture 0 D6940 Stress breaker 65 Fixed partial denture repair necessitated by restorative material D6980 failure NB D7000 - D7999 X. Oral Surgery D7111 Extraction, coronal remnants – primary tooth 10 D7140 Extraction, erupted tooth or exposed root 10 D7210 Surgical removal of erupted tooth 10 D7220 Removal of impacted tooth - soft tissue 30 R D7230 Removal of impacted tooth - partially bony 40 R D7240 Removal of impacted tooth - completely bony 50 R D7241 Removal of impacted tooth-completely bony w/complications 50 R D7250 Surgical removal of residual tooth roots 50 R D7280 Surgical exposure impacted/unerupted tooth - ortho 15 R D7283 Placement of device to facilitate eruption of impacted tooth 15 R D7286 Incisional biopsy of oral tissue-soft 0 R Alveoloplasty in conjunction with extractions - four or more teeth D7310 or tooth spaces – per quadrant 0 Alveoloplasty in conj. With extractions - one to three teeth per D7311 quad 0 Alveoloplasty not in conjunction with extractions - four or more D7320 teeth or tooth spaces – per quadrant 0 Alveoloplasty not in conj. With extractions - one to three teeth per D7321 quad 0 D7340 Vestibuloplasty NB R D7350 Vestibuloplasty - ridge extension NB R D7471 Removal of exostosis - maxilla or mandible 0 R D7472 Removal of torus palatinus 0 R D7473 Removal of torus mandibularis 0 R D7510 Incision and drainage of abscess 0 R D7881 Occlusal orthotic device adjustment TMJ R 2024-01-03100-BB 13 DCL 20240101