Procedure Description Copayment Notes D3425 Apicoectomy molar (1st root) 100 R D3426 Apicoectomy (additional root) 25 R Bone graft in conjunction with periradicular surgery – per tooth; D3428 first surgical site 100 Bone graft in conjunction with periradicular surgery – each D3429 additional contiguous tooth in the same surgical site 50 D3430 Retrograde filling - per root 5 R D3450 Root amputation - per root 0 R D3471 Surgical repair of root resorption ‐ anterior 35 D3472 Surgical repair of root resorption – premolar 35 D3473 Surgical repair of root resorption – molar 35 Surgical exposure of root surface without apicoectomy of repair D3501 of root resorption – anterior 35 Surgical exposure of root surface without apicoectomy or repair D3502 of root resorption – premolar 35 Surgical exposure of root surface without apicoectomy or repair D3503 of root resorption – molar 35 D3911 Intraorifice barrier 0 D3920 Hemisection including root removal 0 R D3921 Decoronation or submergence of an erupted tooth 10 D4000 - D4999 VI. Periodontics D4210 Gingivectomy or gingivoplasty - four or more teeth per quadrant 75 D4211 Gingivectomy or gingivoplasty - one to three teeth per quadrant 35 Gingivectomy or gingivoplasty to allow access for restorative D4212 procedure; per tooth 35 Gingival flap procedure - allowed only in conjunction with D4240 D4263/D4264 0 R Gingival flap procedure - allowed only in conjunction with D4241 D4263/D4264 0 R D4245 Apically positioned flap 0 R D4249 Crown lengthening - hard/soft tissue 35 R Osseous surgery (including elevation of a full thickness flap and closure) – four or more Contiguous teeth or tooth bounded D4260 spaces per quadrant 100 R Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces D4261 per quadrant 75 R D4263 Bone replacement Graft - first site in quadrant 100 R D4264 Bone replacement Graft - each additional site in quadrant 50 R D4270 Pedicle soft tissue graft procedure 100 R Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant, or edentulous tooth position in D4277 graft 50 Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or D4278 edentulous tooth position in same graft site 25 D4341 Periodontal root planing - four or more teeth per quadrant 35 D4342 Periodontal root planing - one to three teeth per quadrant 15 2024-01-03100-BB 10 DCL 20240101