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Periodontics, Continued D4263 Bone replacement graft %u2014 retained natural tooth %u2014 first site in quadrant $240D4264 Bone replacement graft %u2014 retained natural tooth %u2014 each additional site in quadrant $245D4270 Pedicle soft tissue graft procedure $440D4274 Mesial/distal, wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area)$280D4277 Free soft tissue graft procedure (including recipient and donor surgical sites), first tooth, implant or edentulous tooth position in graft$280D4278 Free soft tissue graft procedure (including recipient and donor surgical sites), each additional contiguous tooth, implant, or edentulous tooth position in same graft site$280D4341 Periodontal scaling and root planing %u2014 four or more teeth per quadrant %u2014 limited to 4 quadrants during any 12 consecutive months$100D4342 Periodontal scaling and root planing %u2014 one to three teeth per quadrant %u2014 limited to 4 quadrants during any 12 consecutive months$58D4346 Scaling in presence of generalized moderate or severe gingival inflammation %u2014 full mouth, after oral evaluation %u20141 D1110, D1120, or D4346 per six-month period$65D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis %u2014 limited to 1 treatment per lifetime $120D4910 Periodontal maintenance %u2014 limited to 1 treatment each six-month period $100D4910 Additional periodontal maintenance (within the six-month period) $100D4921 Gingival irrigation %u2014 per quadrant $20Prosthodontics %u2014 Removable%u2014 For all listed dentures and partial dentures, co-payment includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement. The covered person must continue to be eligible, and the service must be provided at the Plan Dentist%u2019s facility where the denture was originally delivered.%u2014 Rebases, relines, and tissue conditioning are limited to 1 per denture during any 12 consecutive months.%u2014 Replacement of a denture or a partial denture requires the existing denture to be 5+ years old.D5110 Complete denture %u2014 maxillary $600D5120 Complete denture %u2014 mandibular $600D5130 Immediate denture %u2014 maxillary $690D5140 Immediate denture %u2014 mandibular $690D5211 Maxillary partial denture %u2014 resin base (including any conventional clasps, rests, and teeth) $480D5212 Mandibular partial denture %u2014 resin base (including any conventional clasps, rests, and teeth) $480D5213 Maxillary partial denture %u2014 cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth)$720D5214 Mandibular partial denture %u2014 cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth)$720D5221 Immediate maxillary partial denture %u2014 resin base (including any conventional clasps, rests, and teeth) $700D5222 Immediate mandibular partial denture %u2014 resin base (including conventional clasps, rests, and teeth) $700D5223 Immediate maxillary partial denture %u2014 cast metal frameworks with resin denture bases (including any conventional clasps, rests, and teeth)$790D5224 Immediate mandibular partial denture %u2014 cast metal frameworks with resin denture bases (including any conventional clasps, rests, and teeth)$790D5225 Maxillary partial denture %u2014 flexible base (including any clasps, rests, and teeth) $700D5226 Mandibular partial denture %u2014 flexible base (including any clasps, rests, and teeth) $700D5410 Adjust complete denture %u2014 maxillary $35D5411 Adjust complete denture %u2014 mandibular $35D5421 Adjust partial denture %u2014 maxillary $35D5422 Adjust partial denture %u2014 mandibular $35D5511 Repair broken complete denture base, mandibular $60D5512 Repair broken complete denture base, maxillary $60D5520 Replace missing or broken teeth %u2014 complete denture (each tooth) $60D5611 Repair resin partial denture base, mandibular $75D5612 Repair resin partial denture base, maxillary $75D5621 Repair cast partial framework, mandibular $95D5622 Repair cast partial framework, maxillary $95D5630 Repair or replace broken clasp per tooth $85D5640 Replace broken teeth %u2014 per tooth $70D5650 Add tooth to existing partial denture $90D5660 Add clasp to existing partial denture per tooth $95D5670 Replace all teeth and acrylic on cast metal framework (maxillary) $365D5671 Replace all teeth and acrylic on cast metal framework (mandibular) $365D5710 Rebase complete maxillary denture $150D5711 Rebase complete mandibular denture $150D5720 Rebase maxillary partial denture $145D5721 Rebase mandibular partial denture $145D5730 Reline complete maxillary denture (chairside) $120(Continued next page)324