Page 147 - Aflac Flipbook 2023

D. PAIN MANAGEMENT AND ADJUNCTIVE SERVICES – continued

D9230 Analgesia, Anxiolysis, Inhalation of Nitrous Oxide $75
D9241 Intravenous Conscious Sedation/Analgesia (first 30 minutes) 120
D9310 Consultation (diagnostic service provided by dentist or physician other than
practitioner providing treatment) 25
D9410 House/Extended-Care Facility Call 25
D9420 Hospital Call 25
D9440 Office Visit (after regularly scheduled hours) 25
D9450 Case Presentation, Detailed and Extensive Treatment Planning 25

E. OTHER PREVENTIVE SERVICES: Benefits in this category are subject to a six-month Waiting Period.

ADA Description Amount
Code
D1351 Sealant (per tooth) $15
D1510 Space Maintainer (fixed, unilateral) 80
D1515 Space Maintainer (fixed, bilateral) 100
D1520 Space Maintainer (removable, unilateral) 80
D1525 Space Maintainer (removable, bilateral) 100
D1550 Recementation of Space Maintainer 35
D1555 Removal of Fixed Space Maintainer 80

F. ORAL SURGERY, GUM TREATMENTS, AND PROSTHETIC REPAIR: Benefits in this category are subject to a
six-month Waiting Period.

ADA Description Amount
Code
D4210 Gingivectomy or Gingivoplasty (four or more contiguous teeth or bounded teeth spaces
per quadrant) $130
D4211 Gingivectomy or Gingivoplasty (one to three teeth per quadrant) 45
D4230 Anatomical Crown Exposure (four or more contiguous teeth per quadrant) 130
D4231 Anatomical Crown Exposure (one to three teeth per quadrant) 45
D4240 Gingival Flap Procedure, Including Root Planing (four or more contiguous teeth or bounded
teeth spaces per quadrant) 225
D4241 Gingival Flap Procedure, Including Root Planing (one to three teeth
per quadrant) 225
D4249 Clinical Crown Lengthening (hard tissue) 250
D4260 Osseous Surgery (including flap entry and closure; four or more contiguous teeth or bounded
teeth spaces per quadrant) 250
D4261 Osseous Surgery (including flap entry and closure; one to three teeth per quadrant) 250
D4263 Bone Replacement Graft (first site in quadrant) 275
D4264 Bone Replacement Graft (each additional site in quadrant) 225
D4270 Pedicle Soft Tissue Graft Procedure 275
D4271 Free Soft Tissue Graft Procedure (including donor site surgery) 275
D4273 Subepithelial Connective Tissue Graft Procedures 300
D4275 Soft Tissue Allograft 275
D4320 Provisional Splinting (intracoronal) 150
D4321 Provisional Splinting (extracoronal) 110
D4341 Periodontal Scaling and Root Planing (four or more contiguous teeth or
bounded teeth spaces per quadrant) 60
D4342 Periodontal Scaling and Root Planing (one to three teeth per quadrant) 60
D4355 Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis 55
D5410 Adjust Complete Denture (maxillary) 20
D5411 Adjust Complete Denture (mandibular) 20

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