Page 19 of 24 MET245_SOB_CA (01/26) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D9243 Administration of moderate sedation - intravenous - each subsequent 15 minute increment, or any portion thereof $60 D9244 In-office administration of minimal sedation – single drug – enteral. In-office administration of a drug, as a single or divided dose, to achieve the desired clinical effect, not to exceed the FDA maximum recommended dose (MRD) for unmonitored home use. The single drug may be administered with or without co-administration of nitrous oxide. $15 D9245 Administration of moderate sedation – enteral. When moderate sedation is achieved by administration of drug(s) by enteral route only. With or without co- administration of nitrous oxide. The level of anesthesia is determined by the provider’s documentation of the anesthetic effects upon the central nervous system. $15 D9246 Administration of moderate sedation – non-intravenous parenteral – first 15 minute increment, or any portion thereof. When moderate sedation is achieved by administration of drug(s) by parenteral route, not including intravenous. With or without co-administration of nitrous oxide. Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room. The level of anesthesia is determined by the provider’s documentation of the anesthetic effects upon the central nervous system. $60 D9247 Administration of moderate sedation – non-intravenous parenteral – each subsequent 15 minute increment, or any portion thereof $60 D9310 Consultation – diagnostic service provided by dentist or physician other than requesting dentist or physician $0 D9311 Consultation with a medical health care professional $0 D9430 Office visit for observation (during regularly scheduled hours) – no other services performed $0 D9440 Office visit – after regularly scheduled hours $30 D9450 Case presentation, subsequent to detailed and extensive treatment planning. $0 D9610 Therapeutic parenteral drug, single administration $15 D9612 Therapeutic parenteral drugs, two or more administrations, different medications $25 D9613 Infiltration of sustained release therapeutic drug, per quadrant. Infiltration of a sustained release pharmacologic agent for long acting surgical site pain control. Not for local anesthesia purposes. $15 D9630 Drugs or medicaments dispensed in the office for home use $15 D9910 Application of desensitizing medicament $15 D9930 Treatment of complication (post-surgical) – unusual circumstances, by report $0 D9932 Cleaning and inspection of removable complete denture, maxillary $55 D9933 Cleaning and inspection of removable complete denture, mandibular $55 D9934 Cleaning and inspection of removable partial denture, maxillary $55 D9935 Cleaning and inspection of removable partial denture, mandibular $55 D9936 Cleaning and inspection of occlusal guard – per appliance. This procedure does not include any adjustments. $55 D9942 Repair and/or reline of occlusal guard $40 D9943 Occlusal guard adjustment $10