Page 18 of 24 MET245_SOB_CA (01/26) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D8702 Repair of fixed retainer, includes reattachment – mandibular $0 • • There is a Co-Payment of $250 for Orthodontic treatment planning and records (pre/post x-rays (cephalometric, panoramic, etc.), photos, study models) . There is a Co-Payment of $25 per visit for Orthodontic visits beyond twenty-four (24) months of active treatment or retention. Adjunctive General Services D9110 Palliative treatment of dental pain per visit: Treatment that relieves pain but is not curative; services provided do not have distinct procedure codes. This is typically reported on a “per-visit” basis for emergency treatment of dental pain. $10 D9120 Fixed partial denture sectioning $0 D9210 Local anesthesia not in conjunction with operative or surgical procedures $0 D9211 Regional block anesthesia $0 D9212 Trigeminal division block anesthesia $0 D9215 Local anesthesia in conjunction with operative or surgical procedures $0 D9219 Evaluation for moderate sedation, deep sedation or general anesthesia $0 D9222 Administration of deep sedation/general anesthesia - first 15 minute increment, or any portion thereof. 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 D9223 Administration of deep sedation/general anesthesia - each subsequent 15 minute increment, or any portion thereof $60 D9224 Administration of general anesthesia with advanced airway – first 15 minute increment, or any portion thereof 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. This procedure is determined by the provider’s documentation of the presence of an advanced airway such as a supraglottic or subglottic airway device, which includes laryngeal tube, esophageal-tracheal tube (Combitube) , laryngeal mask airway, or endotracheal tube. $66 D9225 Administration of general anesthesia with advanced airway – each subsequent 15 minute increment, or any portion thereof $66 D9230 Administration of nitrous oxide - When nitrous oxide is administered as a single agent. $15 D9239 Administration of moderate sedation - intravenous - first 15 minute increment, or any portion thereof. When moderate sedation is achieved by administration and titration of drug(s) intravenously. 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