Page 17 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D7972 Surgical reduction of fibrous tuberosity $125 Orthodontics • Benefits cover twenty-four (24) months of usual & customary Orthodontic treatment and an additional twenty four (24) months of retention. • Comprehensive Orthodontic benefits include all phases of treatment and fixed/removable appliances. D8010 Limited orthodontic treatment of the primary dentition $1,000 D8020 Limited orthodontic treatment of the transitional dentition $1,000 D8030 Limited orthodontic treatment of the adolescent dentition $1,000 D8040 Limited orthodontic treatment of the adult dentition $1,000 D8070 Comprehensive orthodontic treatment of the transitional dentition $1,850 D8080 Comprehensive orthodontic treatment of the adolescent dentition $1,850 D8090 Comprehensive orthodontic treatment of the adult dentition $1,850 D8091 Comprehensive orthodontic treatment with orthognatic surgery Treatment of cranofacial syndromes or orthopedic discrepancies that require multiple phases of orthodontic treatment including monitoring growth and development between active phases of treatment $1,850 D8660 Pre-orthodontic treatment examination to monitor growth and development $35 D8670 Periodic orthodontic treatment visit $35 D8671 Periodic orthodontic treatment associated with orthognatic surgery $35 D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) $300 D8681 Removable orthodontic retainer adjustment $0 D8698 Re-cement or re-bond fixed retainer – maxillary $0 D8699 Re-cement or re-bond fixed retainer – mandibular $0 D8701 Repair of fixed retainer, includes reattachment – maxillary $0 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 Deep sedation/general anesthesia – first 15 minutes $60 D9223 Deep sedation/general anesthesia – each subsequent 15 minute increment $60 D9230 Inhalation of nitrous oxide/analgesia, anxiolysis $15 D9239 Intravenous moderate (conscious) sedation/analgesia- first 15 minutes $60 D9243 Intravenous moderate (conscious) sedation/analgesia – each subsequent 15 minute increment $60 D9248 Non-intravenous conscious sedation $15