Page 18 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment 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 D9942 Repair and/or reline of occlusal guard $40 D9943 Occlusal guard adjustment $10 D9944 Occlusal guard – hard appliance, full arch $85 D9945 Occlusal guard – soft appliance, full arch $85 D9946 Occlusal guard – hard appliance, partial arch $64 D9951 Occlusal adjustment – limited $30 D9952 Occlusal adjustment – complete $100 D9954 Fabrications and delivery of oral appliance therapy (OAT) morning repositioning device $16 D9955 Oral appliance therapy (OAT) titration visit $10 D9986 Missed appointment (less than 24-hr notice) Not to exceed $25 D9987 Cancelled appointment (if less than 24-hr notice, see D9986) $0 Current Dental Terminology © American Dental Association