GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 12 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D8080 Comprehensive orthodontic treatment of the adolescent dentition $1,450 D8090 Comprehensive orthodontic treatment of the adult dentition $1,450 D8210 Removable appliance therapy 25% Discount D8220 Fixed appliance therapy 25% Discount D8660 Pre-orthodontic treatment examination to monitor growth and development $0 D8670 Periodic orthodontic treatment visit $0 D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) $250 D8698 Re-cement or re-bond fixed retainer – maxillary $0 D8699 Re-cement or re-bond fixed retainer – mandibular $0 • Orthodontic treatment plan and records (pre/post x-rays (cephalometric, panoramic, etc.), photos, study models) $250 • Ortho visits beyond 24 months of active treatment or retention $25 per visit 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. $0 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 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 $15 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 D9942 Repair and/or reline of occlusal guard $40 D9944 Occlusal guard – hard appliance, full arch $85