| Code |
Description |
Enrollee Pays |
| D9110 |
Palliative (emergency) treatment of dental pain - minor procedure |
$ 35.00 |
| D9211 |
Regional block anesthesia |
No Cost |
| D9212 |
Trigeminal division block anesthesia |
No Cost |
| D9215 |
Local anesthesia |
No Cost |
| D9220 |
Deep sedation/general anesthesia - first 30 minutes |
$165.00
|
| D9221 |
Deep sedation/general anesthesia - each additional 15 minutes |
$ 80.00 |
| D9241 |
Intravenous conscious sedation/analgesia - first 30 minutes |
$165.00 |
| D9242 |
Intravenous conscious sedation/analgesia - each additional 15 minutes |
$ 80.00 |
| D9310 |
Consultation - diagnostic service provided by a dentist or physician other than requesting dentist or physician |
$ 70.00 |
| D9430 |
Office visit for observation (during regularly scheduled hours) - no other services performed |
$ 5.00 |
| D9440 |
Office visit - after regularly scheduled hours |
$ 50.00 |
| D9450 |
Case presentation, detailed and extensive treatment planning |
$ 10.00 |
| D9972 |
External bleaching - per arch - limited to one bleaching tray and gel for two weeks of self treatment |
$125.00 |
| D9999 |
Unspecified adjunctive procedure, by report - includes failed appointment without 24 hour notice - per 15 minutes of appointment time - up to an overall maximum of $40.00 |
$ 15.00 |
