Procedure Description Copayment Notes Placement of intra-socket biological dressing to aid in hemostasis D7922 or clot stabilization, per site 0 D7961 Buccal/labial frenectomy (frenulectomy) 20 R D7962 Lingual frenectomy (frenulectomy) 20 R D7970 Excision of hyperplastic tissue - per arch 30 R D8000 - D8999 XI. Orthodontic Services D8660 Initial orthodontic diagnostic work-up and X-rays 50 D8070 Full Orthodontic Services 1500 Limited Orthodontic treatment of the primary dentition Prorated Limited Orthodontic treatment of the transitional dentition Prorated Limited Orthodontic treatment of the adolescent dentition Prorated Limited Orthodontic treatment of the adult dentition Prorated Final orthodontic diagnosis, work-up and X-rays Included Lost metal bands or loose brackets * * see orthodontic benefits per plan Lifetime max Orthognathic Surgery $5000 Orthognathic surgery Pre-determination Lifetime max Temporomandibular Joint Treatment $5000 TMJ consultation 30 TMJ treatment C D9000 - D9999 XII. Additional Procedures D9110 Palliative treatment of dental pain per visit 15 D9211 Regional block anesthesia 0 D9212 Trigeminal division block anesthesia 0 D9215 Local anesthesia 0 D9222 Deep sedation/general anesthesia – first 15 minutes 25* Deep sedation/general anesthesia – each subsequent 15 minute D9223 increment 25* R intravenous moderate (conscious) sedation/analgesia- first 15 D9239 minutes 25 Intravenous moderate (conscious) sedation/analgesia – each D9243 subsequent 15 minute increment 25* R Consultation - diagnostic service provided by dentist or physician D9310 other than requesting dentist or physician 0 Office visit - after regularly scheduled hours (nights and D9440 weekends) 20 D9912 Pre-visit patient screening 0 D9944 occlusal guard – hard appliance, full arch 50 D9945 occlusal guard – soft appliance, full arch 13 D9946 occlusal guard – hard appliance, partial arch 25 D9951 Occlusal adjustment - limited 35 D9952 Occlusal adjustment - complete 50 D9986 Missed appointment 10 D9987 Canceled appointment 10 2024-01-03100-BB 14 DCL 20240101