Dental Reimbursement Rates in Hawaii

D0322 — Tomographic Survey D0310 — Sialography D0320 — TMJ Arthrogram D0190 — Screening of a Patient D0210 — Full Mouth X-Rays D0277 — Vertical Bitewing X-Rays (7–8 Films) D0372 — Cone Beam CT — 3D Data Capture (Both Jaws) D0431 — Adjunctive Pre-Diagnostic Test (No Biopsy) D0801 — 3D Surface Scan — Pre-Ortho

D1510 — Space Maintainer — Fixed, Unilateral D1516 — Space Maintainer — Fixed, Bilateral (Maxillary) D1527 — Space Maintainer — Removable, Bilateral (Mandibular) D1575 — Distal Shoe Space Maintainer D1526 — Space Maintainer — Removable, Bilateral (Maxillary) D1208 — Fluoride Application (Excluding Varnish) D1354 — Interim Caries Arresting Medicament (SDF) D1517 — Space Maintainer — Fixed, Bilateral (Mandibular)

D2790 — Crown — Full Cast High Noble Metal D2530 — Inlay — Metallic, 3+ Surfaces D2753 — Crown — Porcelain Fused to Titanium D2710 — Crown — Resin (Indirect) D2721 — Crown — Resin with Base Metal D2722 — Crown — Resin with Noble Metal D2782 — Crown — ¾ Cast Noble Metal D2783 — Crown — ¾ Porcelain/Ceramic D2930 — Prefabricated Stainless Steel Crown — Primary D2934 — Prefabricated Esthetic Coated SS Crown — Primary D2643 — Onlay — Porcelain/Ceramic, 3 Surfaces D2664 — Onlay — Composite/Resin, 4+ Surfaces D2750 — Crown — Porcelain Fused to High Noble Metal D2962 — Labial Veneer — Porcelain (Lab) D2150 — Amalgam Filling — 2 Surfaces, Primary/Permanent D2510 — Inlay — Metallic, 1 Surface D2543 — Onlay — Metallic, 3 Surfaces D2544 — Onlay — Metallic, 4+ Surfaces D2644 — Onlay — Porcelain/Ceramic, 4+ Surfaces D2651 — Inlay — Composite/Resin, 2 Surfaces D2652 — Inlay — Composite/Resin, 3+ Surfaces D2712 — Crown — ¾ Resin (Indirect) D2720 — Crown — Resin with High Noble Metal D2751 — Crown — Porcelain Fused to Base Metal D2780 — Crown — ¾ Cast High Noble Metal D2799 — Provisional Crown D2952 — Post and Core — Cast (w/ Crown) D2960 — Labial Veneer — Resin (Chair-side) D2161 — Amalgam Filling — 4+ Surfaces, Primary/Permanent D2394 — Composite Filling — 4+ Surfaces, Posterior D2520 — Inlay — Metallic, 2 Surfaces D2610 — Inlay — Porcelain/Ceramic, 1 Surface D2620 — Inlay — Porcelain/Ceramic, 2 Surfaces D2662 — Onlay — Composite/Resin, 2 Surfaces D2752 — Crown — Porcelain Fused to Noble Metal D2781 — Crown — ¾ Cast Base Metal D2791 — Crown — Full Cast Base Metal D2932 — Prefabricated Resin Crown D2954 — Prefabricated Post and Core D2955 — Post Removal D2957 — Each Additional Prefabricated Post D2980 — Crown Repair, By Report D2160 — Amalgam Filling — 3 Surfaces, Primary/Permanent D2330 — Composite Filling — 1 Surface, Anterior D2331 — Composite Filling — 2 Surfaces, Anterior D2332 — Composite Filling — 3 Surfaces, Anterior D2392 — Composite Filling — 2 Surfaces, Posterior D2393 — Composite Filling — 3 Surfaces, Posterior D2410 — Gold Foil — 1 Surface D2420 — Gold Foil — 2 Surfaces D2430 — Gold Foil — 3 Surfaces D2650 — Inlay — Composite/Resin, 1 Surface D2792 — Crown — Full Cast Noble Metal D2920 — Re-cement/Re-bond Crown D2931 — Prefabricated Stainless Steel Crown — Permanent D2933 — Prefabricated SS Crown with Resin Window D2950 — Core Buildup Including Pins D2976 — Stump Buildup with Pins D2981 — Inlay Repair, By Report D2990 — Resin Infiltration of Incipient Lesion D2991 — Mineral Infiltration of Incipient Lesion

D3347 — Retreatment — Premolar D3356 — Pulpal Regeneration — Interim Medication D3221 — Pulpal Debridement — Primary/Permanent Teeth D3421 — Apicoectomy — Premolar (First Root) D3450 — Root Amputation — Per Root D3470 — Intentional Reimplantation D3240 — Pulpal Therapy — Posterior, Primary D3320 — Root Canal — Premolar (Excluding Final Restoration) D3330 — Root Canal — Molar (Excluding Final Restoration) D3352 — Apexification/Recalcification — Interim Medication D3425 — Apicoectomy — Molar (First Root) D3428 — Retrograde Filling — Per Root D3430 — Retrograde Filling — Per Root D3431 — Biologically-Based Root Treatment D3220 — Therapeutic Pulpotomy (Excluding Final Restoration) D3310 — Root Canal — Anterior (Excluding Final Restoration) D3332 — Incomplete Endodontic Treatment (Inoperable/Fracture) D3348 — Retreatment — Molar D3432 — Guided Tissue Regeneration (Periradicular Surgery) D3472 — Surgical Repair — Root Resorption (Premolar) D3501 — Surgical Exposure for Canal Access D3502 — Surgical Perforation Repair D3921 — Decoronation/Intentional Submergence D3222 — Partial Pulpotomy for Apexogenesis — Permanent D3230 — Pulpal Therapy — Anterior, Primary D3331 — Treatment of Root Canal Obstruction (Non-Surgical) D3346 — Retreatment — Anterior D3351 — Apexification/Recalcification — Initial Visit D3353 — Apexification/Recalcification — Final Visit D3355 — Pulpal Regeneration — Initial Visit D3357 — Pulpal Regeneration — Final Visit D3429 — Hemisection (Including Root Removal, Not Crown) D3471 — Surgical Repair — Root Resorption (Anterior) D3473 — Surgical Repair — Root Resorption (Molar) D3503 — Surgical Root Repair — Anterior D3910 — Surgical Procedure for Isolation of Tooth D3920 — Hemisection (Not Root Canal/Restoration) D3950 — Canal Prep and Fitting of Preformed Post/Dowel

D4278 — Free Soft Tissue Graft (Each Additional Tooth) D4230 — Anatomical Crown Exposure — 4+ Teeth (Per Quad) D4275 — Non-Autogenous Connective Tissue Graft (First Tooth) D4277 — Free Soft Tissue Graft (First Tooth) D4231 — Anatomical Crown Exposure — 1–3 Teeth (Per Quad) D4249 — Clinical Crown Lengthening — Hard Tissue D4264 — Bone Replacement Graft — Each Additional Site D4286 — Combined Connective Tissue Graft (Each Add'l Tooth) D4211 — Gingivectomy/Gingivoplasty — 1–3 Teeth (Per Quad) D4266 — Guided Tissue Regeneration — Resorbable Barrier D4273 — Autogenous Connective Tissue Graft (First Tooth) D4210 — Gingivectomy/Gingivoplasty — 4+ Teeth (Per Quad) D4261 — Osseous Surgery — 1–3 Teeth (Per Quad) D4263 — Bone Replacement Graft — First Site (Per Quad) D4276 — Combined Connective Tissue & Pedicle Graft D4285 — Non-Autogenous Connective Tissue Graft (Each Add'l) D4341 — Scaling and Root Planing — 4+ Teeth (Per Quad) D4212 — Gingivectomy/Gingivoplasty (Restorative, Per Tooth) D4241 — Gingival Flap Surgery — 1–3 Teeth (Per Quad) D4260 — Osseous Surgery — 4+ Teeth (Per Quad) D4265 — Biologic Material for Tissue Regeneration D4274 — Distal/Proximal Wedge Procedure D4322 — Splint — Intracoronal (Natural Teeth) D4240 — Gingival Flap Surgery — 4+ Teeth (Per Quad) D4245 — Apically Positioned Flap D4270 — Pedicle Soft Tissue Graft D4283 — Autogenous Connective Tissue Graft (Each Add'l Tooth) D4323 — Splint — Extracoronal (Natural Teeth) D4342 — Scaling and Root Planing — 1–3 Teeth (Per Quad) D4346 — Scaling — Generalized Moderate/Severe Gingivitis D4381 — Localized Antimicrobial Delivery (Per Tooth) D4910 — Periodontal Maintenance D4921 — Gingival Irrigation — Per Quadrant

D5283 — Removable Unilateral Partial Denture — 1 Piece (Resin) D5226 — Lower Partial Denture — Flexible Base D5810 — Interim Complete Upper Denture D5227 — Immediate Upper Partial Denture — Flexible Base D5282 — Removable Unilateral Partial Denture — 1 Piece (Metal) D5811 — Interim Complete Lower Denture D5110 — Complete Upper Denture D5284 — Removable Unilateral Partial Denture — 1 Piece (Flex) D5512 — Repair Broken Complete Denture Base (Lower) D5721 — Rebase Lower Partial Denture D5730 — Reline Complete Upper Denture (Chair-side) D5120 — Complete Lower Denture D5140 — Immediate Lower Denture D5221 — Immediate Upper Partial Denture — Resin Base D5224 — Immediate Lower Partial Denture — Cast Metal D5511 — Repair Broken Complete Denture Base (Upper) D5612 — Repair Resin Partial Denture Base (Lower) D5740 — Reline Upper Partial Denture (Chair-side) D5760 — Reline Upper Partial Denture (Lab) D5761 — Reline Lower Partial Denture (Lab) D5821 — Interim Partial Lower Denture D5862 — Precision Attachment — By Report D5877 — Replacement of Locator Male, By Report D5130 — Immediate Upper Denture D5213 — Upper Partial Denture — Cast Metal Framework D5225 — Upper Partial Denture — Flexible Base D5286 — Removable Unilateral Partial Denture — 2 Piece (Metal) D5660 — Add Clasp to Existing Partial Denture D5671 — Replace All Teeth & Acrylic on Cast Metal Framework D5725 — Rebase Hybrid Prosthesis D5731 — Reline Complete Lower Denture (Chair-side) D5865 — Overdenture — Complete (Implant Supported) D5878 — Add Wrought Wire Clasp (Tooth-Supported) D5211 — Upper Partial Denture — Resin Base (w/ Clasps/Rests) D5212 — Lower Partial Denture — Resin Base (w/ Clasps/Rests) D5223 — Immediate Upper Partial Denture — Cast Metal D5621 — Repair Cast Partial Framework (Upper) D5640 — Replace Broken Teeth — Per Tooth D5650 — Add Tooth to Existing Partial Denture D5710 — Rebase Complete Upper Denture D5720 — Rebase Upper Partial Denture D5750 — Reline Complete Upper Denture (Lab) D5751 — Reline Complete Lower Denture (Lab) D5765 — Soft Liner for Complete or Partial Denture D5851 — Tissue Conditioning (Lower) D5866 — Overdenture — Partial (Implant Supported) D5867 — Replacement of Attachment — Implant Overdenture D5982 — Surgical Stent

D6608 — Bridge Retainer — Onlay, Porcelain/Ceramic (2 Surf) D6792 — Bridge Retainer — Full Cast Noble Metal D6055 — Dental Implant-Supported Connecting Bar D6091 — Implant Repair — Abutment Replacement D6191 — Semi-Precision Abutment — Placement D6195 — Implant-Supported Connector Bar (Modification) D6211 — Bridge Pontic — Cast Base Metal D6601 — Bridge Retainer — Inlay, Porcelain/Ceramic (3+ Surf) D6612 — Bridge Retainer — Onlay, Cast Base Metal (2 Surf) D6753 — Bridge Retainer — Porcelain Fused to Titanium D6781 — Bridge Retainer — ¾ Cast Base Metal D6013 — Surgical Placement — Mini Implant D6062 — Implant Abutment — Cast-to (Noble Metal) D6065 — Implant Crown — Porcelain/Ceramic D6070 — Implant Crown — Cast High Noble Metal D6548 — Retainer — Porcelain/Ceramic for Resin-Bonded Bridge D6607 — Bridge Retainer — Inlay, Cast Noble Metal (3+ Surf) D6611 — Bridge Retainer — Onlay, Cast High Noble Metal (3+ Surf) D6784 — Bridge Retainer — ¾ Titanium D6790 — Bridge Retainer — Full Cast High Noble Metal D6061 — Implant Abutment — Prefabricated (Base Metal) D6080 — Implant Maintenance — Cleaning/Inspection D6097 — Abutment-Supported Retainer (Removable) D6121 — Implant-Supported Retainer — FPD (Noble) D6243 — Bridge Pontic — Porcelain Fused to Titanium D6245 — Bridge Pontic — Porcelain/Ceramic D6280 — Bridge Pontic — Resin/Acrylic Denture Tooth D6602 — Bridge Retainer — Inlay, Cast High Noble Metal (2 Surf) D6603 — Bridge Retainer — Inlay, Cast High Noble Metal (3+ Surf) D6606 — Bridge Retainer — Inlay, Cast Noble Metal (2 Surf) D6610 — Bridge Retainer — Onlay, Cast High Noble Metal (2 Surf) D6722 — Bridge Retainer — Resin with Noble Metal D6783 — Bridge Retainer — ¾ Porcelain/Ceramic D6066 — Implant Crown — Porcelain Fused to Metal D6077 — Implant Crown — Noble Metal D6084 — Custom Implant Abutment (Porcelain/Ceramic) D6099 — Implant-Supported Retainer for FPD (Ceramic) D6110 — Implant Bridge Retainer — Porcelain Fused to HNM D6111 — Implant Bridge Retainer — Porcelain Fused to BM D6193 — Stress-Breaking Abutment — Placement D6241 — Bridge Pontic — Porcelain Fused to Base Metal D6253 — Provisional Bridge Pontic D6600 — Bridge Retainer — Inlay, Porcelain/Ceramic (2 Surf) D6604 — Bridge Retainer — Inlay, Cast Base Metal (2 Surf) D6780 — Bridge Retainer — ¾ Cast High Noble Metal D6793 — Bridge Retainer — Full Cast Titanium D6920 — Connector Bar D6010 — Surgical Placement — Endosteal Implant Body D6012 — Surgical Placement — Interim Implant Body D6040 — Surgical Placement — Eposteal Implant D6050 — Custom Fabricated Implant Abutment D6059 — Implant Abutment — Custom, By Report D6076 — Implant Crown — Base Metal D6082 — Implant-Supported Crown Repair, By Report D6101 — Debridement of Peri-Implant Defect — Surgical D6113 — Implant Bridge Retainer — Cast Metal (HNM) D6180 — Implant-Supported Partial Denture (Upper) D6192 — Semi-Precision Abutment — Removal D6240 — Bridge Pontic — Porcelain Fused to High Noble Metal D6605 — Bridge Retainer — Inlay, Cast Base Metal (3+ Surf) D6609 — Bridge Retainer — Onlay, Porcelain/Ceramic (3+ Surf) D6613 — Bridge Retainer — Onlay, Cast Base Metal (3+ Surf) D6614 — Bridge Retainer — Onlay, Cast Noble Metal (2 Surf) D6720 — Bridge Retainer — Resin with High Noble Metal D6750 — Bridge Retainer — Porcelain Fused to High Noble Metal D6752 — Bridge Retainer — Porcelain Fused to Noble Metal D6950 — Precision Attachment D6980 — Fixed Partial Denture Repair, By Report D6011 — Second Stage Implant Surgery D6051 — Interim Implant Abutment D6056 — Prefabricated Implant Abutment D6058 — Implant Abutment — Prefabricated D6067 — Implant Crown — High Noble Metal D6068 — Implant Abutment — Prefabricated D6069 — Implant Crown — Titanium D6072 — Implant Bridge Pontic — Porcelain Fused to Metal D6074 — Implant Bridge Pontic — Porcelain/Ceramic D6085 — Provisional Implant Crown D6087 — Implant Bridge Pontic — Resin D6096 — Remove Broken Implant Retaining Screw D6098 — Implant-Supported Retainer (Removable) D6102 — Bone Graft — Debridement of Peri-Implant Defect D6103 — Bone Graft — Implant Repair (First Site) D6104 — Bone Graft — Implant Repair (Each Add'l Site) D6106 — Bone Graft — Mandibular Symphysis D6107 — Bone Graft — From Extra-Oral Donor Site D6112 — Implant Bridge Retainer — Porcelain/Ceramic D6122 — Implant-Supported Retainer — FPD (Base) D6123 — Implant-Supported Retainer — FPD (Titanium) D6210 — Bridge Pontic — Cast High Noble Metal D6212 — Bridge Pontic — Cast Noble Metal D6250 — Bridge Pontic — Resin with High Noble Metal D6545 — Retainer — Cast Metal for Resin-Bonded Bridge D6549 — Retainer — Resin for Resin-Bonded Bridge D6615 — Bridge Retainer — Onlay, Cast Noble Metal (3+ Surf) D6721 — Bridge Retainer — Resin with Base Metal D6740 — Bridge Retainer — Porcelain/Ceramic D6751 — Bridge Retainer — Porcelain Fused to Base Metal D6782 — Bridge Retainer — ¾ Cast Noble Metal D6791 — Bridge Retainer — Full Cast Base Metal D6930 — Re-cement/Re-bond Bridge D6985 — Pediatric Partial Denture — Fixed

D7230 — Extraction — Partially Bony Impacted Tooth D7260 — Oroantral Fistula Closure D7994 — Surgical Placement — Bone-Fixation Plate D7282 — Mobilization of Erupted/Malpositioned Tooth D7286 — Incisional Biopsy — Oral Tissue (Soft) D7261 — Primary Closure of Sinus Perforation D7272 — Tooth Transplantation D7350 — Vestibuloplasty — Ridge Extension (w/ Graft) D7880 — Occlusal Orthotic Device — By Report D7970 — Excision of Hyperplastic Tissue — Per Arch D7140 — Extraction — Erupted Tooth or Exposed Root D7220 — Extraction — Soft Tissue Impacted Tooth D7240 — Extraction — Completely Bony Impacted Tooth D7252 — Tooth Removal of Impacted Tooth (Soft Tissue) D7321 — Alveoloplasty — Without Extractions (1–3 Teeth) D7340 — Vestibuloplasty — Ridge Extension D7451 — Removal of Benign Odontogenic Cyst > 1.25 cm D7485 — Reduction of Osseous Tuberosity D7520 — Incision and Drainage — Extraoral (Soft Tissue) D7956 — Guided Bone Regeneration — Edentulous Area D7241 — Extraction — Completely Bony Impacted (Complicated) D7251 — Coronectomy — Intentional Partial Tooth Removal D7270 — Tooth Reimplantation/Stabilization D7290 — Surgical Repositioning of Teeth D7311 — Alveoloplasty — With Extractions (1–3 Teeth) D7320 — Alveoloplasty — Without Extractions (Per Quad) D7450 — Removal of Benign Odontogenic Cyst ≤ 1.25 cm D7472 — Removal of Torus Palatinus D7509 — Marsupialization of Cyst D7510 — Incision and Drainage — Intraoral (Soft Tissue) D7511 — Incision and Drainage — Intraoral (Soft Tissue, Complicated) D7210 — Extraction — Surgical (Erupted Tooth) D7250 — Extraction — Residual Root Removal D7471 — Removal of Lateral Exostosis D7881 — Occlusal Orthotic Device — Adjustment D7921 — Collection/Application of Autologous Blood Concentrate D7953 — Bone Replacement Graft — Ridge Preservation D7962 — Lingual Frenectomy D7971 — Excision of Pericoronal Gingiva D7972 — Surgical Reduction of Fibrous Tuberosity

D8091 — Comprehensive Orthodontic — By Report D8090 — Comprehensive Orthodontic — Adult Dentition D8670 — Periodic Orthodontic Treatment Visit D8680 — Orthodontic Retention — Removable Appliance D8698 — Re-cement/Re-bond Fixed Retainer (Mandibular) D8701 — Repair of Fixed Retainer (Includes Re-attachment)

D9410 — House/Extended Care Facility Call D9944 — Occlusal Guard — Hard Appliance (Full Arch) D9945 — Occlusal Guard — Soft Appliance (Full Arch) D9420 — Hospital or ASC Call D9440 — Office Visit — After Regular Hours D9920 — Behavior Management — By Report D9972 — External Bleaching — Per Arch D9974 — Internal Bleaching — Per Tooth D9110 — Palliative (Emergency) Treatment D9120 — Fixed Partial Denture Sectioning D9219 — Evaluation for Moderate Sedation D9222 — Deep Sedation/General Anesthesia — First 15 min D9310 — Consultation — Specialist/Dentist D9311 — Consultation — With Another Dentist/Physician D9430 — Office Visit for Observation (No Services) D9450 — Case Presentation — Treatment Plan D9610 — Therapeutic Parenteral Drug — Single Admin D9942 — Repair/Reline of Occlusal Guard D9943 — Occlusal Guard — By Report D9951 — Occlusal Adjustment — Limited D9952 — Occlusal Adjustment — Complete D9971 — Odontoplasty — 1–2 Teeth D9994 — Dental Case Management — Patient Education