Dental Reimbursement Rates in Idaho

D0320 — TMJ Arthrogram D0277 — Vertical Bitewing X-Rays (7–8 Films) D0470 — Diagnostic Cast D0171 — Re-evaluation — Post-Operative D0210 — Full Mouth X-Rays D0322 — Tomographic Survey D0330 — Panoramic X-Ray D0120 — Periodic Oral Evaluation D0170 — Re-evaluation — Limited, Problem Focused D0190 — Screening of a Patient D0191 — Assessment of a Patient D0240 — Occlusal X-Ray D0274 — Bitewing X-Rays — Four Films D0310 — Sialography D0373 — Cone Beam CT — 3D Interpretation (Both Jaws) D0389 — Cone Beam CT — Airway Assessment Interpretation D0423 — Caries Risk Assessment (6 & Older)

D1520 — Space Maintainer — Removable, Unilateral D1526 — Space Maintainer — Removable, Bilateral (Maxillary) D1575 — Distal Shoe Space Maintainer D1510 — Space Maintainer — Fixed, Unilateral D1516 — Space Maintainer — Fixed, Bilateral (Maxillary) D1517 — Space Maintainer — Fixed, Bilateral (Mandibular) D1527 — Space Maintainer — Removable, Bilateral (Mandibular) D1553 — Re-cement/Re-bond Space Maintainer (Bilateral, Mand) D1120 — Child Prophylaxis D1330 — Oral Hygiene Instructions D1354 — Interim Caries Arresting Medicament (SDF) D1556 — Removal of Fixed Space Maintainer (Unilateral) D1557 — Removal of Fixed Space Maintainer (Bilateral, Max)

D2510 — Inlay — Metallic, 1 Surface D2652 — Inlay — Composite/Resin, 3+ Surfaces D2544 — Onlay — Metallic, 4+ Surfaces D2610 — Inlay — Porcelain/Ceramic, 1 Surface D2720 — Crown — Resin with High Noble Metal D2740 — Crown — Porcelain/Ceramic D2752 — Crown — Porcelain Fused to Noble Metal D2952 — Post and Core — Cast (w/ Crown) D2630 — Inlay — Porcelain/Ceramic, 3+ Surfaces D2662 — Onlay — Composite/Resin, 2 Surfaces D2722 — Crown — Resin with Noble Metal D2750 — Crown — Porcelain Fused to High Noble Metal D2790 — Crown — Full Cast High Noble Metal D2955 — Post Removal D2391 — Composite Filling — 1 Surface, Posterior D2393 — Composite Filling — 3 Surfaces, Posterior D2430 — Gold Foil — 3 Surfaces D2530 — Inlay — Metallic, 3+ Surfaces D2542 — Onlay — Metallic, 2 Surfaces D2791 — Crown — Full Cast Base Metal D2390 — Composite Crown — Anterior, Primary D2620 — Inlay — Porcelain/Ceramic, 2 Surfaces D2642 — Onlay — Porcelain/Ceramic, 2 Surfaces D2643 — Onlay — Porcelain/Ceramic, 3 Surfaces D2712 — Crown — ¾ Resin (Indirect) D2751 — Crown — Porcelain Fused to Base Metal D2961 — Labial Veneer — Resin (Lab) D2520 — Inlay — Metallic, 2 Surfaces D2543 — Onlay — Metallic, 3 Surfaces D2644 — Onlay — Porcelain/Ceramic, 4+ Surfaces D2783 — Crown — ¾ Porcelain/Ceramic D2799 — Provisional Crown D2930 — Prefabricated Stainless Steel Crown — Primary D2962 — Labial Veneer — Porcelain (Lab) D2420 — Gold Foil — 2 Surfaces D2664 — Onlay — Composite/Resin, 4+ Surfaces D2780 — Crown — ¾ Cast High Noble Metal D2931 — Prefabricated Stainless Steel Crown — Permanent D2161 — Amalgam Filling — 4+ Surfaces, Primary/Permanent D2650 — Inlay — Composite/Resin, 1 Surface D2651 — Inlay — Composite/Resin, 2 Surfaces D2663 — Onlay — Composite/Resin, 3 Surfaces D2721 — Crown — Resin with Base Metal D2781 — Crown — ¾ Cast Base Metal D2792 — Crown — Full Cast Noble Metal D2928 — Prefabricated Porcelain/Ceramic Crown — Primary D2933 — Prefabricated SS Crown with Resin Window D2954 — Prefabricated Post and Core D2160 — Amalgam Filling — 3 Surfaces, Primary/Permanent D2392 — Composite Filling — 2 Surfaces, Posterior D2410 — Gold Foil — 1 Surface D2753 — Crown — Porcelain Fused to Titanium D2782 — Crown — ¾ Cast Noble Metal D2932 — Prefabricated Resin Crown D2953 — Post and Core — Each Additional (Cast) D2140 — Amalgam Filling — 1 Surface, Primary/Permanent D2150 — Amalgam Filling — 2 Surfaces, Primary/Permanent D2331 — Composite Filling — 2 Surfaces, Anterior D2332 — Composite Filling — 3 Surfaces, Anterior D2335 — Composite Filling — 4+ Surfaces/Incisal Angle D2394 — Composite Filling — 4+ Surfaces, Posterior D2710 — Crown — Resin (Indirect) D2920 — Re-cement/Re-bond Crown D2934 — Prefabricated Esthetic Coated SS Crown — Primary D2940 — Protective Restoration (Sedative Filling) D2950 — Core Buildup Including Pins D2960 — Labial Veneer — Resin (Chair-side) D2980 — Crown Repair, By Report D2981 — Inlay Repair, By Report D2982 — Onlay Repair, By Report

D3501 — Surgical Exposure for Canal Access D3502 — Surgical Perforation Repair D3346 — Retreatment — Anterior D3320 — Root Canal — Premolar (Excluding Final Restoration) D3470 — Intentional Reimplantation D3920 — Hemisection (Not Root Canal/Restoration) D3347 — Retreatment — Premolar D3431 — Biologically-Based Root Treatment D3450 — Root Amputation — Per Root D3471 — Surgical Repair — Root Resorption (Anterior) D3230 — Pulpal Therapy — Anterior, Primary D3425 — Apicoectomy — Molar (First Root) D3473 — Surgical Repair — Root Resorption (Molar) D3221 — Pulpal Debridement — Primary/Permanent Teeth D3310 — Root Canal — Anterior (Excluding Final Restoration) D3503 — Surgical Root Repair — Anterior D3348 — Retreatment — Molar D3353 — Apexification/Recalcification — Final Visit D3430 — Retrograde Filling — Per Root D3921 — Decoronation/Intentional Submergence D3220 — Therapeutic Pulpotomy (Excluding Final Restoration) D3240 — Pulpal Therapy — Posterior, Primary D3330 — Root Canal — Molar (Excluding Final Restoration) D3331 — Treatment of Root Canal Obstruction (Non-Surgical) D3352 — Apexification/Recalcification — Interim Medication D3355 — Pulpal Regeneration — Initial Visit D3410 — Apicoectomy — Anterior D3421 — Apicoectomy — Premolar (First Root) D3472 — Surgical Repair — Root Resorption (Premolar) D3222 — Partial Pulpotomy for Apexogenesis — Permanent D3351 — Apexification/Recalcification — Initial Visit D3356 — Pulpal Regeneration — Interim Medication D3426 — Apicoectomy — Each Additional Root D3428 — Retrograde Filling — Per Root D3950 — Canal Prep and Fitting of Preformed Post/Dowel D3110 — Pulp Cap — Direct (Excluding Final Restoration) D3120 — Pulp Cap — Indirect (Excluding Final Restoration) D3332 — Incomplete Endodontic Treatment (Inoperable/Fracture) D3333 — Internal Root Repair — Perforation D3357 — Pulpal Regeneration — Final Visit D3429 — Hemisection (Including Root Removal, Not Crown) D3432 — Guided Tissue Regeneration (Periradicular Surgery)

D4260 — Osseous Surgery — 4+ Teeth (Per Quad) D4241 — Gingival Flap Surgery — 1–3 Teeth (Per Quad) D4261 — Osseous Surgery — 1–3 Teeth (Per Quad) D4341 — Scaling and Root Planing — 4+ Teeth (Per Quad) D4273 — Autogenous Connective Tissue Graft (First Tooth) D4267 — Guided Tissue Regeneration — Non-Resorbable Barrier D4275 — Non-Autogenous Connective Tissue Graft (First Tooth) D4323 — Splint — Extracoronal (Natural Teeth) D4249 — Clinical Crown Lengthening — Hard Tissue D4270 — Pedicle Soft Tissue Graft D4210 — Gingivectomy/Gingivoplasty — 4+ Teeth (Per Quad) D4245 — Apically Positioned Flap D4265 — Biologic Material for Tissue Regeneration D4283 — Autogenous Connective Tissue Graft (Each Add'l Tooth) D4286 — Combined Connective Tissue Graft (Each Add'l Tooth) D4355 — Full Mouth Debridement D4230 — Anatomical Crown Exposure — 4+ Teeth (Per Quad) D4240 — Gingival Flap Surgery — 4+ Teeth (Per Quad) D4263 — Bone Replacement Graft — First Site (Per Quad) D4266 — Guided Tissue Regeneration — Resorbable Barrier D4274 — Distal/Proximal Wedge Procedure D4277 — Free Soft Tissue Graft (First Tooth) D4264 — Bone Replacement Graft — Each Additional Site D4212 — Gingivectomy/Gingivoplasty (Restorative, Per Tooth) D4231 — Anatomical Crown Exposure — 1–3 Teeth (Per Quad) D4276 — Combined Connective Tissue & Pedicle Graft D4322 — Splint — Intracoronal (Natural Teeth) D4211 — Gingivectomy/Gingivoplasty — 1–3 Teeth (Per Quad) D4285 — Non-Autogenous Connective Tissue Graft (Each Add'l) D4346 — Scaling — Generalized Moderate/Severe Gingivitis D4910 — Periodontal Maintenance

D5211 — Upper Partial Denture — Resin Base (w/ Clasps/Rests) D5671 — Replace All Teeth & Acrylic on Cast Metal Framework D5214 — Lower Partial Denture — Cast Metal Framework D5821 — Interim Partial Lower Denture D5110 — Complete Upper Denture D5212 — Lower Partial Denture — Resin Base (w/ Clasps/Rests) D5286 — Removable Unilateral Partial Denture — 2 Piece (Metal) D5670 — Replace Teeth & Acrylic on Metal Framework D5811 — Interim Complete Lower Denture D5862 — Precision Attachment — By Report D5877 — Replacement of Locator Male, By Report D5213 — Upper Partial Denture — Cast Metal Framework D5225 — Upper Partial Denture — Flexible Base D5710 — Rebase Complete Upper Denture D5130 — Immediate Upper Denture D5140 — Immediate Lower Denture D5224 — Immediate Lower Partial Denture — Cast Metal D5228 — Immediate Lower Partial Denture — Flexible Base D5282 — Removable Unilateral Partial Denture — 1 Piece (Metal) D5283 — Removable Unilateral Partial Denture — 1 Piece (Resin) D5810 — Interim Complete Upper Denture D5863 — Overdenture — Complete (Implant/Root Supported) D5865 — Overdenture — Complete (Implant Supported) D5878 — Add Wrought Wire Clasp (Tooth-Supported) D5120 — Complete Lower Denture D5226 — Lower Partial Denture — Flexible Base D5227 — Immediate Upper Partial Denture — Flexible Base D5222 — Immediate Lower Partial Denture — Resin Base D5223 — Immediate Upper Partial Denture — Cast Metal D5284 — Removable Unilateral Partial Denture — 1 Piece (Flex) D5621 — Repair Cast Partial Framework (Upper) D5622 — Repair Cast Partial Framework (Lower) D5760 — Reline Upper Partial Denture (Lab) D5761 — Reline Lower Partial Denture (Lab) D5221 — Immediate Upper Partial Denture — Resin Base D5711 — Rebase Complete Lower Denture D5720 — Rebase Upper Partial Denture D5725 — Rebase Hybrid Prosthesis D5750 — Reline Complete Upper Denture (Lab) D5765 — Soft Liner for Complete or Partial Denture D5820 — Interim Partial Upper Denture D5867 — Replacement of Attachment — Implant Overdenture D5512 — Repair Broken Complete Denture Base (Lower) D5520 — Replace Missing/Broken Teeth — Complete Denture D5650 — Add Tooth to Existing Partial Denture D5721 — Rebase Lower Partial Denture D5730 — Reline Complete Upper Denture (Chair-side) D5612 — Repair Resin Partial Denture Base (Lower) D5630 — Repair or Replace Broken Clasp — Per Tooth D5640 — Replace Broken Teeth — Per Tooth D5731 — Reline Complete Lower Denture (Chair-side) D5740 — Reline Upper Partial Denture (Chair-side) D5751 — Reline Complete Lower Denture (Lab) D5850 — Tissue Conditioning (Upper) D5851 — Tissue Conditioning (Lower) D5875 — Modification of Removable Prosthesis (Implant)

D6612 — Bridge Retainer — Onlay, Cast Base Metal (2 Surf) D6120 — Implant-Supported Retainer — FPD (High Noble) D6783 — Bridge Retainer — ¾ Porcelain/Ceramic D6010 — Surgical Placement — Endosteal Implant Body D6784 — Bridge Retainer — ¾ Titanium D6040 — Surgical Placement — Eposteal Implant D6253 — Provisional Bridge Pontic D6781 — Bridge Retainer — ¾ Cast Base Metal D6011 — Second Stage Implant Surgery D6191 — Semi-Precision Abutment — Placement D6607 — Bridge Retainer — Inlay, Cast Noble Metal (3+ Surf) D6610 — Bridge Retainer — Onlay, Cast High Noble Metal (2 Surf) D6614 — Bridge Retainer — Onlay, Cast Noble Metal (2 Surf) D6753 — Bridge Retainer — Porcelain Fused to Titanium D6792 — Bridge Retainer — Full Cast Noble Metal D6050 — Custom Fabricated Implant Abutment D6058 — Implant Abutment — Prefabricated D6074 — Implant Bridge Pontic — Porcelain/Ceramic D6075 — Implant Crown — Porcelain Fused to Titanium D6083 — Implant-Supported Prosthesis Repair, By Report D6113 — Implant Bridge Retainer — Cast Metal (HNM) D6245 — Bridge Pontic — Porcelain/Ceramic D6252 — Bridge Pontic — Resin with Noble Metal D6600 — Bridge Retainer — Inlay, Porcelain/Ceramic (2 Surf) D6601 — Bridge Retainer — Inlay, Porcelain/Ceramic (3+ Surf) D6721 — Bridge Retainer — Resin with Base Metal D6780 — Bridge Retainer — ¾ Cast High Noble Metal D6980 — Fixed Partial Denture Repair, By Report D6059 — Implant Abutment — Custom, By Report D6063 — Implant Abutment — Cast-to (Base Metal) D6069 — Implant Crown — Titanium D6070 — Implant Crown — Cast High Noble Metal D6071 — Implant Crown — Cast Base Metal D6076 — Implant Crown — Base Metal D6086 — Implant Crown — Resin D6241 — Bridge Pontic — Porcelain Fused to Base Metal D6242 — Bridge Pontic — Porcelain Fused to Noble Metal D6250 — Bridge Pontic — Resin with High Noble Metal D6548 — Retainer — Porcelain/Ceramic for Resin-Bonded Bridge D6606 — Bridge Retainer — Inlay, Cast Noble Metal (2 Surf) D6615 — Bridge Retainer — Onlay, Cast Noble Metal (3+ Surf) D6750 — Bridge Retainer — Porcelain Fused to High Noble Metal D6790 — Bridge Retainer — Full Cast High Noble Metal D6061 — Implant Abutment — Prefabricated (Base Metal) D6065 — Implant Crown — Porcelain/Ceramic D6067 — Implant Crown — High Noble Metal D6088 — Implant Bridge Retainer — Resin D6098 — Implant-Supported Retainer (Removable) D6099 — Implant-Supported Retainer for FPD (Ceramic) D6102 — Bone Graft — Debridement of Peri-Implant Defect D6111 — Implant Bridge Retainer — Porcelain Fused to BM D6112 — Implant Bridge Retainer — Porcelain/Ceramic D6195 — Implant-Supported Connector Bar (Modification) D6240 — Bridge Pontic — Porcelain Fused to High Noble Metal D6603 — Bridge Retainer — Inlay, Cast High Noble Metal (3+ Surf) D6604 — Bridge Retainer — Inlay, Cast Base Metal (2 Surf) D6605 — Bridge Retainer — Inlay, Cast Base Metal (3+ Surf) D6751 — Bridge Retainer — Porcelain Fused to Base Metal D6752 — Bridge Retainer — Porcelain Fused to Noble Metal D6791 — Bridge Retainer — Full Cast Base Metal D6012 — Surgical Placement — Interim Implant Body D6057 — Custom Fabricated Implant Abutment D6060 — Implant Abutment — Prefabricated (Noble Metal) D6077 — Implant Crown — Noble Metal D6082 — Implant-Supported Crown Repair, By Report D6122 — Implant-Supported Retainer — FPD (Base) D6212 — Bridge Pontic — Cast Noble Metal D6243 — Bridge Pontic — Porcelain Fused to Titanium D6251 — Bridge Pontic — Resin with Base Metal D6545 — Retainer — Cast Metal for Resin-Bonded Bridge D6609 — Bridge Retainer — Onlay, Porcelain/Ceramic (3+ Surf) D6611 — Bridge Retainer — Onlay, Cast High Noble Metal (3+ Surf) D6720 — Bridge Retainer — Resin with High Noble Metal D6740 — Bridge Retainer — Porcelain/Ceramic D6940 — Bridge Repair, By Report D6013 — Surgical Placement — Mini Implant D6066 — Implant Crown — Porcelain Fused to Metal D6073 — Implant Bridge Pontic — Cast High Noble Metal D6087 — Implant Bridge Pontic — Resin D6091 — Implant Repair — Abutment Replacement D6097 — Abutment-Supported Retainer (Removable) D6101 — Debridement of Peri-Implant Defect — Surgical D6121 — Implant-Supported Retainer — FPD (Noble) D6123 — Implant-Supported Retainer — FPD (Titanium) D6193 — Stress-Breaking Abutment — Placement D6211 — Bridge Pontic — Cast Base Metal D6782 — Bridge Retainer — ¾ Cast Noble Metal D6920 — Connector Bar D6062 — Implant Abutment — Cast-to (Noble Metal) D6064 — Implant Abutment — Prefabricated (Titanium) D6068 — Implant Abutment — Prefabricated D6084 — Custom Implant Abutment (Porcelain/Ceramic) D6103 — Bone Graft — Implant Repair (First Site) D6106 — Bone Graft — Mandibular Symphysis D6107 — Bone Graft — From Extra-Oral Donor Site D6110 — Implant Bridge Retainer — Porcelain Fused to HNM D6192 — Semi-Precision Abutment — Removal D6210 — Bridge Pontic — Cast High Noble Metal D6549 — Retainer — Resin for Resin-Bonded Bridge D6602 — Bridge Retainer — Inlay, Cast High Noble Metal (2 Surf) D6608 — Bridge Retainer — Onlay, Porcelain/Ceramic (2 Surf) D6722 — Bridge Retainer — Resin with Noble Metal D6793 — Bridge Retainer — Full Cast Titanium D6950 — Precision Attachment D6055 — Dental Implant-Supported Connecting Bar D6056 — Prefabricated Implant Abutment D6072 — Implant Bridge Pontic — Porcelain Fused to Metal D6085 — Provisional Implant Crown D6096 — Remove Broken Implant Retaining Screw D6104 — Bone Graft — Implant Repair (Each Add'l Site) D6930 — Re-cement/Re-bond Bridge D6051 — Interim Implant Abutment D6089 — Implant Abutment Modification D6093 — Re-cement/Re-bond Implant Bridge D6114 — Implant Bridge Retainer — Cast Metal (NM) D6115 — Implant Bridge Retainer — Cast Metal (BM) D6613 — Bridge Retainer — Onlay, Cast Base Metal (3+ Surf)

D7350 — Vestibuloplasty — Ridge Extension (w/ Graft) D7340 — Vestibuloplasty — Ridge Extension D7473 — Removal of Torus Mandibularis D7961 — Buccal/Labial Frenectomy D7282 — Mobilization of Erupted/Malpositioned Tooth D7485 — Reduction of Osseous Tuberosity D7994 — Surgical Placement — Bone-Fixation Plate D7451 — Removal of Benign Odontogenic Cyst > 1.25 cm D7957 — Guided Bone Regeneration — Non-Resorbable Membrane D7220 — Extraction — Soft Tissue Impacted Tooth D7240 — Extraction — Completely Bony Impacted Tooth D7472 — Removal of Torus Palatinus D7509 — Marsupialization of Cyst D7953 — Bone Replacement Graft — Ridge Preservation D7251 — Coronectomy — Intentional Partial Tooth Removal D7471 — Removal of Lateral Exostosis D7270 — Tooth Reimplantation/Stabilization D7272 — Tooth Transplantation D7297 — Corticotomy — Four or More Tooth Spaces D7450 — Removal of Benign Odontogenic Cyst ≤ 1.25 cm D7510 — Incision and Drainage — Intraoral (Soft Tissue) D7880 — Occlusal Orthotic Device — By Report D7956 — Guided Bone Regeneration — Edentulous Area D7962 — Lingual Frenectomy D7972 — Surgical Reduction of Fibrous Tuberosity D7260 — Oroantral Fistula Closure D7511 — Incision and Drainage — Intraoral (Soft Tissue, Complicated) D7971 — Excision of Pericoronal Gingiva D7230 — Extraction — Partially Bony Impacted Tooth D7252 — Tooth Removal of Impacted Tooth (Soft Tissue) D7261 — Primary Closure of Sinus Perforation D7280 — Surgical Exposure of Impacted Tooth (Orthodontic) D7286 — Incisional Biopsy — Oral Tissue (Soft) D7290 — Surgical Repositioning of Teeth D7320 — Alveoloplasty — Without Extractions (Per Quad) D7321 — Alveoloplasty — Without Extractions (1–3 Teeth) D7970 — Excision of Hyperplastic Tissue — Per Arch D7111 — Extraction — Coronal Remnants (Primary Tooth) D7250 — Extraction — Residual Root Removal D7284 — Excisional Biopsy — Bone D7285 — Incisional Biopsy — Oral Tissue (Hard) D7310 — Alveoloplasty — With Extractions (Per Quad) D7520 — Incision and Drainage — Extraoral (Soft Tissue) D7820 — Closed Reduction of Dislocation D7850 — Surgical Discectomy (w/ or w/o Implant) D7950 — Osseous/Osteoperiosteal Graft — Mandible/Maxilla

D8090 — Comprehensive Orthodontic — Adult Dentition D8681 — Orthodontic Retention — Fixed Appliance D8698 — Re-cement/Re-bond Fixed Retainer (Mandibular)

D9952 — Occlusal Adjustment — Complete D9944 — Occlusal Guard — Hard Appliance (Full Arch) D9420 — Hospital or ASC Call D9440 — Office Visit — After Regular Hours D9941 — Fabrication of Athletic Mouthguard D9974 — Internal Bleaching — Per Tooth D9110 — Palliative (Emergency) Treatment D9222 — Deep Sedation/General Anesthesia — First 15 min D9230 — Inhalation Analgesia (Nitrous Oxide) D9950 — Occlusion Analysis — Mounted Case D9972 — External Bleaching — Per Arch D9212 — Trigeminal Division Block Anesthesia D9223 — Deep Sedation/General Anesthesia — Each Add'l 15 min D9239 — Intravenous Moderate Sedation — First 15 min D9246 — Non-IV Moderate Conscious Sedation — Each Add'l 15 min D9247 — Non-IV Moderate Conscious Sedation — Supplemental D9310 — Consultation — Specialist/Dentist D9311 — Consultation — With Another Dentist/Physician D9410 — House/Extended Care Facility Call D9920 — Behavior Management — By Report D9930 — Treatment of Complications (Post-Surgical) D9943 — Occlusal Guard — By Report D9945 — Occlusal Guard — Soft Appliance (Full Arch) D9946 — Occlusal Guard — Hard Appliance (Partial Arch) D9951 — Occlusal Adjustment — Limited D9971 — Odontoplasty — 1–2 Teeth D9973 — External Bleaching — Per Tooth