Dental Reimbursement Rates in Montana

D0415 — Collection of Microbial Culture Specimen D0210 — Full Mouth X-Rays D0396 — 3D Volume Rendering of Image Data D0171 — Re-evaluation — Post-Operative D0373 — Cone Beam CT — 3D Interpretation (Both Jaws)

D1517 — Space Maintainer — Fixed, Bilateral (Mandibular) D1526 — Space Maintainer — Removable, Bilateral (Maxillary) D1330 — Oral Hygiene Instructions D1516 — Space Maintainer — Fixed, Bilateral (Maxillary) D1527 — Space Maintainer — Removable, Bilateral (Mandibular)

D2920 — Re-cement/Re-bond Crown D2330 — Composite Filling — 1 Surface, Anterior D2410 — Gold Foil — 1 Surface D2520 — Inlay — Metallic, 2 Surfaces D2644 — Onlay — Porcelain/Ceramic, 4+ Surfaces D2664 — Onlay — Composite/Resin, 4+ Surfaces D2710 — Crown — Resin (Indirect) D2753 — Crown — Porcelain Fused to Titanium D2781 — Crown — ¾ Cast Base Metal D2783 — Crown — ¾ Porcelain/Ceramic D2940 — Protective Restoration (Sedative Filling) D2955 — Post Removal D2960 — Labial Veneer — Resin (Chair-side) D2961 — Labial Veneer — Resin (Lab) D2962 — Labial Veneer — Porcelain (Lab) D2161 — Amalgam Filling — 4+ Surfaces, Primary/Permanent D2510 — Inlay — Metallic, 1 Surface D2542 — Onlay — Metallic, 2 Surfaces D2630 — Inlay — Porcelain/Ceramic, 3+ Surfaces D2750 — Crown — Porcelain Fused to High Noble Metal D2780 — Crown — ¾ Cast High Noble Metal D2782 — Crown — ¾ Cast Noble Metal D2790 — Crown — Full Cast High Noble Metal D2799 — Provisional Crown D2990 — Resin Infiltration of Incipient Lesion

D3332 — Incomplete Endodontic Treatment (Inoperable/Fracture) D3425 — Apicoectomy — Molar (First Root) D3430 — Retrograde Filling — Per Root D3331 — Treatment of Root Canal Obstruction (Non-Surgical) D3346 — Retreatment — Anterior D3351 — Apexification/Recalcification — Initial Visit D3410 — Apicoectomy — Anterior D3471 — Surgical Repair — Root Resorption (Anterior) D3473 — Surgical Repair — Root Resorption (Molar)

D4211 — Gingivectomy/Gingivoplasty — 1–3 Teeth (Per Quad) D4231 — Anatomical Crown Exposure — 1–3 Teeth (Per Quad) D4240 — Gingival Flap Surgery — 4+ Teeth (Per Quad) D4267 — Guided Tissue Regeneration — Non-Resorbable Barrier D4270 — Pedicle Soft Tissue Graft D4276 — Combined Connective Tissue & Pedicle Graft D4278 — Free Soft Tissue Graft (Each Additional Tooth) D4230 — Anatomical Crown Exposure — 4+ Teeth (Per Quad) D4261 — Osseous Surgery — 1–3 Teeth (Per Quad) D4285 — Non-Autogenous Connective Tissue Graft (Each Add'l) D4286 — Combined Connective Tissue Graft (Each Add'l Tooth) D4322 — Splint — Intracoronal (Natural Teeth)

D5140 — Immediate Lower Denture D5211 — Upper Partial Denture — Resin Base (w/ Clasps/Rests) D5212 — Lower Partial Denture — Resin Base (w/ Clasps/Rests) D5221 — Immediate Upper Partial Denture — Resin Base D5226 — Lower Partial Denture — Flexible Base D5670 — Replace Teeth & Acrylic on Metal Framework D5751 — Reline Complete Lower Denture (Lab) D5811 — Interim Complete Lower Denture D5213 — Upper Partial Denture — Cast Metal Framework D5222 — Immediate Lower Partial Denture — Resin Base D5225 — Upper Partial Denture — Flexible Base D5612 — Repair Resin Partial Denture Base (Lower) D5622 — Repair Cast Partial Framework (Lower) D5640 — Replace Broken Teeth — Per Tooth D5711 — Rebase Complete Lower Denture D5720 — Rebase Upper Partial Denture D5760 — Reline Upper Partial Denture (Lab) D5820 — Interim Partial Upper Denture D5863 — Overdenture — Complete (Implant/Root Supported) D5991 — Vesiculobullous Disease Medicament Carrier

D6010 — Surgical Placement — Endosteal Implant Body D6040 — Surgical Placement — Eposteal Implant D6067 — Implant Crown — High Noble Metal D6088 — Implant Bridge Retainer — Resin D6098 — Implant-Supported Retainer (Removable) D6110 — Implant Bridge Retainer — Porcelain Fused to HNM D6112 — Implant Bridge Retainer — Porcelain/Ceramic D6113 — Implant Bridge Retainer — Cast Metal (HNM) D6191 — Semi-Precision Abutment — Placement D6193 — Stress-Breaking Abutment — Placement D6195 — Implant-Supported Connector Bar (Modification) D6212 — Bridge Pontic — Cast Noble Metal D6242 — Bridge Pontic — Porcelain Fused to Noble Metal D6243 — Bridge Pontic — Porcelain Fused to Titanium D6250 — Bridge Pontic — Resin with High Noble Metal D6251 — Bridge Pontic — Resin with Base Metal D6545 — Retainer — Cast Metal for Resin-Bonded Bridge D6614 — Bridge Retainer — Onlay, Cast Noble Metal (2 Surf) D6721 — Bridge Retainer — Resin with Base Metal D6781 — Bridge Retainer — ¾ Cast Base Metal D6784 — Bridge Retainer — ¾ Titanium D6792 — Bridge Retainer — Full Cast Noble Metal D6930 — Re-cement/Re-bond Bridge D6074 — Implant Bridge Pontic — Porcelain/Ceramic D6086 — Implant Crown — Resin D6013 — Surgical Placement — Mini Implant D6057 — Custom Fabricated Implant Abutment D6060 — Implant Abutment — Prefabricated (Noble Metal) D6061 — Implant Abutment — Prefabricated (Base Metal) D6064 — Implant Abutment — Prefabricated (Titanium) D6069 — Implant Crown — Titanium D6076 — Implant Crown — Base Metal D6083 — Implant-Supported Prosthesis Repair, By Report D6085 — Provisional Implant Crown D6087 — Implant Bridge Pontic — Resin D6096 — Remove Broken Implant Retaining Screw D6102 — Bone Graft — Debridement of Peri-Implant Defect D6602 — Bridge Retainer — Inlay, Cast High Noble Metal (2 Surf) D6603 — Bridge Retainer — Inlay, Cast High Noble Metal (3+ Surf) D6612 — Bridge Retainer — Onlay, Cast Base Metal (2 Surf) D6720 — Bridge Retainer — Resin with High Noble Metal D6722 — Bridge Retainer — Resin with Noble Metal D6753 — Bridge Retainer — Porcelain Fused to Titanium D6791 — Bridge Retainer — Full Cast Base Metal

D7962 — Lingual Frenectomy D7240 — Extraction — Completely Bony Impacted Tooth D7251 — Coronectomy — Intentional Partial Tooth Removal D7296 — Corticotomy — One to Three Tooth Spaces D7310 — Alveoloplasty — With Extractions (Per Quad) D7350 — Vestibuloplasty — Ridge Extension (w/ Graft) D7957 — Guided Bone Regeneration — Non-Resorbable Membrane D7961 — Buccal/Labial Frenectomy D7970 — Excision of Hyperplastic Tissue — Per Arch D7272 — Tooth Transplantation D7286 — Incisional Biopsy — Oral Tissue (Soft) D7140 — Extraction — Erupted Tooth or Exposed Root D7270 — Tooth Reimplantation/Stabilization D7311 — Alveoloplasty — With Extractions (1–3 Teeth) D7485 — Reduction of Osseous Tuberosity D7880 — Occlusal Orthotic Device — By Report D7971 — Excision of Pericoronal Gingiva

D9110 — Palliative (Emergency) Treatment D9224 — Deep Sedation/General Anesthesia — First 15 min (Dentist) D9244 — Non-IV Moderate Conscious Sedation (By Non-Treating Dentist) D9410 — House/Extended Care Facility Call D9420 — Hospital or ASC Call D9610 — Therapeutic Parenteral Drug — Single Admin