Dental Reimbursement Rates in Nebraska

D0170 — Re-evaluation — Limited, Problem Focused D0470 — Diagnostic Cast D0240 — Occlusal X-Ray D0350 — Oral/Facial Photographic Images D0190 — Screening of a Patient D0210 — Full Mouth X-Rays D0396 — 3D Volume Rendering of Image Data D0322 — Tomographic Survey D0372 — Cone Beam CT — 3D Data Capture (Both Jaws) D0150 — Comprehensive Oral Evaluation — New/Established D0160 — Detailed/Extensive Oral Evaluation D0310 — Sialography D0431 — Adjunctive Pre-Diagnostic Test (No Biopsy) D0120 — Periodic Oral Evaluation D0140 — Limited Oral Evaluation — Problem Focused D0145 — Oral Evaluation for Patient Under 3 D0230 — Periapical X-Ray — Each Additional Film D0251 — Extraoral — Posterior Dental X-Ray D0274 — Bitewing X-Rays — Four Films D0277 — Vertical Bitewing X-Rays (7–8 Films) D0320 — TMJ Arthrogram D0330 — Panoramic X-Ray D0418 — Analysis of Saliva Specimen D0426 — Caries Risk Assessment & Documentation (Low Risk) D0486 — Accession of Transepithelial Cytologic Sample

D1120 — Child Prophylaxis D1510 — Space Maintainer — Fixed, Unilateral D1517 — Space Maintainer — Fixed, Bilateral (Mandibular) D1527 — Space Maintainer — Removable, Bilateral (Mandibular) D1516 — Space Maintainer — Fixed, Bilateral (Maxillary) D1526 — Space Maintainer — Removable, Bilateral (Maxillary) D1575 — Distal Shoe Space Maintainer D1310 — Nutritional Counseling for Dental Caries D1110 — Adult Prophylaxis (Cleaning) D1206 — Fluoride Varnish Treatment D1330 — Oral Hygiene Instructions D1351 — Dental Sealant — Per Tooth D1520 — Space Maintainer — Removable, Unilateral D1551 — Re-cement/Re-bond Space Maintainer (Unilateral) D1553 — Re-cement/Re-bond Space Maintainer (Bilateral, Mand)

D2933 — Prefabricated SS Crown with Resin Window D2983 — Veneer Repair, By Report D2981 — Inlay Repair, By Report D2934 — Prefabricated Esthetic Coated SS Crown — Primary D2652 — Inlay — Composite/Resin, 3+ Surfaces D2664 — Onlay — Composite/Resin, 4+ Surfaces D2710 — Crown — Resin (Indirect) D2921 — Reattachment of Tooth Fragment D2651 — Inlay — Composite/Resin, 2 Surfaces D2952 — Post and Core — Cast (w/ Crown) D2420 — Gold Foil — 2 Surfaces D2620 — Inlay — Porcelain/Ceramic, 2 Surfaces D2663 — Onlay — Composite/Resin, 3 Surfaces D2783 — Crown — ¾ Porcelain/Ceramic D2150 — Amalgam Filling — 2 Surfaces, Primary/Permanent D2630 — Inlay — Porcelain/Ceramic, 3+ Surfaces D2753 — Crown — Porcelain Fused to Titanium D2160 — Amalgam Filling — 3 Surfaces, Primary/Permanent D2542 — Onlay — Metallic, 2 Surfaces D2980 — Crown Repair, By Report D2982 — Onlay Repair, By Report D2335 — Composite Filling — 4+ Surfaces/Incisal Angle D2391 — Composite Filling — 1 Surface, Posterior D2393 — Composite Filling — 3 Surfaces, Posterior D2510 — Inlay — Metallic, 1 Surface D2610 — Inlay — Porcelain/Ceramic, 1 Surface D2751 — Crown — Porcelain Fused to Base Metal D2161 — Amalgam Filling — 4+ Surfaces, Primary/Permanent D2330 — Composite Filling — 1 Surface, Anterior D2394 — Composite Filling — 4+ Surfaces, Posterior D2520 — Inlay — Metallic, 2 Surfaces D2543 — Onlay — Metallic, 3 Surfaces D2644 — Onlay — Porcelain/Ceramic, 4+ Surfaces D2662 — Onlay — Composite/Resin, 2 Surfaces D2750 — Crown — Porcelain Fused to High Noble Metal D2781 — Crown — ¾ Cast Base Metal D2790 — Crown — Full Cast High Noble Metal D2799 — Provisional Crown D2928 — Prefabricated Porcelain/Ceramic Crown — Primary D2931 — Prefabricated Stainless Steel Crown — Permanent D2950 — Core Buildup Including Pins D2962 — Labial Veneer — Porcelain (Lab) D2331 — Composite Filling — 2 Surfaces, Anterior D2332 — Composite Filling — 3 Surfaces, Anterior D2390 — Composite Crown — Anterior, Primary D2410 — Gold Foil — 1 Surface D2642 — Onlay — Porcelain/Ceramic, 2 Surfaces D2643 — Onlay — Porcelain/Ceramic, 3 Surfaces D2712 — Crown — ¾ Resin (Indirect) D2720 — Crown — Resin with High Noble Metal D2721 — Crown — Resin with Base Metal D2740 — Crown — Porcelain/Ceramic D2782 — Crown — ¾ Cast Noble Metal D2791 — Crown — Full Cast Base Metal D2951 — Pin Retention — Per Tooth D2140 — Amalgam Filling — 1 Surface, Primary/Permanent D2430 — Gold Foil — 3 Surfaces D2530 — Inlay — Metallic, 3+ Surfaces D2650 — Inlay — Composite/Resin, 1 Surface D2722 — Crown — Resin with Noble Metal D2752 — Crown — Porcelain Fused to Noble Metal D2932 — Prefabricated Resin Crown D2953 — Post and Core — Each Additional (Cast) D2954 — Prefabricated Post and Core D2955 — Post Removal D2960 — Labial Veneer — Resin (Chair-side) D2961 — Labial Veneer — Resin (Lab) D2990 — Resin Infiltration of Incipient Lesion

D3331 — Treatment of Root Canal Obstruction (Non-Surgical) D3501 — Surgical Exposure for Canal Access D3346 — Retreatment — Anterior D3347 — Retreatment — Premolar D3356 — Pulpal Regeneration — Interim Medication D3503 — Surgical Root Repair — Anterior D3310 — Root Canal — Anterior (Excluding Final Restoration) D3431 — Biologically-Based Root Treatment D3910 — Surgical Procedure for Isolation of Tooth D3425 — Apicoectomy — Molar (First Root) D3473 — Surgical Repair — Root Resorption (Molar) D3240 — Pulpal Therapy — Posterior, Primary D3320 — Root Canal — Premolar (Excluding Final Restoration) D3421 — Apicoectomy — Premolar (First Root) D3428 — Retrograde Filling — Per Root D3471 — Surgical Repair — Root Resorption (Anterior) D3230 — Pulpal Therapy — Anterior, Primary D3330 — Root Canal — Molar (Excluding Final Restoration) D3348 — Retreatment — Molar D3429 — Hemisection (Including Root Removal, Not Crown) D3472 — Surgical Repair — Root Resorption (Premolar) D3220 — Therapeutic Pulpotomy (Excluding Final Restoration) D3221 — Pulpal Debridement — Primary/Permanent Teeth D3355 — Pulpal Regeneration — Initial Visit D3450 — Root Amputation — Per Root D3470 — Intentional Reimplantation D3920 — Hemisection (Not Root Canal/Restoration) D3921 — Decoronation/Intentional Submergence D3950 — Canal Prep and Fitting of Preformed Post/Dowel D3333 — Internal Root Repair — Perforation D3410 — Apicoectomy — Anterior D3432 — Guided Tissue Regeneration (Periradicular Surgery) D3110 — Pulp Cap — Direct (Excluding Final Restoration) D3120 — Pulp Cap — Indirect (Excluding Final Restoration) D3332 — Incomplete Endodontic Treatment (Inoperable/Fracture) D3351 — Apexification/Recalcification — Initial Visit D3352 — Apexification/Recalcification — Interim Medication D3353 — Apexification/Recalcification — Final Visit D3357 — Pulpal Regeneration — Final Visit D3426 — Apicoectomy — Each Additional Root D3502 — Surgical Perforation Repair

D4270 — Pedicle Soft Tissue Graft D4283 — Autogenous Connective Tissue Graft (Each Add'l Tooth) D4286 — Combined Connective Tissue Graft (Each Add'l Tooth) D4275 — Non-Autogenous Connective Tissue Graft (First Tooth) D4240 — Gingival Flap Surgery — 4+ Teeth (Per Quad) D4265 — Biologic Material for Tissue Regeneration D4273 — Autogenous Connective Tissue Graft (First Tooth) D4323 — Splint — Extracoronal (Natural Teeth) D4211 — Gingivectomy/Gingivoplasty — 1–3 Teeth (Per Quad) D4230 — Anatomical Crown Exposure — 4+ Teeth (Per Quad) D4261 — Osseous Surgery — 1–3 Teeth (Per Quad) D4276 — Combined Connective Tissue & Pedicle Graft D4285 — Non-Autogenous Connective Tissue Graft (Each Add'l) D4910 — Periodontal Maintenance D4245 — Apically Positioned Flap D4260 — Osseous Surgery — 4+ Teeth (Per Quad) D4210 — Gingivectomy/Gingivoplasty — 4+ Teeth (Per Quad) D4277 — Free Soft Tissue Graft (First Tooth) D4322 — Splint — Intracoronal (Natural Teeth) D4341 — Scaling and Root Planing — 4+ Teeth (Per Quad) D4212 — Gingivectomy/Gingivoplasty (Restorative, Per Tooth) D4263 — Bone Replacement Graft — First Site (Per Quad) D4278 — Free Soft Tissue Graft (Each Additional Tooth) D4342 — Scaling and Root Planing — 1–3 Teeth (Per Quad) D4346 — Scaling — Generalized Moderate/Severe Gingivitis D4241 — Gingival Flap Surgery — 1–3 Teeth (Per Quad) D4249 — Clinical Crown Lengthening — Hard Tissue D4264 — Bone Replacement Graft — Each Additional Site D4266 — Guided Tissue Regeneration — Resorbable Barrier D4268 — Surgical Revision (Failed Previous Graft Site) D4274 — Distal/Proximal Wedge Procedure D4381 — Localized Antimicrobial Delivery (Per Tooth)

D5212 — Lower Partial Denture — Resin Base (w/ Clasps/Rests) D5286 — Removable Unilateral Partial Denture — 2 Piece (Metal) D5130 — Immediate Upper Denture D5211 — Upper Partial Denture — Resin Base (w/ Clasps/Rests) D5863 — Overdenture — Complete (Implant/Root Supported) D5225 — Upper Partial Denture — Flexible Base D5650 — Add Tooth to Existing Partial Denture D5711 — Rebase Complete Lower Denture D5411 — Adjust Complete Lower Denture D5222 — Immediate Lower Partial Denture — Resin Base D5283 — Removable Unilateral Partial Denture — 1 Piece (Resin) D5821 — Interim Partial Lower Denture D5877 — Replacement of Locator Male, By Report D5120 — Complete Lower Denture D5223 — Immediate Upper Partial Denture — Cast Metal D5224 — Immediate Lower Partial Denture — Cast Metal D5228 — Immediate Lower Partial Denture — Flexible Base D5284 — Removable Unilateral Partial Denture — 1 Piece (Flex) D5670 — Replace Teeth & Acrylic on Metal Framework D5721 — Rebase Lower Partial Denture D5731 — Reline Complete Lower Denture (Chair-side) D5282 — Removable Unilateral Partial Denture — 1 Piece (Metal) D5421 — Adjust Partial Upper Denture D5671 — Replace All Teeth & Acrylic on Cast Metal Framework D5730 — Reline Complete Upper Denture (Chair-side) D5741 — Reline Lower Partial Denture (Chair-side) D5811 — Interim Complete Lower Denture D5865 — Overdenture — Complete (Implant Supported) D5213 — Upper Partial Denture — Cast Metal Framework D5214 — Lower Partial Denture — Cast Metal Framework D5221 — Immediate Upper Partial Denture — Resin Base D5227 — Immediate Upper Partial Denture — Flexible Base D5640 — Replace Broken Teeth — Per Tooth D5660 — Add Clasp to Existing Partial Denture D5720 — Rebase Upper Partial Denture D5810 — Interim Complete Upper Denture D5862 — Precision Attachment — By Report D5867 — Replacement of Attachment — Implant Overdenture D5110 — Complete Upper Denture D5140 — Immediate Lower Denture D5226 — Lower Partial Denture — Flexible Base D5511 — Repair Broken Complete Denture Base (Upper) D5512 — Repair Broken Complete Denture Base (Lower) D5520 — Replace Missing/Broken Teeth — Complete Denture D5611 — Repair Resin Partial Denture Base (Upper) D5612 — Repair Resin Partial Denture Base (Lower) D5622 — Repair Cast Partial Framework (Lower) D5725 — Rebase Hybrid Prosthesis D5740 — Reline Upper Partial Denture (Chair-side) D5750 — Reline Complete Upper Denture (Lab) D5751 — Reline Complete Lower Denture (Lab) D5761 — Reline Lower Partial Denture (Lab) D5820 — Interim Partial Upper Denture D5850 — Tissue Conditioning (Upper) D5851 — Tissue Conditioning (Lower) D5878 — Add Wrought Wire Clasp (Tooth-Supported) D5982 — Surgical Stent

D6093 — Re-cement/Re-bond Implant Bridge D6074 — Implant Bridge Pontic — Porcelain/Ceramic D6083 — Implant-Supported Prosthesis Repair, By Report D6103 — Bone Graft — Implant Repair (First Site) D6193 — Stress-Breaking Abutment — Placement D6545 — Retainer — Cast Metal for Resin-Bonded Bridge D6056 — Prefabricated Implant Abutment D6253 — Provisional Bridge Pontic D6610 — Bridge Retainer — Onlay, Cast High Noble Metal (2 Surf) D6099 — Implant-Supported Retainer for FPD (Ceramic) D6548 — Retainer — Porcelain/Ceramic for Resin-Bonded Bridge D6069 — Implant Crown — Titanium D6073 — Implant Bridge Pontic — Cast High Noble Metal D6075 — Implant Crown — Porcelain Fused to Titanium D6104 — Bone Graft — Implant Repair (Each Add'l Site) D6067 — Implant Crown — High Noble Metal D6070 — Implant Crown — Cast High Noble Metal D6191 — Semi-Precision Abutment — Placement D6212 — Bridge Pontic — Cast Noble Metal D6609 — Bridge Retainer — Onlay, Porcelain/Ceramic (3+ Surf) D6051 — Interim Implant Abutment D6064 — Implant Abutment — Prefabricated (Titanium) D6088 — Implant Bridge Retainer — Resin D6097 — Abutment-Supported Retainer (Removable) D6121 — Implant-Supported Retainer — FPD (Noble) D6606 — Bridge Retainer — Inlay, Cast Noble Metal (2 Surf) D6614 — Bridge Retainer — Onlay, Cast Noble Metal (2 Surf) D6011 — Second Stage Implant Surgery D6058 — Implant Abutment — Prefabricated D6061 — Implant Abutment — Prefabricated (Base Metal) D6062 — Implant Abutment — Cast-to (Noble Metal) D6063 — Implant Abutment — Cast-to (Base Metal) D6065 — Implant Crown — Porcelain/Ceramic D6068 — Implant Abutment — Prefabricated D6072 — Implant Bridge Pontic — Porcelain Fused to Metal D6077 — Implant Crown — Noble Metal D6082 — Implant-Supported Crown Repair, By Report D6084 — Custom Implant Abutment (Porcelain/Ceramic) D6091 — Implant Repair — Abutment Replacement D6098 — Implant-Supported Retainer (Removable) D6102 — Bone Graft — Debridement of Peri-Implant Defect D6120 — Implant-Supported Retainer — FPD (High Noble) D6603 — Bridge Retainer — Inlay, Cast High Noble Metal (3+ Surf) D6605 — Bridge Retainer — Inlay, Cast Base Metal (3+ Surf) D6608 — Bridge Retainer — Onlay, Porcelain/Ceramic (2 Surf) D6613 — Bridge Retainer — Onlay, Cast Base Metal (3+ Surf) D6782 — Bridge Retainer — ¾ Cast Noble Metal D6792 — Bridge Retainer — Full Cast Noble Metal D6040 — Surgical Placement — Eposteal Implant D6057 — Custom Fabricated Implant Abutment D6066 — Implant Crown — Porcelain Fused to Metal D6086 — Implant Crown — Resin D6092 — Re-cement/Re-bond Implant Crown D6106 — Bone Graft — Mandibular Symphysis D6107 — Bone Graft — From Extra-Oral Donor Site D6122 — Implant-Supported Retainer — FPD (Base) D6192 — Semi-Precision Abutment — Removal D6198 — Remove Interim Implant Body D6607 — Bridge Retainer — Inlay, Cast Noble Metal (3+ Surf) D6612 — Bridge Retainer — Onlay, Cast Base Metal (2 Surf) D6722 — Bridge Retainer — Resin with Noble Metal D6780 — Bridge Retainer — ¾ Cast High Noble Metal D6930 — Re-cement/Re-bond Bridge D6010 — Surgical Placement — Endosteal Implant Body D6013 — Surgical Placement — Mini Implant D6071 — Implant Crown — Cast Base Metal D6076 — Implant Crown — Base Metal D6085 — Provisional Implant Crown D6087 — Implant Bridge Pontic — Resin D6101 — Debridement of Peri-Implant Defect — Surgical D6110 — Implant Bridge Retainer — Porcelain Fused to HNM D6123 — Implant-Supported Retainer — FPD (Titanium) D6242 — Bridge Pontic — Porcelain Fused to Noble Metal D6251 — Bridge Pontic — Resin with Base Metal D6252 — Bridge Pontic — Resin with Noble Metal D6549 — Retainer — Resin for Resin-Bonded Bridge D6600 — Bridge Retainer — Inlay, Porcelain/Ceramic (2 Surf) D6602 — Bridge Retainer — Inlay, Cast High Noble Metal (2 Surf) D6611 — Bridge Retainer — Onlay, Cast High Noble Metal (3+ Surf) D6740 — Bridge Retainer — Porcelain/Ceramic D6751 — Bridge Retainer — Porcelain Fused to Base Metal D6783 — Bridge Retainer — ¾ Porcelain/Ceramic D6790 — Bridge Retainer — Full Cast High Noble Metal D6920 — Connector Bar D6940 — Bridge Repair, By Report D6012 — Surgical Placement — Interim Implant Body D6050 — Custom Fabricated Implant Abutment D6055 — Dental Implant-Supported Connecting Bar D6059 — Implant Abutment — Custom, By Report D6060 — Implant Abutment — Prefabricated (Noble Metal) D6089 — Implant Abutment Modification D6096 — Remove Broken Implant Retaining Screw D6111 — Implant Bridge Retainer — Porcelain Fused to BM D6113 — Implant Bridge Retainer — Cast Metal (HNM) D6114 — Implant Bridge Retainer — Cast Metal (NM) D6195 — Implant-Supported Connector Bar (Modification) D6196 — Implant Provisional Crown (Implant Placement Visit) D6210 — Bridge Pontic — Cast High Noble Metal D6211 — Bridge Pontic — Cast Base Metal D6241 — Bridge Pontic — Porcelain Fused to Base Metal D6243 — Bridge Pontic — Porcelain Fused to Titanium D6245 — Bridge Pontic — Porcelain/Ceramic D6250 — Bridge Pontic — Resin with High Noble Metal D6601 — Bridge Retainer — Inlay, Porcelain/Ceramic (3+ Surf) D6604 — Bridge Retainer — Inlay, Cast Base Metal (2 Surf) D6615 — Bridge Retainer — Onlay, Cast Noble Metal (3+ Surf) D6721 — Bridge Retainer — Resin with Base Metal D6752 — Bridge Retainer — Porcelain Fused to Noble Metal D6781 — Bridge Retainer — ¾ Cast Base Metal D6791 — Bridge Retainer — Full Cast Base Metal D6793 — Bridge Retainer — Full Cast Titanium D6950 — Precision Attachment

D7972 — Surgical Reduction of Fibrous Tuberosity D7321 — Alveoloplasty — Without Extractions (1–3 Teeth) D7320 — Alveoloplasty — Without Extractions (Per Quad) D7485 — Reduction of Osseous Tuberosity D7511 — Incision and Drainage — Intraoral (Soft Tissue, Complicated) D7280 — Surgical Exposure of Impacted Tooth (Orthodontic) D7290 — Surgical Repositioning of Teeth D7261 — Primary Closure of Sinus Perforation D7311 — Alveoloplasty — With Extractions (1–3 Teeth) D7970 — Excision of Hyperplastic Tissue — Per Arch D7953 — Bone Replacement Graft — Ridge Preservation D7450 — Removal of Benign Odontogenic Cyst ≤ 1.25 cm D7509 — Marsupialization of Cyst D7520 — Incision and Drainage — Extraoral (Soft Tissue) D7297 — Corticotomy — Four or More Tooth Spaces D7451 — Removal of Benign Odontogenic Cyst > 1.25 cm D7510 — Incision and Drainage — Intraoral (Soft Tissue) D7994 — Surgical Placement — Bone-Fixation Plate D7230 — Extraction — Partially Bony Impacted Tooth D7250 — Extraction — Residual Root Removal D7270 — Tooth Reimplantation/Stabilization D7285 — Incisional Biopsy — Oral Tissue (Hard) D7296 — Corticotomy — One to Three Tooth Spaces D7350 — Vestibuloplasty — Ridge Extension (w/ Graft) D7880 — Occlusal Orthotic Device — By Report D7961 — Buccal/Labial Frenectomy D7962 — Lingual Frenectomy D7111 — Extraction — Coronal Remnants (Primary Tooth) D7240 — Extraction — Completely Bony Impacted Tooth D7241 — Extraction — Completely Bony Impacted (Complicated) D7251 — Coronectomy — Intentional Partial Tooth Removal D7252 — Tooth Removal of Impacted Tooth (Soft Tissue) D7272 — Tooth Transplantation D7286 — Incisional Biopsy — Oral Tissue (Soft) D7288 — Brush Biopsy — Transepithelial Sample Collection D7295 — Harvest of Bone for Graft D7310 — Alveoloplasty — With Extractions (Per Quad) D7410 — Excision of Benign Lesion ≤ 1.25 cm D7471 — Removal of Lateral Exostosis D7473 — Removal of Torus Mandibularis D7521 — Incision and Drainage — Extraoral (Soft Tissue, Complicated) D7910 — Suture of Wound (Up to 5 cm) D7956 — Guided Bone Regeneration — Edentulous Area

D9239 — Intravenous Moderate Sedation — First 15 min D9941 — Fabrication of Athletic Mouthguard D9974 — Internal Bleaching — Per Tooth D9972 — External Bleaching — Per Arch D9243 — Intravenous Moderate Sedation — Each Add'l 15 min D9310 — Consultation — Specialist/Dentist D9950 — Occlusion Analysis — Mounted Case D9944 — Occlusal Guard — Hard Appliance (Full Arch) D9110 — Palliative (Emergency) Treatment D9222 — Deep Sedation/General Anesthesia — First 15 min D9223 — Deep Sedation/General Anesthesia — Each Add'l 15 min D9410 — House/Extended Care Facility Call D9420 — Hospital or ASC Call D9430 — Office Visit for Observation (No Services) D9440 — Office Visit — After Regular Hours D9612 — Therapeutic Parenteral Drug — Two+ Administrations D9630 — Drugs or Medicaments (Not Otherwise Classified) D9910 — Application of Desensitizing Medicament D9211 — Regional Block Anesthesia D9224 — Deep Sedation/General Anesthesia — First 15 min (Dentist) D9225 — Deep Sedation/General Anesthesia — Each Add'l 15 min (Dentist) D9230 — Inhalation Analgesia (Nitrous Oxide) D9450 — Case Presentation — Treatment Plan D9951 — Occlusal Adjustment — Limited D9952 — Occlusal Adjustment — Complete D9970 — Enamel Microabrasion D9971 — Odontoplasty — 1–2 Teeth