Dental Reimbursement Rates in Oklahoma

D0330 — Panoramic X-Ray D0145 — Oral Evaluation for Patient Under 3 D0170 — Re-evaluation — Limited, Problem Focused D0220 — Periapical X-Ray — First Film D0274 — Bitewing X-Rays — Four Films D0310 — Sialography D0321 — Other TMJ Films D0340 — 2D Cephalometric X-Ray D0415 — Collection of Microbial Culture Specimen D0120 — Periodic Oral Evaluation D0160 — Detailed/Extensive Oral Evaluation D0171 — Re-evaluation — Post-Operative D0251 — Extraoral — Posterior Dental X-Ray D0270 — Bitewing X-Ray — Single Film D0272 — Bitewing X-Rays — Two Films D0322 — Tomographic Survey D0374 — Cone Beam CT — 3D Re-formatting D0425 — Caries Susceptibility Test D0431 — Adjunctive Pre-Diagnostic Test (No Biopsy) D0486 — Accession of Transepithelial Cytologic Sample

D1110 — Adult Prophylaxis (Cleaning) D1510 — Space Maintainer — Fixed, Unilateral D1301 — Panoramic Radiograph for Caries Risk D1527 — Space Maintainer — Removable, Bilateral (Mandibular) D1516 — Space Maintainer — Fixed, Bilateral (Maxillary) D1517 — Space Maintainer — Fixed, Bilateral (Mandibular) D1526 — Space Maintainer — Removable, Bilateral (Maxillary) D1120 — Child Prophylaxis D1520 — Space Maintainer — Removable, Unilateral D1552 — Re-cement/Re-bond Space Maintainer (Bilateral, Max) D1575 — Distal Shoe Space Maintainer

D2652 — Inlay — Composite/Resin, 3+ Surfaces D2791 — Crown — Full Cast Base Metal D2991 — Mineral Infiltration of Incipient Lesion D2544 — Onlay — Metallic, 4+ Surfaces D2620 — Inlay — Porcelain/Ceramic, 2 Surfaces D2643 — Onlay — Porcelain/Ceramic, 3 Surfaces D2710 — Crown — Resin (Indirect) D2390 — Composite Crown — Anterior, Primary D2651 — Inlay — Composite/Resin, 2 Surfaces D2783 — Crown — ¾ Porcelain/Ceramic D2751 — Crown — Porcelain Fused to Base Metal D2150 — Amalgam Filling — 2 Surfaces, Primary/Permanent D2335 — Composite Filling — 4+ Surfaces/Incisal Angle D2420 — Gold Foil — 2 Surfaces D2520 — Inlay — Metallic, 2 Surfaces D2542 — Onlay — Metallic, 2 Surfaces D2642 — Onlay — Porcelain/Ceramic, 2 Surfaces D2644 — Onlay — Porcelain/Ceramic, 4+ Surfaces D2792 — Crown — Full Cast Noble Metal D2980 — Crown Repair, By Report D2331 — Composite Filling — 2 Surfaces, Anterior D2663 — Onlay — Composite/Resin, 3 Surfaces D2664 — Onlay — Composite/Resin, 4+ Surfaces D2720 — Crown — Resin with High Noble Metal D2722 — Crown — Resin with Noble Metal D2752 — Crown — Porcelain Fused to Noble Metal D2753 — Crown — Porcelain Fused to Titanium D2780 — Crown — ¾ Cast High Noble Metal D2782 — Crown — ¾ Cast Noble Metal D2790 — Crown — Full Cast High Noble Metal D2799 — Provisional Crown D2931 — Prefabricated Stainless Steel Crown — Permanent D2934 — Prefabricated Esthetic Coated SS Crown — Primary D2981 — Inlay Repair, By Report D2982 — Onlay Repair, By Report D2140 — Amalgam Filling — 1 Surface, Primary/Permanent D2392 — Composite Filling — 2 Surfaces, Posterior D2410 — Gold Foil — 1 Surface D2510 — Inlay — Metallic, 1 Surface D2610 — Inlay — Porcelain/Ceramic, 1 Surface D2630 — Inlay — Porcelain/Ceramic, 3+ Surfaces D2662 — Onlay — Composite/Resin, 2 Surfaces D2920 — Re-cement/Re-bond Crown D2950 — Core Buildup Including Pins D2952 — Post and Core — Cast (w/ Crown) D2954 — Prefabricated Post and Core D2957 — Each Additional Prefabricated Post D2983 — Veneer Repair, By Report D2161 — Amalgam Filling — 4+ Surfaces, Primary/Permanent D2332 — Composite Filling — 3 Surfaces, Anterior D2393 — Composite Filling — 3 Surfaces, Posterior D2394 — Composite Filling — 4+ Surfaces, Posterior D2530 — Inlay — Metallic, 3+ Surfaces D2543 — Onlay — Metallic, 3 Surfaces D2650 — Inlay — Composite/Resin, 1 Surface D2712 — Crown — ¾ Resin (Indirect) D2740 — Crown — Porcelain/Ceramic D2781 — Crown — ¾ Cast Base Metal D2915 — Re-cement/Re-bond Cast or Prefab Post & Core D2921 — Reattachment of Tooth Fragment D2928 — Prefabricated Porcelain/Ceramic Crown — Primary D2930 — Prefabricated Stainless Steel Crown — Primary D2933 — Prefabricated SS Crown with Resin Window D2953 — Post and Core — Each Additional (Cast) D2955 — Post Removal D2961 — Labial Veneer — Resin (Lab) D2962 — Labial Veneer — Porcelain (Lab) D2990 — Resin Infiltration of Incipient Lesion

D3353 — Apexification/Recalcification — Final Visit D3472 — Surgical Repair — Root Resorption (Premolar) D3473 — Surgical Repair — Root Resorption (Molar) D3310 — Root Canal — Anterior (Excluding Final Restoration) D3347 — Retreatment — Premolar D3425 — Apicoectomy — Molar (First Root) D3320 — Root Canal — Premolar (Excluding Final Restoration) D3332 — Incomplete Endodontic Treatment (Inoperable/Fracture) D3333 — Internal Root Repair — Perforation D3346 — Retreatment — Anterior D3348 — Retreatment — Molar D3356 — Pulpal Regeneration — Interim Medication D3410 — Apicoectomy — Anterior D3429 — Hemisection (Including Root Removal, Not Crown) D3471 — Surgical Repair — Root Resorption (Anterior) D3220 — Therapeutic Pulpotomy (Excluding Final Restoration) D3230 — Pulpal Therapy — Anterior, Primary D3330 — Root Canal — Molar (Excluding Final Restoration) D3355 — Pulpal Regeneration — Initial Visit D3421 — Apicoectomy — Premolar (First Root) D3426 — Apicoectomy — Each Additional Root D3428 — Retrograde Filling — Per Root D3502 — Surgical Perforation Repair D3503 — Surgical Root Repair — Anterior D3920 — Hemisection (Not Root Canal/Restoration) D3120 — Pulp Cap — Indirect (Excluding Final Restoration) D3221 — Pulpal Debridement — Primary/Permanent Teeth D3222 — Partial Pulpotomy for Apexogenesis — Permanent D3351 — Apexification/Recalcification — Initial Visit D3357 — Pulpal Regeneration — Final Visit D3431 — Biologically-Based Root Treatment D3432 — Guided Tissue Regeneration (Periradicular Surgery) D3450 — Root Amputation — Per Root D3470 — Intentional Reimplantation D3501 — Surgical Exposure for Canal Access D3910 — Surgical Procedure for Isolation of Tooth D3921 — Decoronation/Intentional Submergence D3950 — Canal Prep and Fitting of Preformed Post/Dowel

D4249 — Clinical Crown Lengthening — Hard Tissue D4341 — Scaling and Root Planing — 4+ Teeth (Per Quad) D4210 — Gingivectomy/Gingivoplasty — 4+ Teeth (Per Quad) D4277 — Free Soft Tissue Graft (First Tooth) D4240 — Gingival Flap Surgery — 4+ Teeth (Per Quad) D4263 — Bone Replacement Graft — First Site (Per Quad) D4276 — Combined Connective Tissue & Pedicle Graft D4283 — Autogenous Connective Tissue Graft (Each Add'l Tooth) D4286 — Combined Connective Tissue Graft (Each Add'l Tooth) D4230 — Anatomical Crown Exposure — 4+ Teeth (Per Quad) D4231 — Anatomical Crown Exposure — 1–3 Teeth (Per Quad) D4266 — Guided Tissue Regeneration — Resorbable Barrier D4267 — Guided Tissue Regeneration — Non-Resorbable Barrier D4275 — Non-Autogenous Connective Tissue Graft (First Tooth) D4241 — Gingival Flap Surgery — 1–3 Teeth (Per Quad) D4245 — Apically Positioned Flap D4261 — Osseous Surgery — 1–3 Teeth (Per Quad) D4265 — Biologic Material for Tissue Regeneration D4270 — Pedicle Soft Tissue Graft D4278 — Free Soft Tissue Graft (Each Additional Tooth) D4323 — Splint — Extracoronal (Natural Teeth) D4910 — Periodontal Maintenance D4211 — Gingivectomy/Gingivoplasty — 1–3 Teeth (Per Quad) D4260 — Osseous Surgery — 4+ Teeth (Per Quad) D4264 — Bone Replacement Graft — Each Additional Site D4273 — Autogenous Connective Tissue Graft (First Tooth) D4274 — Distal/Proximal Wedge Procedure D4342 — Scaling and Root Planing — 1–3 Teeth (Per Quad) D4346 — Scaling — Generalized Moderate/Severe Gingivitis

D5710 — Rebase Complete Upper Denture D5865 — Overdenture — Complete (Implant Supported) D5130 — Immediate Upper Denture D5213 — Upper Partial Denture — Cast Metal Framework D5140 — Immediate Lower Denture D5228 — Immediate Lower Partial Denture — Flexible Base D5214 — Lower Partial Denture — Cast Metal Framework D5286 — Removable Unilateral Partial Denture — 2 Piece (Metal) D5622 — Repair Cast Partial Framework (Lower) D5864 — Overdenture — Partial (Implant/Root Supported) D5866 — Overdenture — Partial (Implant Supported) D5671 — Replace All Teeth & Acrylic on Cast Metal Framework D5711 — Rebase Complete Lower Denture D5810 — Interim Complete Upper Denture D5120 — Complete Lower Denture D5211 — Upper Partial Denture — Resin Base (w/ Clasps/Rests) D5221 — Immediate Upper Partial Denture — Resin Base D5222 — Immediate Lower Partial Denture — Resin Base D5223 — Immediate Upper Partial Denture — Cast Metal D5282 — Removable Unilateral Partial Denture — 1 Piece (Metal) D5284 — Removable Unilateral Partial Denture — 1 Piece (Flex) D5511 — Repair Broken Complete Denture Base (Upper) D5720 — Rebase Upper Partial Denture D5820 — Interim Partial Upper Denture D5821 — Interim Partial Lower Denture D5850 — Tissue Conditioning (Upper) D5851 — Tissue Conditioning (Lower) D5867 — Replacement of Attachment — Implant Overdenture D5110 — Complete Upper Denture D5212 — Lower Partial Denture — Resin Base (w/ Clasps/Rests) D5225 — Upper Partial Denture — Flexible Base D5226 — Lower Partial Denture — Flexible Base D5640 — Replace Broken Teeth — Per Tooth D5650 — Add Tooth to Existing Partial Denture D5670 — Replace Teeth & Acrylic on Metal Framework D5725 — Rebase Hybrid Prosthesis D5730 — Reline Complete Upper Denture (Chair-side) D5741 — Reline Lower Partial Denture (Chair-side) D5760 — Reline Upper Partial Denture (Lab) D5811 — Interim Complete Lower Denture D5862 — Precision Attachment — By Report D5878 — Add Wrought Wire Clasp (Tooth-Supported) D5992 — Adjust Maxillofacial Prosthetic Appliance D5227 — Immediate Upper Partial Denture — Flexible Base D5520 — Replace Missing/Broken Teeth — Complete Denture D5611 — Repair Resin Partial Denture Base (Upper) D5612 — Repair Resin Partial Denture Base (Lower) D5660 — Add Clasp to Existing Partial Denture D5731 — Reline Complete Lower Denture (Chair-side) D5740 — Reline Upper Partial Denture (Chair-side) D5750 — Reline Complete Upper Denture (Lab) D5751 — Reline Complete Lower Denture (Lab) D5863 — Overdenture — Complete (Implant/Root Supported) D5991 — Vesiculobullous Disease Medicament Carrier D5993 — Maintenance/Cleaning of Maxillofacial Prosthesis

D6195 — Implant-Supported Connector Bar (Modification) D6107 — Bone Graft — From Extra-Oral Donor Site D6120 — Implant-Supported Retainer — FPD (High Noble) D6077 — Implant Crown — Noble Metal D6110 — Implant Bridge Retainer — Porcelain Fused to HNM D6061 — Implant Abutment — Prefabricated (Base Metal) D6097 — Abutment-Supported Retainer (Removable) D6243 — Bridge Pontic — Porcelain Fused to Titanium D6252 — Bridge Pontic — Resin with Noble Metal D6012 — Surgical Placement — Interim Implant Body D6065 — Implant Crown — Porcelain/Ceramic D6073 — Implant Bridge Pontic — Cast High Noble Metal D6086 — Implant Crown — Resin D6123 — Implant-Supported Retainer — FPD (Titanium) D6611 — Bridge Retainer — Onlay, Cast High Noble Metal (3+ Surf) D6614 — Bridge Retainer — Onlay, Cast Noble Metal (2 Surf) D6721 — Bridge Retainer — Resin with Base Metal D6740 — Bridge Retainer — Porcelain/Ceramic D6010 — Surgical Placement — Endosteal Implant Body D6060 — Implant Abutment — Prefabricated (Noble Metal) D6066 — Implant Crown — Porcelain Fused to Metal D6072 — Implant Bridge Pontic — Porcelain Fused to Metal D6075 — Implant Crown — Porcelain Fused to Titanium D6112 — Implant Bridge Retainer — Porcelain/Ceramic D6113 — Implant Bridge Retainer — Cast Metal (HNM) D6121 — Implant-Supported Retainer — FPD (Noble) D6250 — Bridge Pontic — Resin with High Noble Metal D6545 — Retainer — Cast Metal for Resin-Bonded Bridge D6608 — Bridge Retainer — Onlay, Porcelain/Ceramic (2 Surf) D6780 — Bridge Retainer — ¾ Cast High Noble Metal D6791 — Bridge Retainer — Full Cast Base Metal D6011 — Second Stage Implant Surgery D6013 — Surgical Placement — Mini Implant D6063 — Implant Abutment — Cast-to (Base Metal) D6067 — Implant Crown — High Noble Metal D6070 — Implant Crown — Cast High Noble Metal D6074 — Implant Bridge Pontic — Porcelain/Ceramic D6076 — Implant Crown — Base Metal D6082 — Implant-Supported Crown Repair, By Report D6084 — Custom Implant Abutment (Porcelain/Ceramic) D6101 — Debridement of Peri-Implant Defect — Surgical D6103 — Bone Graft — Implant Repair (First Site) D6104 — Bone Graft — Implant Repair (Each Add'l Site) D6106 — Bone Graft — Mandibular Symphysis D6192 — Semi-Precision Abutment — Removal D6193 — Stress-Breaking Abutment — Placement D6240 — Bridge Pontic — Porcelain Fused to High Noble Metal D6241 — Bridge Pontic — Porcelain Fused to Base Metal D6548 — Retainer — Porcelain/Ceramic for Resin-Bonded Bridge D6549 — Retainer — Resin for Resin-Bonded Bridge D6601 — Bridge Retainer — Inlay, Porcelain/Ceramic (3+ Surf) D6603 — Bridge Retainer — Inlay, Cast High Noble Metal (3+ Surf) D6605 — Bridge Retainer — Inlay, Cast Base Metal (3+ Surf) D6609 — Bridge Retainer — Onlay, Porcelain/Ceramic (3+ Surf) D6610 — Bridge Retainer — Onlay, Cast High Noble Metal (2 Surf) D6612 — Bridge Retainer — Onlay, Cast Base Metal (2 Surf) D6751 — Bridge Retainer — Porcelain Fused to Base Metal D6793 — Bridge Retainer — Full Cast Titanium D6040 — Surgical Placement — Eposteal Implant D6050 — Custom Fabricated Implant Abutment D6051 — Interim Implant Abutment D6055 — Dental Implant-Supported Connecting Bar D6057 — Custom Fabricated Implant Abutment D6059 — Implant Abutment — Custom, By Report D6064 — Implant Abutment — Prefabricated (Titanium) D6068 — Implant Abutment — Prefabricated D6069 — Implant Crown — Titanium D6071 — Implant Crown — Cast Base Metal D6083 — Implant-Supported Prosthesis Repair, By Report D6085 — Provisional Implant Crown D6087 — Implant Bridge Pontic — Resin D6088 — Implant Bridge Retainer — Resin D6092 — Re-cement/Re-bond Implant Crown D6093 — Re-cement/Re-bond Implant Bridge D6102 — Bone Graft — Debridement of Peri-Implant Defect D6111 — Implant Bridge Retainer — Porcelain Fused to BM D6191 — Semi-Precision Abutment — Placement D6211 — Bridge Pontic — Cast Base Metal D6212 — Bridge Pontic — Cast Noble Metal D6242 — Bridge Pontic — Porcelain Fused to Noble Metal D6245 — Bridge Pontic — Porcelain/Ceramic D6251 — Bridge Pontic — Resin with Base Metal D6280 — Bridge Pontic — Resin/Acrylic Denture Tooth D6607 — Bridge Retainer — Inlay, Cast Noble Metal (3+ 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 D6753 — Bridge Retainer — Porcelain Fused to Titanium D6783 — Bridge Retainer — ¾ Porcelain/Ceramic D6784 — Bridge Retainer — ¾ Titanium D6792 — Bridge Retainer — Full Cast Noble Metal D6058 — Implant Abutment — Prefabricated D6080 — Implant Maintenance — Cleaning/Inspection D6089 — Implant Abutment Modification D6091 — Implant Repair — Abutment Replacement D6098 — Implant-Supported Retainer (Removable) D6099 — Implant-Supported Retainer for FPD (Ceramic) D6122 — Implant-Supported Retainer — FPD (Base) D6253 — Provisional Bridge Pontic D6600 — Bridge Retainer — Inlay, Porcelain/Ceramic (2 Surf) D6604 — Bridge Retainer — Inlay, Cast Base Metal (2 Surf) D6606 — Bridge Retainer — Inlay, Cast Noble Metal (2 Surf) D6613 — Bridge Retainer — Onlay, Cast Base Metal (3+ Surf) D6615 — Bridge Retainer — Onlay, Cast Noble Metal (3+ Surf) D6722 — Bridge Retainer — Resin with Noble Metal D6781 — Bridge Retainer — ¾ Cast Base Metal D6782 — Bridge Retainer — ¾ Cast Noble Metal D6790 — Bridge Retainer — Full Cast High Noble Metal D6930 — Re-cement/Re-bond Bridge D6940 — Bridge Repair, By Report D6950 — Precision Attachment

D7284 — Excisional Biopsy — Bone D7350 — Vestibuloplasty — Ridge Extension (w/ Graft) D7321 — Alveoloplasty — Without Extractions (1–3 Teeth) D7451 — Removal of Benign Odontogenic Cyst > 1.25 cm D7473 — Removal of Torus Mandibularis D7290 — Surgical Repositioning of Teeth D7957 — Guided Bone Regeneration — Non-Resorbable Membrane D7230 — Extraction — Partially Bony Impacted Tooth D7250 — Extraction — Residual Root Removal D7270 — Tooth Reimplantation/Stabilization D7287 — Exfoliative Cytological Sample Collection D7297 — Corticotomy — Four or More Tooth Spaces D7310 — Alveoloplasty — With Extractions (Per Quad) D7485 — Reduction of Osseous Tuberosity D7994 — Surgical Placement — Bone-Fixation Plate D7210 — Extraction — Surgical (Erupted Tooth) D7240 — Extraction — Completely Bony Impacted Tooth D7272 — Tooth Transplantation D7340 — Vestibuloplasty — Ridge Extension D7956 — Guided Bone Regeneration — Edentulous Area D7220 — Extraction — Soft Tissue Impacted Tooth D7282 — Mobilization of Erupted/Malpositioned Tooth D7320 — Alveoloplasty — Without Extractions (Per Quad) D7410 — Excision of Benign Lesion ≤ 1.25 cm D7450 — Removal of Benign Odontogenic Cyst ≤ 1.25 cm D7472 — Removal of Torus Palatinus D7510 — Incision and Drainage — Intraoral (Soft Tissue) D7520 — Incision and Drainage — Extraoral (Soft Tissue) D7955 — Repair of Maxillofacial Soft/Hard Tissue Defect D7961 — Buccal/Labial Frenectomy D7111 — Extraction — Coronal Remnants (Primary Tooth) D7140 — Extraction — Erupted Tooth or Exposed Root D7251 — Coronectomy — Intentional Partial Tooth Removal D7252 — Tooth Removal of Impacted Tooth (Soft Tissue) D7283 — Placement of Device for Eruption of Impacted Tooth D7285 — Incisional Biopsy — Oral Tissue (Hard) D7286 — Incisional Biopsy — Oral Tissue (Soft) D7296 — Corticotomy — One to Three Tooth Spaces D7311 — Alveoloplasty — With Extractions (1–3 Teeth) D7511 — Incision and Drainage — Intraoral (Soft Tissue, Complicated) D7740 — Mandible — Closed Reduction (No Interdental Fixation) D7750 — Malar/Zygomatic — Open (No Interdental Fixation) D7880 — Occlusal Orthotic Device — By Report D7953 — Bone Replacement Graft — Ridge Preservation D7962 — Lingual Frenectomy D7971 — Excision of Pericoronal Gingiva D7972 — Surgical Reduction of Fibrous Tuberosity

D8090 — Comprehensive Orthodontic — Adult Dentition D8698 — Re-cement/Re-bond Fixed Retainer (Mandibular) D8070 — Comprehensive Orthodontic — Transitional Dentition D8080 — Comprehensive Orthodontic — Adolescent Dentition D8091 — Comprehensive Orthodontic — By Report D8210 — Removable Appliance Therapy D8220 — Fixed Appliance Therapy D8671 — Periodic Orthodontic Treatment Visit (As Part of Contract) D8696 — Repair of Orthodontic Appliance D8701 — Repair of Fixed Retainer (Includes Re-attachment) D8702 — Replacement of Lost/Broken Retainer (Removable)

D9440 — Office Visit — After Regular Hours D9972 — External Bleaching — Per Arch D9612 — Therapeutic Parenteral Drug — Two+ Administrations D9920 — Behavior Management — By Report D9224 — Deep Sedation/General Anesthesia — First 15 min (Dentist) D9944 — Occlusal Guard — Hard Appliance (Full Arch) D9950 — Occlusion Analysis — Mounted Case D9311 — Consultation — With Another Dentist/Physician D9945 — Occlusal Guard — Soft Appliance (Full Arch) D9952 — Occlusal Adjustment — Complete D9974 — Internal Bleaching — Per Tooth D9211 — Regional Block Anesthesia D9219 — Evaluation for Moderate Sedation D9223 — Deep Sedation/General Anesthesia — Each Add'l 15 min D9245 — Non-IV Moderate Conscious Sedation — First 15 min D9246 — Non-IV Moderate Conscious Sedation — Each Add'l 15 min D9247 — Non-IV Moderate Conscious Sedation — Supplemental D9410 — House/Extended Care Facility Call D9430 — Office Visit for Observation (No Services) D9610 — Therapeutic Parenteral Drug — Single Admin D9630 — Drugs or Medicaments (Not Otherwise Classified) D9910 — Application of Desensitizing Medicament D9941 — Fabrication of Athletic Mouthguard D9970 — Enamel Microabrasion D9973 — External Bleaching — Per Tooth D9975 — External Bleaching (Home Application, Per Arch)