Dental Reimbursement Rates in Rhode Island

D0322 — Tomographic Survey D0320 — TMJ Arthrogram D0340 — 2D Cephalometric X-Ray D0274 — Bitewing X-Rays — Four Films D0310 — Sialography

D1120 — Child Prophylaxis D1517 — Space Maintainer — Fixed, Bilateral (Mandibular) D1510 — Space Maintainer — Fixed, Unilateral D1516 — Space Maintainer — Fixed, Bilateral (Maxillary) D1575 — Distal Shoe Space Maintainer D1206 — Fluoride Varnish Treatment D1310 — Nutritional Counseling for Dental Caries D1520 — Space Maintainer — Removable, Unilateral D1527 — Space Maintainer — Removable, Bilateral (Mandibular) D1552 — Re-cement/Re-bond Space Maintainer (Bilateral, Max)

D2792 — Crown — Full Cast Noble Metal D2160 — Amalgam Filling — 3 Surfaces, Primary/Permanent D2430 — Gold Foil — 3 Surfaces D2520 — Inlay — Metallic, 2 Surfaces D2662 — Onlay — Composite/Resin, 2 Surfaces D2932 — Prefabricated Resin Crown D2791 — Crown — Full Cast Base Metal D2335 — Composite Filling — 4+ Surfaces/Incisal Angle D2393 — Composite Filling — 3 Surfaces, Posterior D2543 — Onlay — Metallic, 3 Surfaces D2610 — Inlay — Porcelain/Ceramic, 1 Surface D2650 — Inlay — Composite/Resin, 1 Surface D2780 — Crown — ¾ Cast High Noble Metal D2954 — Prefabricated Post and Core D2960 — Labial Veneer — Resin (Chair-side) D2544 — Onlay — Metallic, 4+ Surfaces D2753 — Crown — Porcelain Fused to Titanium D2510 — Inlay — Metallic, 1 Surface D2664 — Onlay — Composite/Resin, 4+ Surfaces D2740 — Crown — Porcelain/Ceramic D2391 — Composite Filling — 1 Surface, Posterior D2751 — Crown — Porcelain Fused to Base Metal D2928 — Prefabricated Porcelain/Ceramic Crown — Primary D2952 — Post and Core — Cast (w/ Crown) D2390 — Composite Crown — Anterior, Primary D2542 — Onlay — Metallic, 2 Surfaces D2620 — Inlay — Porcelain/Ceramic, 2 Surfaces D2643 — Onlay — Porcelain/Ceramic, 3 Surfaces D2652 — Inlay — Composite/Resin, 3+ Surfaces D2722 — Crown — Resin with Noble Metal D2750 — Crown — Porcelain Fused to High Noble Metal D2782 — Crown — ¾ Cast Noble Metal D2790 — Crown — Full Cast High Noble Metal D2799 — Provisional Crown D2955 — Post Removal D2962 — Labial Veneer — Porcelain (Lab) D2982 — Onlay Repair, By Report D2332 — Composite Filling — 3 Surfaces, Anterior D2420 — Gold Foil — 2 Surfaces D2630 — Inlay — Porcelain/Ceramic, 3+ Surfaces D2642 — Onlay — Porcelain/Ceramic, 2 Surfaces D2644 — Onlay — Porcelain/Ceramic, 4+ Surfaces D2663 — Onlay — Composite/Resin, 3 Surfaces D2710 — Crown — Resin (Indirect) D2720 — Crown — Resin with High Noble Metal D2721 — Crown — Resin with Base Metal D2752 — Crown — Porcelain Fused to Noble Metal D2910 — Re-cement/Re-bond Inlay, Onlay, Veneer, or Partial D2931 — Prefabricated Stainless Steel Crown — Permanent D2934 — Prefabricated Esthetic Coated SS Crown — Primary D2953 — Post and Core — Each Additional (Cast) D2961 — Labial Veneer — Resin (Lab) D2980 — Crown Repair, By Report D2981 — Inlay Repair, By Report D2983 — Veneer Repair, By Report

D3353 — Apexification/Recalcification — Final Visit D3347 — Retreatment — Premolar D3426 — Apicoectomy — Each Additional Root D3432 — Guided Tissue Regeneration (Periradicular Surgery) D3450 — Root Amputation — Per Root D3920 — Hemisection (Not Root Canal/Restoration) D3950 — Canal Prep and Fitting of Preformed Post/Dowel D3503 — Surgical Root Repair — Anterior D3310 — Root Canal — Anterior (Excluding Final Restoration) D3333 — Internal Root Repair — Perforation D3346 — Retreatment — Anterior D3357 — Pulpal Regeneration — Final Visit D3921 — Decoronation/Intentional Submergence D3240 — Pulpal Therapy — Posterior, Primary D3331 — Treatment of Root Canal Obstruction (Non-Surgical) D3355 — Pulpal Regeneration — Initial Visit D3470 — Intentional Reimplantation D3230 — Pulpal Therapy — Anterior, Primary D3320 — Root Canal — Premolar (Excluding Final Restoration) D3332 — Incomplete Endodontic Treatment (Inoperable/Fracture) D3348 — Retreatment — Molar D3351 — Apexification/Recalcification — Initial Visit D3421 — Apicoectomy — Premolar (First Root) D3425 — Apicoectomy — Molar (First Root) D3428 — Retrograde Filling — Per Root D3471 — Surgical Repair — Root Resorption (Anterior) D3472 — Surgical Repair — Root Resorption (Premolar) D3473 — Surgical Repair — Root Resorption (Molar) D3501 — Surgical Exposure for Canal Access D3502 — Surgical Perforation Repair

D4265 — Biologic Material for Tissue Regeneration D4212 — Gingivectomy/Gingivoplasty (Restorative, Per Tooth) D4266 — Guided Tissue Regeneration — Resorbable Barrier D4260 — Osseous Surgery — 4+ Teeth (Per Quad) D4210 — Gingivectomy/Gingivoplasty — 4+ Teeth (Per Quad) D4261 — Osseous Surgery — 1–3 Teeth (Per Quad) D4240 — Gingival Flap Surgery — 4+ Teeth (Per Quad) D4273 — Autogenous Connective Tissue Graft (First Tooth) D4323 — Splint — Extracoronal (Natural Teeth) D4211 — Gingivectomy/Gingivoplasty — 1–3 Teeth (Per Quad) D4231 — Anatomical Crown Exposure — 1–3 Teeth (Per Quad) D4245 — Apically Positioned Flap D4249 — Clinical Crown Lengthening — Hard Tissue D4276 — Combined Connective Tissue & Pedicle Graft D4278 — Free Soft Tissue Graft (Each Additional Tooth) D4910 — Periodontal Maintenance D4230 — Anatomical Crown Exposure — 4+ Teeth (Per Quad) D4264 — Bone Replacement Graft — Each Additional Site D4267 — Guided Tissue Regeneration — Non-Resorbable Barrier D4270 — Pedicle Soft Tissue Graft D4275 — Non-Autogenous Connective Tissue Graft (First Tooth) D4277 — Free Soft Tissue Graft (First Tooth) D4283 — Autogenous Connective Tissue Graft (Each Add'l Tooth) D4285 — Non-Autogenous Connective Tissue Graft (Each Add'l) D4322 — Splint — Intracoronal (Natural Teeth) D4341 — Scaling and Root Planing — 4+ Teeth (Per Quad) D4342 — Scaling and Root Planing — 1–3 Teeth (Per Quad) D4346 — Scaling — Generalized Moderate/Severe Gingivitis D4355 — Full Mouth Debridement

D5865 — Overdenture — Complete (Implant Supported) D5211 — Upper Partial Denture — Resin Base (w/ Clasps/Rests) D5213 — Upper Partial Denture — Cast Metal Framework D5283 — Removable Unilateral Partial Denture — 1 Piece (Resin) D5751 — Reline Complete Lower Denture (Lab) D5851 — Tissue Conditioning (Lower) D5110 — Complete Upper Denture D5222 — Immediate Lower Partial Denture — Resin Base D5223 — Immediate Upper Partial Denture — Cast Metal D5611 — Repair Resin Partial Denture Base (Upper) D5621 — Repair Cast Partial Framework (Upper) D5650 — Add Tooth to Existing Partial Denture D5731 — Reline Complete Lower Denture (Chair-side) D5212 — Lower Partial Denture — Resin Base (w/ Clasps/Rests) D5810 — Interim Complete Upper Denture D5820 — Interim Partial Upper Denture D5226 — Lower Partial Denture — Flexible Base D5660 — Add Clasp to Existing Partial Denture D5710 — Rebase Complete Upper Denture D5761 — Reline Lower Partial Denture (Lab) D5221 — Immediate Upper Partial Denture — Resin Base D5224 — Immediate Lower Partial Denture — Cast Metal D5227 — Immediate Upper Partial Denture — Flexible Base D5284 — Removable Unilateral Partial Denture — 1 Piece (Flex) D5622 — Repair Cast Partial Framework (Lower) D5671 — Replace All Teeth & Acrylic on Cast Metal Framework D5760 — Reline Upper Partial Denture (Lab) D5765 — Soft Liner for Complete or Partial Denture D5811 — Interim Complete Lower Denture D5120 — Complete Lower Denture D5140 — Immediate Lower Denture D5225 — Upper Partial Denture — Flexible Base D5282 — Removable Unilateral Partial Denture — 1 Piece (Metal) D5286 — Removable Unilateral Partial Denture — 2 Piece (Metal) D5612 — Repair Resin Partial Denture Base (Lower) D5711 — Rebase Complete Lower Denture D5730 — Reline Complete Upper Denture (Chair-side) D5750 — Reline Complete Upper Denture (Lab) D5821 — Interim Partial Lower Denture D5850 — Tissue Conditioning (Upper) D5863 — Overdenture — Complete (Implant/Root Supported) D5864 — Overdenture — Partial (Implant/Root Supported) D5867 — Replacement of Attachment — Implant Overdenture D5878 — Add Wrought Wire Clasp (Tooth-Supported)

D6082 — Implant-Supported Crown Repair, By Report D6085 — Provisional Implant Crown D6083 — Implant-Supported Prosthesis Repair, By Report D6077 — Implant Crown — Noble Metal D6240 — Bridge Pontic — Porcelain Fused to High Noble Metal D6056 — Prefabricated Implant Abutment D6066 — Implant Crown — Porcelain Fused to Metal D6110 — Implant Bridge Retainer — Porcelain Fused to HNM D6250 — Bridge Pontic — Resin with High Noble Metal D6549 — Retainer — Resin for Resin-Bonded Bridge D6782 — Bridge Retainer — ¾ Cast Noble Metal D6791 — Bridge Retainer — Full Cast Base Metal D6792 — Bridge Retainer — Full Cast Noble Metal D6011 — Second Stage Implant Surgery D6059 — Implant Abutment — Custom, By Report D6065 — Implant Crown — Porcelain/Ceramic D6212 — Bridge Pontic — Cast Noble Metal D6751 — Bridge Retainer — Porcelain Fused to Base Metal D6058 — Implant Abutment — Prefabricated D6113 — Implant Bridge Retainer — Cast Metal (HNM) D6195 — Implant-Supported Connector Bar (Modification) D6613 — Bridge Retainer — Onlay, Cast Base Metal (3+ Surf) D6722 — Bridge Retainer — Resin with Noble Metal D6752 — Bridge Retainer — Porcelain Fused to Noble Metal D6010 — Surgical Placement — Endosteal Implant Body D6063 — Implant Abutment — Cast-to (Base Metal) D6072 — Implant Bridge Pontic — Porcelain Fused to Metal D6098 — Implant-Supported Retainer (Removable) D6604 — Bridge Retainer — Inlay, Cast Base Metal (2 Surf) D6950 — Precision Attachment D6980 — Fixed Partial Denture Repair, By Report D6062 — Implant Abutment — Cast-to (Noble Metal) D6064 — Implant Abutment — Prefabricated (Titanium) D6097 — Abutment-Supported Retainer (Removable) D6099 — Implant-Supported Retainer for FPD (Ceramic) D6104 — Bone Graft — Implant Repair (Each Add'l Site) D6740 — Bridge Retainer — Porcelain/Ceramic D6067 — Implant Crown — High Noble Metal D6106 — Bone Graft — Mandibular Symphysis D6211 — Bridge Pontic — Cast Base Metal D6720 — Bridge Retainer — Resin with High Noble Metal D6061 — Implant Abutment — Prefabricated (Base Metal) D6068 — Implant Abutment — Prefabricated D6073 — Implant Bridge Pontic — Cast High Noble Metal D6084 — Custom Implant Abutment (Porcelain/Ceramic) D6111 — Implant Bridge Retainer — Porcelain Fused to BM D6112 — Implant Bridge Retainer — Porcelain/Ceramic D6120 — Implant-Supported Retainer — FPD (High Noble) D6245 — Bridge Pontic — Porcelain/Ceramic D6251 — Bridge Pontic — Resin with Base Metal D6603 — Bridge Retainer — Inlay, Cast High Noble Metal (3+ Surf) D6614 — Bridge Retainer — Onlay, Cast Noble Metal (2 Surf) D6721 — Bridge Retainer — Resin with Base Metal D6793 — Bridge Retainer — Full Cast Titanium D6940 — Bridge Repair, By Report D6013 — Surgical Placement — Mini Implant D6040 — Surgical Placement — Eposteal Implant D6057 — Custom Fabricated Implant Abutment D6070 — Implant Crown — Cast High Noble Metal D6076 — Implant Crown — Base Metal D6087 — Implant Bridge Pontic — Resin D6103 — Bone Graft — Implant Repair (First Site) D6121 — Implant-Supported Retainer — FPD (Noble) D6191 — Semi-Precision Abutment — Placement D6242 — Bridge Pontic — Porcelain Fused to Noble Metal D6252 — Bridge Pontic — Resin with Noble Metal D6605 — Bridge Retainer — Inlay, Cast Base Metal (3+ Surf) D6606 — Bridge Retainer — Inlay, Cast Noble Metal (2 Surf) D6750 — Bridge Retainer — Porcelain Fused to High Noble Metal D6753 — Bridge Retainer — Porcelain Fused to Titanium D6781 — Bridge Retainer — ¾ Cast Base Metal D6012 — Surgical Placement — Interim Implant Body D6050 — Custom Fabricated Implant Abutment D6055 — Dental Implant-Supported Connecting Bar D6069 — Implant Crown — Titanium D6071 — Implant Crown — Cast Base Metal D6074 — Implant Bridge Pontic — Porcelain/Ceramic D6075 — Implant Crown — Porcelain Fused to Titanium D6089 — Implant Abutment Modification D6091 — Implant Repair — Abutment Replacement D6092 — Re-cement/Re-bond Implant Crown D6096 — Remove Broken Implant Retaining Screw D6101 — Debridement of Peri-Implant Defect — Surgical D6122 — Implant-Supported Retainer — FPD (Base) D6123 — Implant-Supported Retainer — FPD (Titanium) D6192 — Semi-Precision Abutment — Removal D6193 — Stress-Breaking Abutment — Placement D6210 — Bridge Pontic — Cast High Noble Metal D6241 — Bridge Pontic — Porcelain Fused to Base Metal D6243 — Bridge Pontic — Porcelain Fused to Titanium D6600 — Bridge Retainer — Inlay, Porcelain/Ceramic (2 Surf) D6602 — Bridge Retainer — Inlay, Cast High Noble Metal (2 Surf) D6612 — Bridge Retainer — Onlay, Cast Base Metal (2 Surf) D6780 — Bridge Retainer — ¾ Cast High Noble Metal D6790 — Bridge Retainer — Full Cast High Noble Metal

D7286 — Incisional Biopsy — Oral Tissue (Soft) D7953 — Bone Replacement Graft — Ridge Preservation D7320 — Alveoloplasty — Without Extractions (Per Quad) D7472 — Removal of Torus Palatinus D7261 — Primary Closure of Sinus Perforation D7220 — Extraction — Soft Tissue Impacted Tooth D7282 — Mobilization of Erupted/Malpositioned Tooth D7485 — Reduction of Osseous Tuberosity D7451 — Removal of Benign Odontogenic Cyst > 1.25 cm D7450 — Removal of Benign Odontogenic Cyst ≤ 1.25 cm D7471 — Removal of Lateral Exostosis D7957 — Guided Bone Regeneration — Non-Resorbable Membrane D7240 — Extraction — Completely Bony Impacted Tooth D7340 — Vestibuloplasty — Ridge Extension D7509 — Marsupialization of Cyst D7520 — Incision and Drainage — Extraoral (Soft Tissue) D7994 — Surgical Placement — Bone-Fixation Plate D7210 — Extraction — Surgical (Erupted Tooth) D7252 — Tooth Removal of Impacted Tooth (Soft Tissue) D7270 — Tooth Reimplantation/Stabilization D7296 — Corticotomy — One to Three Tooth Spaces D7297 — Corticotomy — Four or More Tooth Spaces D7956 — Guided Bone Regeneration — Edentulous Area D7961 — Buccal/Labial Frenectomy D7140 — Extraction — Erupted Tooth or Exposed Root D7241 — Extraction — Completely Bony Impacted (Complicated) D7251 — Coronectomy — Intentional Partial Tooth Removal D7260 — Oroantral Fistula Closure D7272 — Tooth Transplantation D7280 — Surgical Exposure of Impacted Tooth (Orthodontic) D7288 — Brush Biopsy — Transepithelial Sample Collection D7290 — Surgical Repositioning of Teeth D7310 — Alveoloplasty — With Extractions (Per Quad) D7473 — Removal of Torus Mandibularis D7510 — Incision and Drainage — Intraoral (Soft Tissue) D7962 — Lingual Frenectomy D7970 — Excision of Hyperplastic Tissue — Per Arch D7972 — Surgical Reduction of Fibrous Tuberosity

D8660 — Pre-Orthodontic Treatment Exam D8220 — Fixed Appliance Therapy D8702 — Replacement of Lost/Broken Retainer (Removable)

D9410 — House/Extended Care Facility Call D9952 — Occlusal Adjustment — Complete D9944 — Occlusal Guard — Hard Appliance (Full Arch) D9420 — Hospital or ASC Call D9950 — Occlusion Analysis — Mounted Case D9972 — External Bleaching — Per Arch D9129 — Metal-Based Temporization/Splinting (Each Additional) D9224 — Deep Sedation/General Anesthesia — First 15 min (Dentist) D9239 — Intravenous Moderate Sedation — First 15 min D9245 — Non-IV Moderate Conscious Sedation — First 15 min D9430 — Office Visit for Observation (No Services) D9612 — Therapeutic Parenteral Drug — Two+ Administrations D9912 — Pre-Visit Patient Screening