Dental Reimbursement Rates in South Dakota

D0210 — Full Mouth X-Rays D0320 — TMJ Arthrogram D0322 — Tomographic Survey D0418 — Analysis of Saliva Specimen

D1330 — Oral Hygiene Instructions D1520 — Space Maintainer — Removable, Unilateral D1527 — Space Maintainer — Removable, Bilateral (Mandibular) D1553 — Re-cement/Re-bond Space Maintainer (Bilateral, Mand)

D2393 — Composite Filling — 3 Surfaces, Posterior D2520 — Inlay — Metallic, 2 Surfaces D2720 — Crown — Resin with High Noble Metal D2752 — Crown — Porcelain Fused to Noble Metal D2753 — Crown — Porcelain Fused to Titanium D2799 — Provisional Crown D2929 — Prefabricated Porcelain/Ceramic Crown — Permanent D2650 — Inlay — Composite/Resin, 1 Surface D2740 — Crown — Porcelain/Ceramic D2950 — Core Buildup Including Pins D2643 — Onlay — Porcelain/Ceramic, 3 Surfaces D2652 — Inlay — Composite/Resin, 3+ Surfaces D2160 — Amalgam Filling — 3 Surfaces, Primary/Permanent D2651 — Inlay — Composite/Resin, 2 Surfaces D2722 — Crown — Resin with Noble Metal D2750 — Crown — Porcelain Fused to High Noble Metal D2783 — Crown — ¾ Porcelain/Ceramic D2790 — Crown — Full Cast High Noble Metal D2791 — Crown — Full Cast Base Metal D2792 — Crown — Full Cast Noble Metal D2991 — Mineral Infiltration of Incipient Lesion

D3431 — Biologically-Based Root Treatment D3425 — Apicoectomy — Molar (First Root) D3472 — Surgical Repair — Root Resorption (Premolar) D3110 — Pulp Cap — Direct (Excluding Final Restoration) D3120 — Pulp Cap — Indirect (Excluding Final Restoration) D3221 — Pulpal Debridement — Primary/Permanent Teeth D3333 — Internal Root Repair — Perforation D3351 — Apexification/Recalcification — Initial Visit D3421 — Apicoectomy — Premolar (First Root) D3426 — Apicoectomy — Each Additional Root D3473 — Surgical Repair — Root Resorption (Molar)

D4249 — Clinical Crown Lengthening — Hard Tissue D4278 — Free Soft Tissue Graft (Each Additional Tooth) D4265 — Biologic Material for Tissue Regeneration D4210 — Gingivectomy/Gingivoplasty — 4+ Teeth (Per Quad) D4240 — Gingival Flap Surgery — 4+ Teeth (Per Quad) D4260 — Osseous Surgery — 4+ Teeth (Per Quad) D4275 — Non-Autogenous Connective Tissue Graft (First Tooth) D4277 — Free Soft Tissue Graft (First Tooth) D4283 — Autogenous Connective Tissue Graft (Each Add'l Tooth) D4910 — Periodontal Maintenance

D5223 — Immediate Upper Partial Denture — Cast Metal D5214 — Lower Partial Denture — Cast Metal Framework D5282 — Removable Unilateral Partial Denture — 1 Piece (Metal) D5286 — Removable Unilateral Partial Denture — 2 Piece (Metal) 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 D5228 — Immediate Lower Partial Denture — Flexible Base D5612 — Repair Resin Partial Denture Base (Lower) D5863 — Overdenture — Complete (Implant/Root Supported) D5864 — Overdenture — Partial (Implant/Root Supported) D5110 — Complete Upper Denture D5660 — Add Clasp to Existing Partial Denture D5730 — Reline Complete Upper Denture (Chair-side) D5221 — Immediate Upper Partial Denture — Resin Base D5224 — Immediate Lower Partial Denture — Cast Metal D5225 — Upper Partial Denture — Flexible Base D5284 — Removable Unilateral Partial Denture — 1 Piece (Flex) D5512 — Repair Broken Complete Denture Base (Lower) D5520 — Replace Missing/Broken Teeth — Complete Denture D5670 — Replace Teeth & Acrylic on Metal Framework D5721 — Rebase Lower Partial Denture D5750 — Reline Complete Upper Denture (Lab) D5865 — Overdenture — Complete (Implant Supported) D5993 — Maintenance/Cleaning of Maxillofacial Prosthesis

D6110 — Implant Bridge Retainer — Porcelain Fused to HNM D6603 — Bridge Retainer — Inlay, Cast High Noble Metal (3+ Surf) D6056 — Prefabricated Implant Abutment D6072 — Implant Bridge Pontic — Porcelain Fused to Metal D6082 — Implant-Supported Crown Repair, By Report D6087 — Implant Bridge Pontic — Resin D6099 — Implant-Supported Retainer for FPD (Ceramic) D6210 — Bridge Pontic — Cast High Noble Metal D6602 — Bridge Retainer — Inlay, Cast High Noble Metal (2 Surf) D6608 — Bridge Retainer — Onlay, Porcelain/Ceramic (2 Surf) D6611 — Bridge Retainer — Onlay, Cast High Noble Metal (3+ Surf) D6613 — Bridge Retainer — Onlay, Cast Base Metal (3+ Surf) D6793 — Bridge Retainer — Full Cast Titanium D6050 — Custom Fabricated Implant Abutment D6601 — Bridge Retainer — Inlay, Porcelain/Ceramic (3+ Surf) D6606 — Bridge Retainer — Inlay, Cast Noble Metal (2 Surf) D6609 — Bridge Retainer — Onlay, Porcelain/Ceramic (3+ Surf) D6610 — Bridge Retainer — Onlay, Cast High Noble Metal (2 Surf) D6615 — Bridge Retainer — Onlay, Cast Noble Metal (3+ Surf) D6782 — Bridge Retainer — ¾ Cast Noble Metal D6010 — Surgical Placement — Endosteal Implant Body D6070 — Implant Crown — Cast High Noble Metal D6088 — Implant Bridge Retainer — Resin D6792 — Bridge Retainer — Full Cast Noble Metal D6057 — Custom Fabricated Implant Abutment D6061 — Implant Abutment — Prefabricated (Base Metal) D6063 — Implant Abutment — Cast-to (Base Metal) D6066 — Implant Crown — Porcelain Fused to Metal D6068 — Implant Abutment — Prefabricated D6071 — Implant Crown — Cast Base Metal D6077 — Implant Crown — Noble Metal D6083 — Implant-Supported Prosthesis Repair, By Report D6085 — Provisional Implant Crown D6098 — Implant-Supported Retainer (Removable) D6103 — Bone Graft — Implant Repair (First Site) D6111 — Implant Bridge Retainer — Porcelain Fused to BM D6114 — Implant Bridge Retainer — Cast Metal (NM) D6121 — Implant-Supported Retainer — FPD (Noble) D6123 — Implant-Supported Retainer — FPD (Titanium) D6193 — Stress-Breaking Abutment — Placement D6242 — Bridge Pontic — Porcelain Fused to Noble Metal D6243 — Bridge Pontic — Porcelain Fused to Titanium D6252 — Bridge Pontic — Resin with Noble Metal D6253 — Provisional Bridge Pontic D6545 — Retainer — Cast Metal for Resin-Bonded Bridge D6549 — Retainer — Resin for Resin-Bonded Bridge D6612 — Bridge Retainer — Onlay, Cast Base Metal (2 Surf) D6720 — Bridge Retainer — Resin with High Noble Metal D6721 — Bridge Retainer — Resin with Base Metal D6740 — Bridge Retainer — Porcelain/Ceramic D6751 — Bridge Retainer — Porcelain Fused to Base Metal D6791 — Bridge Retainer — Full Cast Base Metal D6950 — Precision Attachment

D7471 — Removal of Lateral Exostosis D7485 — Reduction of Osseous Tuberosity D7280 — Surgical Exposure of Impacted Tooth (Orthodontic) D7282 — Mobilization of Erupted/Malpositioned Tooth D7971 — Excision of Pericoronal Gingiva D7220 — Extraction — Soft Tissue Impacted Tooth D7240 — Extraction — Completely Bony Impacted Tooth D7320 — Alveoloplasty — Without Extractions (Per Quad) D7340 — Vestibuloplasty — Ridge Extension D7472 — Removal of Torus Palatinus D7473 — Removal of Torus Mandibularis D7321 — Alveoloplasty — Without Extractions (1–3 Teeth) D7520 — Incision and Drainage — Extraoral (Soft Tissue) D7230 — Extraction — Partially Bony Impacted Tooth D7250 — Extraction — Residual Root Removal D7272 — Tooth Transplantation D7285 — Incisional Biopsy — Oral Tissue (Hard) D7310 — Alveoloplasty — With Extractions (Per Quad) D7972 — Surgical Reduction of Fibrous Tuberosity

D9972 — External Bleaching — Per Arch D9944 — Occlusal Guard — Hard Appliance (Full Arch) D9212 — Trigeminal Division Block Anesthesia D9223 — Deep Sedation/General Anesthesia — Each Add'l 15 min D9239 — Intravenous Moderate Sedation — First 15 min D9243 — Intravenous Moderate Sedation — Each Add'l 15 min D9941 — Fabrication of Athletic Mouthguard D9945 — Occlusal Guard — Soft Appliance (Full Arch)