Dental Reimbursement Rates in Vermont

D0190 — Screening of a Patient D0320 — TMJ Arthrogram D0322 — Tomographic Survey D0364 — Cone Beam CT — Limited Field (<1 Jaw) D0425 — Caries Susceptibility Test

D1526 — Space Maintainer — Removable, Bilateral (Maxillary) D1556 — Removal of Fixed Space Maintainer (Unilateral)

D2620 — Inlay — Porcelain/Ceramic, 2 Surfaces D2721 — Crown — Resin with Base Metal D2642 — Onlay — Porcelain/Ceramic, 2 Surfaces D2643 — Onlay — Porcelain/Ceramic, 3 Surfaces D2662 — Onlay — Composite/Resin, 2 Surfaces D2782 — Crown — ¾ Cast Noble Metal D2783 — Crown — ¾ Porcelain/Ceramic D2931 — Prefabricated Stainless Steel Crown — Permanent D2961 — Labial Veneer — Resin (Lab) D2792 — Crown — Full Cast Noble Metal D2391 — Composite Filling — 1 Surface, Posterior D2530 — Inlay — Metallic, 3+ Surfaces D2543 — Onlay — Metallic, 3 Surfaces D2544 — Onlay — Metallic, 4+ Surfaces D2610 — Inlay — Porcelain/Ceramic, 1 Surface D2644 — Onlay — Porcelain/Ceramic, 4+ Surfaces D2712 — Crown — ¾ Resin (Indirect) D2751 — Crown — Porcelain Fused to Base Metal D2752 — Crown — Porcelain Fused to Noble Metal D2753 — Crown — Porcelain Fused to Titanium D2780 — Crown — ¾ Cast High Noble Metal D2799 — Provisional Crown D2960 — Labial Veneer — Resin (Chair-side)

D3320 — Root Canal — Premolar (Excluding Final Restoration) D3347 — Retreatment — Premolar D3421 — Apicoectomy — Premolar (First Root) D3921 — Decoronation/Intentional Submergence

D4261 — Osseous Surgery — 1–3 Teeth (Per Quad) D4270 — Pedicle Soft Tissue Graft D4286 — Combined Connective Tissue Graft (Each Add'l Tooth) D4342 — Scaling and Root Planing — 1–3 Teeth (Per Quad) D4211 — Gingivectomy/Gingivoplasty — 1–3 Teeth (Per Quad) D4260 — Osseous Surgery — 4+ Teeth (Per Quad) D4266 — Guided Tissue Regeneration — Resorbable Barrier D4267 — Guided Tissue Regeneration — Non-Resorbable Barrier D4273 — Autogenous Connective Tissue Graft (First Tooth) D4341 — Scaling and Root Planing — 4+ Teeth (Per Quad) D4355 — Full Mouth Debridement

D5120 — Complete Lower Denture D5284 — Removable Unilateral Partial Denture — 1 Piece (Flex) D5650 — Add Tooth to Existing Partial Denture D5760 — Reline Upper Partial Denture (Lab) D5877 — Replacement of Locator Male, By Report D5228 — Immediate Lower Partial Denture — Flexible Base D5221 — Immediate Upper Partial Denture — Resin Base D5224 — Immediate Lower Partial Denture — Cast Metal D5227 — Immediate Upper Partial Denture — Flexible Base D5286 — Removable Unilateral Partial Denture — 2 Piece (Metal) D5621 — Repair Cast Partial Framework (Upper) D5721 — Rebase Lower Partial Denture D5761 — Reline Lower Partial Denture (Lab) D5850 — Tissue Conditioning (Upper) D5851 — Tissue Conditioning (Lower) D5995 — Periodontal Medicament Carrier (Lab-Processed)

D6122 — Implant-Supported Retainer — FPD (Base) D6241 — Bridge Pontic — Porcelain Fused to Base Metal D6607 — Bridge Retainer — Inlay, Cast Noble Metal (3+ Surf) D6077 — Implant Crown — Noble Metal D6110 — Implant Bridge Retainer — Porcelain Fused to HNM D6112 — Implant Bridge Retainer — Porcelain/Ceramic D6123 — Implant-Supported Retainer — FPD (Titanium) D6192 — Semi-Precision Abutment — Removal D6600 — Bridge Retainer — Inlay, Porcelain/Ceramic (2 Surf) D6609 — Bridge Retainer — Onlay, Porcelain/Ceramic (3+ Surf) D6980 — Fixed Partial Denture Repair, By Report D6088 — Implant Bridge Retainer — Resin D6549 — Retainer — Resin for Resin-Bonded Bridge D6602 — Bridge Retainer — Inlay, Cast High Noble Metal (2 Surf) D6612 — Bridge Retainer — Onlay, Cast Base Metal (2 Surf) D6722 — Bridge Retainer — Resin with Noble Metal D6750 — Bridge Retainer — Porcelain Fused to High Noble Metal D6781 — Bridge Retainer — ¾ Cast Base Metal D6051 — Interim Implant Abutment D6058 — Implant Abutment — Prefabricated D6059 — Implant Abutment — Custom, By Report D6064 — Implant Abutment — Prefabricated (Titanium) D6065 — Implant Crown — Porcelain/Ceramic D6067 — Implant Crown — High Noble Metal D6072 — Implant Bridge Pontic — Porcelain Fused to Metal D6074 — Implant Bridge Pontic — Porcelain/Ceramic D6075 — Implant Crown — Porcelain Fused to Titanium D6076 — Implant Crown — Base Metal D6084 — Custom Implant Abutment (Porcelain/Ceramic) D6086 — Implant Crown — Resin D6102 — Bone Graft — Debridement of Peri-Implant Defect D6120 — Implant-Supported Retainer — FPD (High Noble) D6195 — Implant-Supported Connector Bar (Modification) D6198 — Remove Interim Implant Body D6240 — Bridge Pontic — Porcelain Fused to High Noble Metal D6245 — Bridge Pontic — Porcelain/Ceramic D6545 — Retainer — Cast Metal for Resin-Bonded Bridge D6601 — Bridge Retainer — Inlay, Porcelain/Ceramic (3+ Surf) D6604 — Bridge Retainer — Inlay, Cast Base Metal (2 Surf) D6605 — Bridge Retainer — Inlay, Cast Base Metal (3+ Surf) D6608 — Bridge Retainer — Onlay, Porcelain/Ceramic (2 Surf) D6615 — Bridge Retainer — Onlay, Cast Noble Metal (3+ Surf) D6751 — Bridge Retainer — Porcelain Fused to Base Metal D6780 — Bridge Retainer — ¾ Cast High Noble Metal D6784 — Bridge Retainer — ¾ Titanium D6792 — Bridge Retainer — Full Cast Noble Metal D6793 — Bridge Retainer — Full Cast Titanium D6950 — Precision Attachment

D7956 — Guided Bone Regeneration — Edentulous Area D7252 — Tooth Removal of Impacted Tooth (Soft Tissue) D7260 — Oroantral Fistula Closure D7509 — Marsupialization of Cyst D7511 — Incision and Drainage — Intraoral (Soft Tissue, Complicated) D7972 — Surgical Reduction of Fibrous Tuberosity D7111 — Extraction — Coronal Remnants (Primary Tooth) D7210 — Extraction — Surgical (Erupted Tooth) D7261 — Primary Closure of Sinus Perforation D7272 — Tooth Transplantation D7280 — Surgical Exposure of Impacted Tooth (Orthodontic) D7290 — Surgical Repositioning of Teeth D7320 — Alveoloplasty — Without Extractions (Per Quad) D7321 — Alveoloplasty — Without Extractions (1–3 Teeth) D7350 — Vestibuloplasty — Ridge Extension (w/ Graft) D7450 — Removal of Benign Odontogenic Cyst ≤ 1.25 cm D7451 — Removal of Benign Odontogenic Cyst > 1.25 cm D7473 — Removal of Torus Mandibularis D7485 — Reduction of Osseous Tuberosity D7510 — Incision and Drainage — Intraoral (Soft Tissue) D7520 — Incision and Drainage — Extraoral (Soft Tissue) D7880 — Occlusal Orthotic Device — By Report D7962 — Lingual Frenectomy D7971 — Excision of Pericoronal Gingiva

D9950 — Occlusion Analysis — Mounted Case D9223 — Deep Sedation/General Anesthesia — Each Add'l 15 min D9246 — Non-IV Moderate Conscious Sedation — Each Add'l 15 min