Dental Reimbursement Rates in West Virginia

D0320 — TMJ Arthrogram D0180 — Comprehensive Periodontal Evaluation D0240 — Occlusal X-Ray D0322 — Tomographic Survey D0140 — Limited Oral Evaluation — Problem Focused D0145 — Oral Evaluation for Patient Under 3 D0250 — Extraoral — 2D Projection D0251 — Extraoral — Posterior Dental X-Ray D0310 — Sialography D0801 — 3D Surface Scan — Pre-Ortho

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

D2652 — Inlay — Composite/Resin, 3+ Surfaces D2642 — Onlay — Porcelain/Ceramic, 2 Surfaces D2721 — Crown — Resin with Base Metal D2750 — Crown — Porcelain Fused to High Noble Metal D2664 — Onlay — Composite/Resin, 4+ Surfaces D2520 — Inlay — Metallic, 2 Surfaces D2543 — Onlay — Metallic, 3 Surfaces D2929 — Prefabricated Porcelain/Ceramic Crown — Permanent D2390 — Composite Crown — Anterior, Primary D2420 — Gold Foil — 2 Surfaces D2712 — Crown — ¾ Resin (Indirect) D2740 — Crown — Porcelain/Ceramic D2799 — Provisional Crown D2982 — Onlay Repair, By Report D2430 — Gold Foil — 3 Surfaces D2510 — Inlay — Metallic, 1 Surface D2542 — Onlay — Metallic, 2 Surfaces D2610 — Inlay — Porcelain/Ceramic, 1 Surface D2643 — Onlay — Porcelain/Ceramic, 3 Surfaces D2651 — Inlay — Composite/Resin, 2 Surfaces D2662 — Onlay — Composite/Resin, 2 Surfaces D2722 — Crown — Resin with Noble Metal D2751 — Crown — Porcelain Fused to Base Metal D2753 — Crown — Porcelain Fused to Titanium D2780 — Crown — ¾ Cast High Noble Metal D2781 — Crown — ¾ Cast Base Metal D2782 — Crown — ¾ Cast Noble Metal D2791 — Crown — Full Cast Base Metal D2792 — Crown — Full Cast Noble Metal D2931 — Prefabricated Stainless Steel Crown — Permanent D2933 — Prefabricated SS Crown with Resin Window D2956 — Prefabricated Post and Core — Additional D2980 — Crown Repair, By Report D2161 — Amalgam Filling — 4+ Surfaces, Primary/Permanent D2332 — Composite Filling — 3 Surfaces, Anterior D2394 — Composite Filling — 4+ Surfaces, Posterior D2544 — Onlay — Metallic, 4+ Surfaces D2650 — Inlay — Composite/Resin, 1 Surface D2710 — Crown — Resin (Indirect) D2752 — Crown — Porcelain Fused to Noble Metal D2783 — Crown — ¾ Porcelain/Ceramic D2920 — Re-cement/Re-bond Crown D2928 — Prefabricated Porcelain/Ceramic Crown — Primary D2930 — Prefabricated Stainless Steel Crown — Primary D2932 — Prefabricated Resin Crown D2950 — Core Buildup Including Pins D2960 — Labial Veneer — Resin (Chair-side) D2961 — Labial Veneer — Resin (Lab) D2981 — Inlay Repair, By Report D2983 — Veneer Repair, By Report D2990 — Resin Infiltration of Incipient Lesion

D3230 — Pulpal Therapy — Anterior, Primary D3473 — Surgical Repair — Root Resorption (Molar) D3950 — Canal Prep and Fitting of Preformed Post/Dowel D3351 — Apexification/Recalcification — Initial Visit D3352 — Apexification/Recalcification — Interim Medication D3357 — Pulpal Regeneration — Final Visit D3450 — Root Amputation — Per Root D3222 — Partial Pulpotomy for Apexogenesis — Permanent D3410 — Apicoectomy — Anterior D3426 — Apicoectomy — Each Additional Root D3429 — Hemisection (Including Root Removal, Not Crown) D3471 — Surgical Repair — Root Resorption (Anterior) D3910 — Surgical Procedure for Isolation of Tooth D3221 — Pulpal Debridement — Primary/Permanent Teeth D3320 — Root Canal — Premolar (Excluding Final Restoration) D3331 — Treatment of Root Canal Obstruction (Non-Surgical) D3346 — Retreatment — Anterior D3347 — Retreatment — Premolar D3348 — Retreatment — Molar D3353 — Apexification/Recalcification — Final Visit D3355 — Pulpal Regeneration — Initial Visit D3425 — Apicoectomy — Molar (First Root) D3430 — Retrograde Filling — Per Root D3470 — Intentional Reimplantation D3921 — Decoronation/Intentional Submergence D3220 — Therapeutic Pulpotomy (Excluding Final Restoration) D3240 — Pulpal Therapy — Posterior, Primary D3310 — Root Canal — Anterior (Excluding Final Restoration) D3330 — Root Canal — Molar (Excluding Final Restoration) D3332 — Incomplete Endodontic Treatment (Inoperable/Fracture) D3333 — Internal Root Repair — Perforation D3431 — Biologically-Based Root Treatment D3432 — Guided Tissue Regeneration (Periradicular Surgery) D3920 — Hemisection (Not Root Canal/Restoration)

D4245 — Apically Positioned Flap D4230 — Anatomical Crown Exposure — 4+ Teeth (Per Quad) D4240 — Gingival Flap Surgery — 4+ Teeth (Per Quad) D4249 — Clinical Crown Lengthening — Hard Tissue D4273 — Autogenous Connective Tissue Graft (First Tooth) D4231 — Anatomical Crown Exposure — 1–3 Teeth (Per Quad) D4265 — Biologic Material for Tissue Regeneration D4267 — Guided Tissue Regeneration — Non-Resorbable Barrier D4270 — Pedicle Soft Tissue Graft D4276 — Combined Connective Tissue & Pedicle Graft D4212 — Gingivectomy/Gingivoplasty (Restorative, Per Tooth) D4260 — Osseous Surgery — 4+ Teeth (Per Quad) D4266 — Guided Tissue Regeneration — Resorbable Barrier D4275 — Non-Autogenous Connective Tissue Graft (First Tooth) D4283 — Autogenous Connective Tissue Graft (Each Add'l Tooth) D4342 — Scaling and Root Planing — 1–3 Teeth (Per Quad) D4355 — Full Mouth Debridement D4210 — Gingivectomy/Gingivoplasty — 4+ Teeth (Per Quad) D4261 — Osseous Surgery — 1–3 Teeth (Per Quad) D4263 — Bone Replacement Graft — First Site (Per Quad) D4264 — Bone Replacement Graft — Each Additional Site D4274 — Distal/Proximal Wedge Procedure D4277 — Free Soft Tissue Graft (First Tooth) D4286 — Combined Connective Tissue Graft (Each Add'l Tooth)

D5751 — Reline Complete Lower Denture (Lab) D5878 — Add Wrought Wire Clasp (Tooth-Supported) D5120 — Complete Lower Denture D5130 — Immediate Upper Denture D5213 — Upper Partial Denture — Cast Metal Framework D5214 — Lower Partial Denture — Cast Metal Framework D5711 — Rebase Complete Lower Denture D5864 — Overdenture — Partial (Implant/Root Supported) D5865 — Overdenture — Complete (Implant Supported) D5866 — Overdenture — Partial (Implant Supported) D5867 — Replacement of Attachment — Implant Overdenture D5140 — Immediate Lower Denture D5211 — Upper Partial Denture — Resin Base (w/ Clasps/Rests) D5212 — Lower Partial Denture — Resin Base (w/ Clasps/Rests) D5222 — Immediate Lower Partial Denture — Resin Base D5223 — Immediate Upper Partial Denture — Cast Metal D5224 — Immediate Lower Partial Denture — Cast Metal D5225 — Upper Partial Denture — Flexible Base D5228 — Immediate Lower Partial Denture — Flexible Base D5283 — Removable Unilateral Partial Denture — 1 Piece (Resin) D5286 — Removable Unilateral Partial Denture — 2 Piece (Metal) D5671 — Replace All Teeth & Acrylic on Cast Metal Framework D5710 — Rebase Complete Upper Denture D5740 — Reline Upper Partial Denture (Chair-side) D5810 — Interim Complete Upper Denture D5811 — Interim Complete Lower Denture D5862 — Precision Attachment — By Report D5863 — Overdenture — Complete (Implant/Root Supported) D5110 — Complete Upper Denture D5221 — Immediate Upper Partial Denture — Resin Base D5226 — Lower Partial Denture — Flexible Base D5227 — Immediate Upper Partial Denture — Flexible Base D5282 — Removable Unilateral Partial Denture — 1 Piece (Metal) D5284 — Removable Unilateral Partial Denture — 1 Piece (Flex) D5611 — Repair Resin Partial Denture Base (Upper) D5650 — Add Tooth to Existing Partial Denture D5660 — Add Clasp to Existing Partial Denture D5670 — Replace Teeth & Acrylic on Metal Framework D5720 — Rebase Upper Partial Denture D5721 — Rebase Lower Partial Denture D5725 — Rebase Hybrid Prosthesis D5730 — Reline Complete Upper Denture (Chair-side) D5731 — Reline Complete Lower Denture (Chair-side) D5750 — Reline Complete Upper Denture (Lab) D5760 — Reline Upper Partial Denture (Lab) D5851 — Tissue Conditioning (Lower) D5877 — Replacement of Locator Male, By Report

D6077 — Implant Crown — Noble Metal D6058 — Implant Abutment — Prefabricated D6740 — Bridge Retainer — Porcelain/Ceramic D6040 — Surgical Placement — Eposteal Implant D6750 — Bridge Retainer — Porcelain Fused to High Noble Metal D6076 — Implant Crown — Base Metal D6086 — Implant Crown — Resin D6191 — Semi-Precision Abutment — Placement D6245 — Bridge Pontic — Porcelain/Ceramic D6604 — Bridge Retainer — Inlay, Cast Base Metal (2 Surf) D6605 — Bridge Retainer — Inlay, Cast Base Metal (3+ Surf) D6614 — Bridge Retainer — Onlay, Cast Noble Metal (2 Surf) D6055 — Dental Implant-Supported Connecting Bar D6057 — Custom Fabricated Implant Abutment D6063 — Implant Abutment — Cast-to (Base Metal) D6065 — Implant Crown — Porcelain/Ceramic D6066 — Implant Crown — Porcelain Fused to Metal D6069 — Implant Crown — Titanium D6071 — Implant Crown — Cast Base Metal D6074 — Implant Bridge Pontic — Porcelain/Ceramic D6075 — Implant Crown — Porcelain Fused to Titanium D6104 — Bone Graft — Implant Repair (Each Add'l Site) D6123 — Implant-Supported Retainer — FPD (Titanium) D6212 — Bridge Pontic — Cast Noble Metal D6600 — Bridge Retainer — Inlay, Porcelain/Ceramic (2 Surf) D6602 — Bridge Retainer — Inlay, Cast High Noble Metal (2 Surf) D6603 — Bridge Retainer — Inlay, Cast High Noble Metal (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) D6720 — Bridge Retainer — Resin with High Noble Metal D6721 — Bridge Retainer — Resin with Base Metal D6751 — Bridge Retainer — Porcelain Fused to Base Metal D6753 — Bridge Retainer — Porcelain Fused to Titanium D6780 — Bridge Retainer — ¾ Cast High Noble Metal D6784 — Bridge Retainer — ¾ Titanium D6792 — Bridge Retainer — Full Cast Noble Metal D6920 — Connector Bar D6010 — Surgical Placement — Endosteal Implant Body D6011 — Second Stage Implant Surgery D6013 — Surgical Placement — Mini Implant D6059 — Implant Abutment — Custom, By Report D6060 — Implant Abutment — Prefabricated (Noble Metal) D6062 — Implant Abutment — Cast-to (Noble Metal) D6068 — Implant Abutment — Prefabricated D6072 — Implant Bridge Pontic — Porcelain Fused to Metal D6080 — Implant Maintenance — Cleaning/Inspection D6084 — Custom Implant Abutment (Porcelain/Ceramic) D6088 — Implant Bridge Retainer — Resin D6097 — Abutment-Supported Retainer (Removable) D6099 — Implant-Supported Retainer for FPD (Ceramic) D6103 — Bone Graft — Implant Repair (First Site) D6107 — Bone Graft — From Extra-Oral Donor Site D6111 — Implant Bridge Retainer — Porcelain Fused to BM D6122 — Implant-Supported Retainer — FPD (Base) D6195 — Implant-Supported Connector Bar (Modification) D6253 — Provisional Bridge Pontic D6601 — Bridge Retainer — Inlay, Porcelain/Ceramic (3+ Surf) D6607 — Bridge Retainer — Inlay, Cast Noble Metal (3+ 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) D6722 — Bridge Retainer — Resin with Noble Metal D6781 — Bridge Retainer — ¾ Cast Base Metal D6790 — Bridge Retainer — Full Cast High Noble Metal D6940 — Bridge Repair, By Report D6012 — Surgical Placement — Interim Implant Body D6050 — Custom Fabricated Implant Abutment D6051 — Interim Implant Abutment D6056 — Prefabricated Implant Abutment D6064 — Implant Abutment — Prefabricated (Titanium) D6067 — Implant Crown — High Noble Metal D6070 — Implant Crown — Cast High Noble Metal D6073 — Implant Bridge Pontic — Cast High Noble Metal D6083 — Implant-Supported Prosthesis Repair, By Report D6085 — Provisional Implant Crown D6087 — Implant Bridge Pontic — Resin D6089 — Implant Abutment Modification D6096 — Remove Broken Implant Retaining Screw D6106 — Bone Graft — Mandibular Symphysis D6110 — Implant Bridge Retainer — Porcelain Fused to HNM D6112 — Implant Bridge Retainer — Porcelain/Ceramic D6120 — Implant-Supported Retainer — FPD (High Noble) D6121 — Implant-Supported Retainer — FPD (Noble) D6193 — Stress-Breaking Abutment — Placement D6196 — Implant Provisional Crown (Implant Placement Visit) D6241 — Bridge Pontic — Porcelain Fused to Base Metal D6242 — Bridge Pontic — Porcelain Fused to Noble Metal D6243 — Bridge Pontic — Porcelain Fused to Titanium D6250 — Bridge Pontic — Resin with High Noble Metal D6251 — Bridge Pontic — Resin with Base Metal D6252 — Bridge Pontic — Resin with Noble Metal D6612 — Bridge Retainer — Onlay, Cast Base Metal (2 Surf) D6782 — Bridge Retainer — ¾ Cast Noble Metal D6783 — Bridge Retainer — ¾ Porcelain/Ceramic D6791 — Bridge Retainer — Full Cast Base Metal D6793 — Bridge Retainer — Full Cast Titanium

D7350 — Vestibuloplasty — Ridge Extension (w/ Graft) D7510 — Incision and Drainage — Intraoral (Soft Tissue) D7511 — Incision and Drainage — Intraoral (Soft Tissue, Complicated) D7972 — Surgical Reduction of Fibrous Tuberosity D7451 — Removal of Benign Odontogenic Cyst > 1.25 cm D7971 — Excision of Pericoronal Gingiva D7111 — Extraction — Coronal Remnants (Primary Tooth) D7240 — Extraction — Completely Bony Impacted Tooth D7251 — Coronectomy — Intentional Partial Tooth Removal D7260 — Oroantral Fistula Closure D7261 — Primary Closure of Sinus Perforation D7285 — Incisional Biopsy — Oral Tissue (Hard) D7290 — Surgical Repositioning of Teeth D7450 — Removal of Benign Odontogenic Cyst ≤ 1.25 cm D7471 — Removal of Lateral Exostosis D7472 — Removal of Torus Palatinus D7970 — Excision of Hyperplastic Tissue — Per Arch D7140 — Extraction — Erupted Tooth or Exposed Root D7241 — Extraction — Completely Bony Impacted (Complicated) D7270 — Tooth Reimplantation/Stabilization D7280 — Surgical Exposure of Impacted Tooth (Orthodontic) D7320 — Alveoloplasty — Without Extractions (Per Quad) D7340 — Vestibuloplasty — Ridge Extension D7473 — Removal of Torus Mandibularis D7509 — Marsupialization of Cyst D7880 — Occlusal Orthotic Device — By Report D7950 — Osseous/Osteoperiosteal Graft — Mandible/Maxilla D7210 — Extraction — Surgical (Erupted Tooth) D7230 — Extraction — Partially Bony Impacted Tooth D7272 — Tooth Transplantation D7282 — Mobilization of Erupted/Malpositioned Tooth D7283 — Placement of Device for Eruption of Impacted Tooth D7286 — Incisional Biopsy — Oral Tissue (Soft) D7287 — Exfoliative Cytological Sample Collection D7297 — Corticotomy — Four or More Tooth Spaces D7321 — Alveoloplasty — Without Extractions (1–3 Teeth) D7485 — Reduction of Osseous Tuberosity D7520 — Incision and Drainage — Extraoral (Soft Tissue) D7921 — Collection/Application of Autologous Blood Concentrate D7953 — Bone Replacement Graft — Ridge Preservation D7955 — Repair of Maxillofacial Soft/Hard Tissue Defect D7957 — Guided Bone Regeneration — Non-Resorbable Membrane D7961 — Buccal/Labial Frenectomy D7962 — Lingual Frenectomy D7994 — Surgical Placement — Bone-Fixation Plate

D8670 — Periodic Orthodontic Treatment Visit D8091 — Comprehensive Orthodontic — By Report D8660 — Pre-Orthodontic Treatment Exam D8697 — Re-cement/Re-bond Fixed Retainer (Maxillary) D8702 — Replacement of Lost/Broken Retainer (Removable)

D9945 — Occlusal Guard — Soft Appliance (Full Arch) D9211 — Regional Block Anesthesia D9972 — External Bleaching — Per Arch D9120 — Fixed Partial Denture Sectioning D9224 — Deep Sedation/General Anesthesia — First 15 min (Dentist) D9225 — Deep Sedation/General Anesthesia — Each Add'l 15 min (Dentist) D9239 — Intravenous Moderate Sedation — First 15 min D9247 — Non-IV Moderate Conscious Sedation — Supplemental D9420 — Hospital or ASC Call D9440 — Office Visit — After Regular Hours D9950 — Occlusion Analysis — Mounted Case D9951 — Occlusal Adjustment — Limited D9952 — Occlusal Adjustment — Complete