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Public Notice of Final Action for Setting Payment Rates for Dental Services

Effective for services provided on or after July 1, 2024, SCDHHS will amend the South Carolina Title XIX State Plan to update the reimbursement rates for the State Plan covered dental services delivered to beneficiaries who are under 21 years of age as follows:

State Plan Dental Services Preventive Dental Benefit
Procedure CodeDescriptionCurrent RateNew Rate
D0120Periodic oral evaluation - established patient$24$28
D0140Limited oral evaluation - problem focused$39$40
D0145Oral evaluation for a patient under three years of age$63$70
D0150Comprehensive oral evaluation - new or established patient$42$49
D0160Detailed and extensive oral evaluation - problem focused$75$90
D0210Intraoral - comprehensive series of radiographic images$56$85
D0220Intraoral - periapical first radiographic image$13$15
D0230Intraoral - periapical each additional radiographic image$11$13
D0270Bitewing - single radiographic image$12.50$15
D0272Bitewings - two radiographic images$19$21
D0274Bitewings - four radiographic images$28$32
D0330Panoramic radiographic image$50.50$63
D1110Prophylaxis - adult$50.50$56
D1120Prophylaxis - child$35$38
D1206Topical application of fluoride varnish$16.50$19
D1208Topical application of fluoride - excluding varnish$16.50$19
D1351Sealant - per tooth$30$33
D1510Space maintainer - fixed, unilateral - per quadrant$173$190
D1516Space maintainer - fixed - bilateral, maxillary$243$270
D1517Space maintainer - fixed - bilateral, mandibular$243$270
D2330Resin-based composite - one surface, anterior$100$120
D2331Resin-based composite - two surfaces, anterior$100$120
D2332Resin-based composite - three surfaces, anterior$106.30$130
D2335Resin-based composite - four or more surfaces$135$160
D2390Resin-based composite crown, anterior$153$250
D2391Resin-based composite - one surface, posterior$110$117
D2392Resin-based composite - two surfaces, posterior$110$118
D2393Resin-based composite - three surfaces, posterior$135$152
D2394Resin-based composite - four or more surfaces, posterior$175$200
D2929Prefabricated porcelain/ceramic crown - primary tooth$140$183
D2930Prefabricated stainless steel crown - primary tooth$140$147
D2931Prefabricated stainless steel crown - permanent tooth$145$180
D2932Prefabricated resin crown$153$176
D2934Prefabricated esthetic coated stainless-steel crown - primary tooth$135$175
D2950Core buildup, including any pins when required$135$150
D2951Pin retention - per tooth, in addition to restoration$39.50$50
D2954Prefabricated post and core in addition to crown$153$175
D3220Therapeutic pulpotomy (excluding final restoration)$85$96
D3310Endodontic therapy, anterior tooth (excluding final restoration)$385$440
D3320Endodontic therapy, premolar tooth (excl. final restoration)$465$501
D3330Endodontic therapy, molar tooth (excluding final restoration)$560$600
D5110Complete denture - maxillary$660$720
D5120Complete denture - mandibular$660$720
D5211Maxillary partial denture - resin base$565$700
D5212Mandibular partial denture - resin base$650$700
D5511Repair broken complete denture base, mandibular$83$90
D5512Repair broken complete denture base, maxillary$83$90
D5520Replace missing broken teeth - complete denture (each tooth)$75$90
D5611Repair resin partial denture base, mandibular$81$85
D5612Repair resin partial denture base, maxillary$81$85
D5640Replace broken teeth - per tooth$66$92
D7111Extraction, coronal remnants - primary tooth$67$68
D7140Extraction, erupted tooth or exposed root (simple)$143.40$144
D7210Extraction, erupted tooth requiring removal of bone (surgical)$143.40$144
D7220Removal of impacted tooth - soft tissue$240$242
D7230Removal of impacted tooth - partially bony$240$242
D7240Removal of impacted tooth - completely bony$281$285
D7241Removal of impacted tooth - bony, with unusual complication$355$360
D7250Removal of residual tooth roots (cutting procedure)$155$165
D9222Deep sedation/general anesthesia - first 15 minutes$94$270
D9223Deep sedation/general anesthesia - each subsequent 15 min$94$95
D9230Inhalation of nitrous oxide/analgesia, anxiolysis$32.50$35
D9239Intravenous moderate sedation/analgesia- first 15 minutes$88$120
D9243Intravenous moderate sedation/analgesia - each 15 min$88$90
D9248Non-intravenous conscious sedation$75$109
D9310Consultation - from referral by dentist or physician$63$76
D9420Hospital or ambulatory surgical center call$88$98
D9920Behavior management$52$71

SCDHHS is updating rates to support the provider network and ensure access to care for these services.

Based on the action noted above, SCDHHS anticipates a budget impact of approximately $19.6 million (total dollars) per year.

Copies of this notice are available at each South Carolina Healthy Connections Medicaid county office and at for public review. Additional information regarding these actions is available upon request at the address cited below.

Any written comments submitted may be reviewed by the public at the SCDHHS, Bureau of Policy, 1801 Main Street, Columbia, South Carolina, Monday through Friday between the hours of 9 a.m. and 5 p.m.

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