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 Code | Description | Current Rate | New Rate |
| D0120 | Periodic oral evaluation - established patient | $24 | $28 |
| D0140 | Limited oral evaluation - problem focused | $39 | $40 |
| D0145 | Oral evaluation for a patient under three years of age | $63 | $70 |
| D0150 | Comprehensive oral evaluation - new or established patient | $42 | $49 |
| D0160 | Detailed and extensive oral evaluation - problem focused | $75 | $90 |
| D0210 | Intraoral - comprehensive series of radiographic images | $56 | $85 |
| D0220 | Intraoral - periapical first radiographic image | $13 | $15 |
| D0230 | Intraoral - periapical each additional radiographic image | $11 | $13 |
| D0270 | Bitewing - single radiographic image | $12.50 | $15 |
| D0272 | Bitewings - two radiographic images | $19 | $21 |
| D0274 | Bitewings - four radiographic images | $28 | $32 |
| D0330 | Panoramic radiographic image | $50.50 | $63 |
| D1110 | Prophylaxis - adult | $50.50 | $56 |
| D1120 | Prophylaxis - child | $35 | $38 |
| D1206 | Topical application of fluoride varnish | $16.50 | $19 |
| D1208 | Topical application of fluoride - excluding varnish | $16.50 | $19 |
| D1351 | Sealant - per tooth | $30 | $33 |
| D1510 | Space maintainer - fixed, unilateral - per quadrant | $173 | $190 |
| D1516 | Space maintainer - fixed - bilateral, maxillary | $243 | $270 |
| D1517 | Space maintainer - fixed - bilateral, mandibular | $243 | $270 |
| D2330 | Resin-based composite - one surface, anterior | $100 | $120 |
| D2331 | Resin-based composite - two surfaces, anterior | $100 | $120 |
| D2332 | Resin-based composite - three surfaces, anterior | $106.30 | $130 |
| D2335 | Resin-based composite - four or more surfaces | $135 | $160 |
| D2390 | Resin-based composite crown, anterior | $153 | $250 |
| D2391 | Resin-based composite - one surface, posterior | $110 | $117 |
| D2392 | Resin-based composite - two surfaces, posterior | $110 | $118 |
| D2393 | Resin-based composite - three surfaces, posterior | $135 | $152 |
| D2394 | Resin-based composite - four or more surfaces, posterior | $175 | $200 |
| D2929 | Prefabricated porcelain/ceramic crown - primary tooth | $140 | $183 |
| D2930 | Prefabricated stainless steel crown - primary tooth | $140 | $147 |
| D2931 | Prefabricated stainless steel crown - permanent tooth | $145 | $180 |
| D2932 | Prefabricated resin crown | $153 | $176 |
| D2934 | Prefabricated esthetic coated stainless-steel crown - primary tooth | $135 | $175 |
| D2950 | Core buildup, including any pins when required | $135 | $150 |
| D2951 | Pin retention - per tooth, in addition to restoration | $39.50 | $50 |
| D2954 | Prefabricated post and core in addition to crown | $153 | $175 |
| D3220 | Therapeutic pulpotomy (excluding final restoration) | $85 | $96 |
| D3310 | Endodontic therapy, anterior tooth (excluding final restoration) | $385 | $440 |
| D3320 | Endodontic therapy, premolar tooth (excl. final restoration) | $465 | $501 |
| D3330 | Endodontic therapy, molar tooth (excluding final restoration) | $560 | $600 |
| D5110 | Complete denture - maxillary | $660 | $720 |
| D5120 | Complete denture - mandibular | $660 | $720 |
| D5211 | Maxillary partial denture - resin base | $565 | $700 |
| D5212 | Mandibular partial denture - resin base | $650 | $700 |
| D5511 | Repair broken complete denture base, mandibular | $83 | $90 |
| D5512 | Repair broken complete denture base, maxillary | $83 | $90 |
| D5520 | Replace missing broken teeth - complete denture (each tooth) | $75 | $90 |
| D5611 | Repair resin partial denture base, mandibular | $81 | $85 |
| D5612 | Repair resin partial denture base, maxillary | $81 | $85 |
| D5640 | Replace broken teeth - per tooth | $66 | $92 |
| D7111 | Extraction, coronal remnants - primary tooth | $67 | $68 |
| D7140 | Extraction, erupted tooth or exposed root (simple) | $143.40 | $144 |
| D7210 | Extraction, erupted tooth requiring removal of bone (surgical) | $143.40 | $144 |
| D7220 | Removal of impacted tooth - soft tissue | $240 | $242 |
| D7230 | Removal of impacted tooth - partially bony | $240 | $242 |
| D7240 | Removal of impacted tooth - completely bony | $281 | $285 |
| D7241 | Removal of impacted tooth - bony, with unusual complication | $355 | $360 |
| D7250 | Removal of residual tooth roots (cutting procedure) | $155 | $165 |
| D9222 | Deep sedation/general anesthesia - first 15 minutes | $94 | $270 |
| D9223 | Deep sedation/general anesthesia - each subsequent 15 min | $94 | $95 |
| D9230 | Inhalation of nitrous oxide/analgesia, anxiolysis | $32.50 | $35 |
| D9239 | Intravenous moderate sedation/analgesia- first 15 minutes | $88 | $120 |
| D9243 | Intravenous moderate sedation/analgesia - each 15 min | $88 | $90 |
| D9248 | Non-intravenous conscious sedation | $75 | $109 |
| D9310 | Consultation - from referral by dentist or physician | $63 | $76 |
| D9420 | Hospital or ambulatory surgical center call | $88 | $98 |
| D9920 | Behavior 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 www.scdhhs.gov 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.