State Plan Dental Rates Increase
MB#
24-025
Effective for dates of service on or after July 1, 2024, the South Carolina Department of Health and Human Services (SCDHHS) will increase the reimbursement rates for the South Carolina Healthy Connections Medicaid State Plan dental services listed in this bulletin. These rate increases will apply to services rendered to Healthy Connections Medicaid members who are under 21 years old or enrolled in the Intellectual Disability and Related Disabilities (ID/RD) waiver program. These reimbursement rate increases apply only to providers enrolled in the Healthy Connections Medicaid Program as the dental provider type. The Dental Fee Schedule available on SCDHHS' website will be updated by July 1, 2024.
The services impacted by this rate increase include:
| 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 | $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 | $55 |
| 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 (excluding 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 minutes | $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 minutes | $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 |
For questions about this bulletin, please contact the DentaQuest Provider Service Center at (888) 307-6553 or carolinaproviders@dentaquest.com.
Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.