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State Plan Dental Rates Increase


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 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$15
D0272Bitewings - two radiographic images$19$21
D0274Bitewings - four radiographic images$28$32
D0330Panoramic radiographic image$50.50$63
D1110Prophylaxis - adult$50.50$55
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 (excluding 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 minutes$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 minutes$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

For questions about this bulletin, please contact the DentaQuest Provider Service Center at (888) 307-6553 or

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

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