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State Plan Dental Rates Increases


The South Carolina Department of Health and Human Services (SCDHHS) is updating the rates for selected State Plan dental services rendered on or after Jan. 1, 2023, to Healthy Connections Medicaid members who are under 21 years of age or who are enrolled in the Intellectual Disability and Related Disabilities (ID/RD) waiver. These rates apply only to providers enrolled in Healthy Connections Medicaid Program as a “dental” provider type.

State Plan Dental Services  
Preventive Dental Benefit
Procedure CodeDescriptionCurrent RateNew Rate
D0120Periodic oral evaluation - established patient$23.00$24.00
D0140Limited oral evaluation - problem focused$38.50$39.00
D0145Oral evaluation for a patient under three years of age$36.00$63.00
D0150Comprehensive oral evaluation - new or established patient$40.50$42.00
D0160Detailed and extensive oral evaluation - problem focused$74.00$75.00
D0210Intraoral - comprehensive series of radiographic images$50.09$56.00
D0220Intraoral - periapical first radiographic image$12.83$13.00
D0230Intraoral - periapical each additional radiographic image$10.39$11.00
D0240Intraoral - occlusal radiographic image$18.94$21.00
D0270Bitewing - single radiographic image$12.22$12.50
D0272Bitewings - two radiographic images$18.94$19.00
D0274Bitewings - four radiographic images$27.51$28.00
D0330Panoramic radiographic image$50.09$50.50
D1110Prophylaxis - adult$50.40$50.50
D1120Prophylaxis - child$34.80$35.00
D1206Topical application of fluoride varnish$16.20$16.50
D1208Topical application of fluoride - excluding varnish$16.20$16.50
D1354Application of caries arresting medicament - per tooth$10.00$15.00
D1510Space maintainer - fixed, unilateral - per quadrant$172.80$173.00
D1516Space maintainer - fixed - bilateral, maxillary$242.40$243.00
D1517Space maintainer - fixed - bilateral, mandibular$242.40$243.00
D2140Amalgam - one surface, primary or permanent$61.09$65.00
D2150Amalgam - two surfaces, primary or permanent$79.42$80.00
D2160Amalgam - three surfaces, primary or permanent$95.91$98.00
D2161Amalgam - four or more surfaces, primary or permanent$116.68$118.00
D2330Resin-based composite - one surface, anterior$68.42$100.00
D2331Resin-based composite - two surfaces, anterior$86.75$100.00
D2335Resin-based composite - four or more surfaces$125.85$135.00
D2390Resin-based composite crown, anterior$152.73$153.00
D2391Resin-based composite - one surface, posterior$80.03$110.00
D2392Resin-based composite - two surfaces, posterior$104.46$110.00
D2393Resin-based composite - three surfaces, posterior$129.51$135.00
D2394Resin-based composite - four or more surfaces, posterior$158.83$175.00
D2929Prefabricated porcelain/ceramic crown - primary tooth$126.46$140.00
D2930Prefabricated stainless steel crown - primary tooth$126.46$140.00
D2931Prefabricated stainless steel crown - permanent tooth$142.96$145.00
D2932Prefabricated resin crown$152.73$153.00
D2934Prefabricated esthetic coated stainless steel crown - primary tooth$126.46$135.00
D2950Core buildup, including any pins when required$120.96$135.00
D2951Pin retention - per tooth, in addition to restoration$27.50$39.50
D2954Prefabricated post and core in addition to crown$152.73$153.00
D3220Therapeutic pulpotomy (excluding final restoration)$81.86$85.00
D3310Endodontic therapy, anterior tooth (excluding final restoration)$346.38$385.00
D3320Endodontic therapy, premolar tooth (excluding final restoration)$423.36$465.00
D3330Endodontic therapy, molar tooth (excluding final restoration)$546.76$560.00
D5110Complete denture - maxillary$659.17$660.00
D5120Complete denture - mandibular$659.17$660.00
D5211Maxillary partial denture - resin base$556.54$565.00
D5212Mandibular partial denture - resin base$646.33$650.00
D5511Repair broken complete denture base, mandibular$72.09$83.00
D5512Repair broken complete denture base, maxillary$72.09$83.00
D5520Replace missing or broken teeth - complete denture (each tooth)$59.87$75.00
D5611Repair resin partial denture base, mandibular$78.20$81.00
D5612Repair resin partial denture base, maxillary$78.20$81.00
D5640Replace broken teeth - per tooth$65.98$66.00
D7111Extraction, coronal remnants - primary tooth$66.60$67.00
D7140Extraction, erupted tooth or exposed root (simple)$88.80$143.40
D7220Removal of impacted tooth - soft tissue$179.40$240.00
D7230Removal of impacted tooth - partially bony$238.80$240.00
D7240Removal of impacted tooth - completely bony$280.80$281.00
D7241Removal of impacted tooth – bony, with unusual surgical complication$352.80$355.00
D7250Removal of residual tooth roots (cutting procedure)$151.20$155.00
D9222Deep sedation/general anesthesia - first 15 minutes$90.24$94.00
D9223Deep sedation/general anesthesia - each subsequent 15 min$90.24$94.00
D9239Intravenous moderate sedation/analgesia- first 15 minutes$74.00$88.00
D9243Intravenous moderate sedation/analgesia - each subsequent 15 min$74.00$88.00
D9248Non-intravenous conscious sedation$65.80$75.00
D9310Consultation – from referral by dentist or physician$62.00$63.00
D9420Hospital or ambulatory surgical center call$87.50$88.00
D9920Behavior management$51.70$52.00

The updated dental rates will be published on SCDHHS’ Dental Fee Schedule available on the agency’s website by Jan. 1, 2023.

For questions about this Medicaid 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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