State Plan Dental Rates Increases
MB#
22-032
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.
| Procedure Code | Description | Current Rate | New Rate |
|---|---|---|---|
| D0120 | Periodic oral evaluation - established patient | $23.00 | $24.00 |
| D0140 | Limited oral evaluation - problem focused | $38.50 | $39.00 |
| D0145 | Oral evaluation for a patient under three years of age | $36.00 | $63.00 |
| D0150 | Comprehensive oral evaluation - new or established patient | $40.50 | $42.00 |
| D0160 | Detailed and extensive oral evaluation - problem focused | $74.00 | $75.00 |
| D0210 | Intraoral - comprehensive series of radiographic images | $50.09 | $56.00 |
| D0220 | Intraoral - periapical first radiographic image | $12.83 | $13.00 |
| D0230 | Intraoral - periapical each additional radiographic image | $10.39 | $11.00 |
| D0240 | Intraoral - occlusal radiographic image | $18.94 | $21.00 |
| D0270 | Bitewing - single radiographic image | $12.22 | $12.50 |
| D0272 | Bitewings - two radiographic images | $18.94 | $19.00 |
| D0274 | Bitewings - four radiographic images | $27.51 | $28.00 |
| D0330 | Panoramic radiographic image | $50.09 | $50.50 |
| D1110 | Prophylaxis - adult | $50.40 | $50.50 |
| D1120 | Prophylaxis - child | $34.80 | $35.00 |
| D1206 | Topical application of fluoride varnish | $16.20 | $16.50 |
| D1208 | Topical application of fluoride - excluding varnish | $16.20 | $16.50 |
| D1354 | Application of caries arresting medicament - per tooth | $10.00 | $15.00 |
| D1510 | Space maintainer - fixed, unilateral - per quadrant | $172.80 | $173.00 |
| D1516 | Space maintainer - fixed - bilateral, maxillary | $242.40 | $243.00 |
| D1517 | Space maintainer - fixed - bilateral, mandibular | $242.40 | $243.00 |
| D2140 | Amalgam - one surface, primary or permanent | $61.09 | $65.00 |
| D2150 | Amalgam - two surfaces, primary or permanent | $79.42 | $80.00 |
| D2160 | Amalgam - three surfaces, primary or permanent | $95.91 | $98.00 |
| D2161 | Amalgam - four or more surfaces, primary or permanent | $116.68 | $118.00 |
| D2330 | Resin-based composite - one surface, anterior | $68.42 | $100.00 |
| D2331 | Resin-based composite - two surfaces, anterior | $86.75 | $100.00 |
| D2335 | Resin-based composite - four or more surfaces | $125.85 | $135.00 |
| D2390 | Resin-based composite crown, anterior | $152.73 | $153.00 |
| D2391 | Resin-based composite - one surface, posterior | $80.03 | $110.00 |
| D2392 | Resin-based composite - two surfaces, posterior | $104.46 | $110.00 |
| D2393 | Resin-based composite - three surfaces, posterior | $129.51 | $135.00 |
| D2394 | Resin-based composite - four or more surfaces, posterior | $158.83 | $175.00 |
| D2929 | Prefabricated porcelain/ceramic crown - primary tooth | $126.46 | $140.00 |
| D2930 | Prefabricated stainless steel crown - primary tooth | $126.46 | $140.00 |
| D2931 | Prefabricated stainless steel crown - permanent tooth | $142.96 | $145.00 |
| D2932 | Prefabricated resin crown | $152.73 | $153.00 |
| D2934 | Prefabricated esthetic coated stainless steel crown - primary tooth | $126.46 | $135.00 |
| D2950 | Core buildup, including any pins when required | $120.96 | $135.00 |
| D2951 | Pin retention - per tooth, in addition to restoration | $27.50 | $39.50 |
| D2954 | Prefabricated post and core in addition to crown | $152.73 | $153.00 |
| D3220 | Therapeutic pulpotomy (excluding final restoration) | $81.86 | $85.00 |
| D3310 | Endodontic therapy, anterior tooth (excluding final restoration) | $346.38 | $385.00 |
| D3320 | Endodontic therapy, premolar tooth (excluding final restoration) | $423.36 | $465.00 |
| D3330 | Endodontic therapy, molar tooth (excluding final restoration) | $546.76 | $560.00 |
| D5110 | Complete denture - maxillary | $659.17 | $660.00 |
| D5120 | Complete denture - mandibular | $659.17 | $660.00 |
| D5211 | Maxillary partial denture - resin base | $556.54 | $565.00 |
| D5212 | Mandibular partial denture - resin base | $646.33 | $650.00 |
| D5511 | Repair broken complete denture base, mandibular | $72.09 | $83.00 |
| D5512 | Repair broken complete denture base, maxillary | $72.09 | $83.00 |
| D5520 | Replace missing or broken teeth - complete denture (each tooth) | $59.87 | $75.00 |
| D5611 | Repair resin partial denture base, mandibular | $78.20 | $81.00 |
| D5612 | Repair resin partial denture base, maxillary | $78.20 | $81.00 |
| D5640 | Replace broken teeth - per tooth | $65.98 | $66.00 |
| D7111 | Extraction, coronal remnants - primary tooth | $66.60 | $67.00 |
| D7140 | Extraction, erupted tooth or exposed root (simple) | $88.80 | $143.40 |
| D7220 | Removal of impacted tooth - soft tissue | $179.40 | $240.00 |
| D7230 | Removal of impacted tooth - partially bony | $238.80 | $240.00 |
| D7240 | Removal of impacted tooth - completely bony | $280.80 | $281.00 |
| D7241 | Removal of impacted tooth – bony, with unusual surgical complication | $352.80 | $355.00 |
| D7250 | Removal of residual tooth roots (cutting procedure) | $151.20 | $155.00 |
| D9222 | Deep sedation/general anesthesia - first 15 minutes | $90.24 | $94.00 |
| D9223 | Deep sedation/general anesthesia - each subsequent 15 min | $90.24 | $94.00 |
| D9239 | Intravenous moderate sedation/analgesia- first 15 minutes | $74.00 | $88.00 |
| D9243 | Intravenous moderate sedation/analgesia - each subsequent 15 min | $74.00 | $88.00 |
| D9248 | Non-intravenous conscious sedation | $65.80 | $75.00 |
| D9310 | Consultation – from referral by dentist or physician | $62.00 | $63.00 |
| D9420 | Hospital or ambulatory surgical center call | $87.50 | $88.00 |
| D9920 | Behavior 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 carolinaproviders@dentaquest.com.
Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.