CurrentHawaii Department of Human Services | Med-QUEST DivisionPolicy N/A
Children and Adult Dental Fee Schedule (Fee Schedule — Effective 04/01/2026)
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Lists Medicaid dental procedure codes, descriptions, and fee schedule amounts for children and adults effective for service dates on or after 04/01/2026; intended for Hawaii Medicaid providers and refers to Medicaid Provider Manual Chapter 14 for coverage details.
Policy Summary
PayerHawaii Department of Human Services | Med-QUEST Division
PolicyChildren and Adult Dental Fee Schedule
Policy CodePolicy N/A
Change TypeNo material change
Effective DateApr 1, 2026
Next Review DateN/A
Key ActionConsult Medicaid Provider Manual Chapter 14 for specific coverage, limitations, and prior authorization requirements.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
100+dental procedure codes and line items listed (approximate)
04/01/2026effective service date
regional ratesrates by region and provider type
variesdifferent payment amounts for Oahu vs Neighbor Islands
Chapter 14referenced for specific coverage details
Coverage and Fee Schedule Scope
Coverage stance
This schedule provides reimbursement amounts but does not itself define coverage rules; coverage and eligibility criteria are in the Medicaid Provider Manual Chapter 14.
This document is a fee schedule and only specifies allowed reimbursement amounts by procedure code and provider/region column.
Coverage, medical necessity, eligibility, limitations, and prior authorization requirements are defined in the Medicaid Provider Manual Chapter 14; providers must consult Chapter 14 for coverage rules.
Coverage stance for listed procedures
Fee schedule lists covered procedures and amounts; detailed coverage criteria are in the referenced Medicaid Provider Manual Chapter 14.
The fee schedule lists procedure codes with allowed amounts and regional/provider-type columns (e.g., Oahu vs Neighbor Islands; GP/ENDO/ORTHO/OS/PEDO).
This schedule does not itself specify utilization limits, medical necessity criteria, or prior authorization rules — those details are in Medicaid Provider Manual Chapter 14.
Providers should bill using the listed CDT/D procedure codes and apply the appropriate regional/provider-type rate column as shown in the schedule.
Coverage guidance
General coverage stance and referral to manual
The schedule summarizes which services have listed fees and where entries are N/A; it is a billing and reimbursement reference rather than a coverage policy.
For specific coverage criteria, limitations, prior authorization requirements, and billing rules, providers must consult Medicaid Provider Manual Chapter 14 as referenced throughout the schedule.
Regional and specialty variations (Oahu vs Neighbor Islands and specialty columns such as ORTHO, ENDO, PEDO, OS) affect the applicable allowed amount and should be used when submitting claims.
Fee schedule coverage entries
Entries show whether services are covered and the applicable fee by provider type and region; many entries show N/A where not covered or vary by specialty/region.
Fee lines indicate coverage status and allowed amounts by provider type and geography (examples: D8080/D8090 orthodontics show ORTHO.Oahu and ORTHO.Neighbor Island rates; some specialty/provider cells marked N/A).
Palliative care (D9110) is listed with GP/ENDO/PEDO Oahu and Neighbor Island rates (e.g., GP.Oahu = $59.28; GP.Neighbor = $63.25).
Nitrous oxide codes (D9230/D9239) are listed with standard rates (e.g., GP/Oahu = $55.99; PEDO.Oahu = $58.24).
Behavior management (D9920) is listed uniformly across provider types and regions (e.g., $80.00).
Teledentistry codes (D9995/D9996) appear in the schedule; many provider-type/geography cells show N/A in the displayed extract.
Procedure Codes and Regional Rates
Example dental procedure codes presentCPTCovered
| D0120 | Periodic Oral Evaluation - Established Patient (listed in schedule) |
| D0140 | Limited Oral Evaluation - Problem Focused (listed in schedule) |
| D0210 | Intraoral - Complete Series (listed in schedule) |
| D0274 | Bitewings - Four Radiographic Images (listed in schedule) |
| D2740 | Crown - Porcelain/Ceramic (listed in schedule) |
| D2750 | Crown - Porcelain Fused to High Noble Metal (listed in schedule) |
Sample dental procedure codes in excerptCPTCovered
| D2394 | Resin-based Composite - Four or More Surfaces, Posterior |
| D2740 | Crown - Porcelain/Ceramic |
| D3310 | Endodontic Therapy, Anterior Tooth (Excluding Final Restoration) |
| D3346 | Retreatment of Previous Root Canal Therapy - Anterior |
| D4910 | Periodontal Maintenance |
D54xx denture adjustments/repairsCPTCovered
| D5410 | Adjust Complete Denture - Maxillary |
| D5411 | Adjust Complete Denture - Mandibular |
| D5421 | Adjust Partial Denture - Maxillary |
| D5422 | Adjust Partial Denture - Mandibular |
D55xx-D56xx denture repair/replaceCPTCovered
| D5511 | Repair Broken Complete Denture Base, Mandibular |
| D5512 | Repair Broken Complete Denture Base, Maxillary |
| D5520 | Replace Missing/Broken tooth - Complete Denture (each tooth) |
| D5611 | Repair broken partial denture base, mandibular |
| D5612 | Repair broken partial denture base, maxillary |
| D5621 | Repair Cast Framework, mandibular |
| D5622 | Repair Cast Framework, maxillary |
D56xx-D57xx rebasing/reliningCPTCovered
| D5650 | Add Tooth to Existing Partial Denture |
| D5660 | Add Clasp to Existing Partial Denture |
| D5710 | Rebase Complete Maxillary Denture |
| D5711 | Rebase Complete Mandibular Denture |
| D5720 | Rebase Maxillary Partial Denture |
| D5721 | Rebase Mandibular Partial Denture |
| D5730 | Reline Complete Maxillary Denture (direct) |
| D5731 | Reline Complete Mandibular Denture (direct) |
D57xx-D58xx relines and interim partialsCPTCovered
| D5760 | Reline Maxillary Partial Denture (indirect) |
| D5761 | Reline Mandibular Partial Denture (indirect) |
| D5765 | Soft liner for complete or partial removable denture - indirect |
| D5820 | Interim Partial Denture, maxillary |
| D5821 | Interim Partial Denture, mandibular |
D7xxx oral surgery extractions and surgical proceduresCPTCovered
| D7140 | Extraction, erupted tooth requiring removal of bone and/or sectioning |
| D7210 | Removal of Impacted Tooth - Soft Tissue |
| D7230 | Removal of Impacted Tooth - Partially Bony |
| D7240 | Removal of Impacted Tooth - Completely Bony |
| D7241 | Removal of Impacted Tooth - Completely Bony, with unusual surgical complications |
| D7250 | Surgical removal of residual tooth roots |
| D7260 | Oroantral Fistula Closure |
| D7261 | Primary closure of a sinus perforation |
D72xx-D73xx eruption, biopsies, alveoloplastyCPTCovered
| D7270 | Exposure of an Unerupted Tooth |
| D7282 | Mobilization of Erupted or Malpositioned Tooth to Aid Eruption |
| D7283 | Placement of Device to Facilitate Eruption of Impacted Tooth |
| D7285 | Incisional Biopsy of Oral Tissue - Hard (bone, tooth) |
| D7286 | Incisional Biopsy of Oral Tissue - Soft |
| D7310 | Alveoloplasty in conjunction with Extractions (4 or more teeth) |
| D7311 | Alveoloplasty in conjunction with Extractions (one to three teeth) |
D73xx-D80xx surgical and orthodontic codesCPT
| D7320 | Alveoloplasty not in conjunction with Extractions (4 or more teeth) |
| D7321 | Alveoloplasty not in conjunction with Extractions (one to three teeth) |
| D7410 | Excision of Benign Lesion up to 1.25 cm |
| D7411 | Excision of Benign Lesion greater than 1.25 cm |
| D7510 | Incision and Drainage of Abscess, Intraoral soft tissue |
| D7961 | Buccal/Labial Frenectomy |
| D7962 | Lingual Frenectomy |
| D7970 | Excision of Hyperplastic Tissue - Per Arch |
| D7971 | Excision of Pericoronal Gingiva |
| D8010 | Limited orthodontic treatment of the primary dentition (N/A in parts of schedule) |
1–10 of 13
1/2
Comprehensive OrthodonticsCPTCovered
| D8080 | Comprehensive Orthodontic Treatment of the Adolescent/Adult Dentition |
| D8090 | Comprehensive Orthodontic Treatment of the Adult Dentition |
Palliative careCPTCovered
| D9110 | Palliative Treatment of Dental Pain - per visit |
Nitrous oxideCPTCovered
| D9230 | Inhalation of Nitrous Oxide/Analgesia, Anxiolysis |
| D9239 | Inhalation of Nitrous Oxide/Analgesia, Anxiolysis (other) |
Behavioral managementCPTCovered
| D9920 | Behavior Management |
TeledentistryCPTCovered
| D9995 | Teledentistry - synchronous; real-time encounter |
| D9996 | Teledentistry - asynchronous; store-and-forward |
Regional payment variations
Regional fee columnsSchedule provides distinct dollar amounts by geography (Oahu vs Neighbor Islands) for many procedures (e.g., D2394: Oahu $192.44, Neighbor $208.47; D2740: Oahu $543.72, Neighbor $589.03).
Provider-specialty adjustmentsRates vary further by provider specialty columns (ENDO, ORTHO, OS, PEDO) in addition to geographic columns (see D3310, D3330 entries).
N/A entries by regionSome cells show N/A for certain provider types or regions indicating the service is not applicable or not covered in that column (see CBCT and other entries).
Use correct regional column when billingProviders must bill using the listed procedure code and the applicable regional rate column (Oahu or Neighbor Islands).
Orthodontic coverage notes
Orthodontic codes availabilityOrthodontic codes (e.g., D8010, D8020, D8080/D8090) show mixed availability: some entries marked N/A in parts of the schedule while ORTHO columns list substantial rates (e.g., D8080 ORTHO.Oahu $5,044.00; ORTHO.Neighbor Island $5,352.46–$5,415.09).
Geographic-specific ORTHO ratesComprehensive Orthodontic Treatment (D8080/D8090) lists ORTHO.Oahu $5,044.00 and ORTHO.Neighbor Island values around $5,352.46–$5,415.09; OS and PEDO columns are N/A for these codes.
Limited orthodontics marked N/ALimited orthodontic treatment codes (D8010, D8020) are shown as N/A in multiple columns while Neighbor columns include a large value ($1,311.05) in the excerpt.
Provider Guidance and Manual References
Documentation Required
See Medicaid Provider Manual Chapter 14
Please see Medicaid Provider Manual Chapter 14 for specific coverage details.
Documentation Required
See Medicaid Provider Manual Chapter 14
Please see Medicaid Provider Manual Chapter 14 for specific coverage details.
Documentation Required
See Medicaid Provider Manual Chapter 14
Please see Medicaid Provider Manual Chapter 14 for specific coverage details.
Documentation Required
See Medicaid Provider Manual Chapter 14
Please see Medicaid Provider Manual Chapter 14 for specific coverage details.
Column and Term Definitions
Column abbreviations
NeighborNeighbor = Neighbor Islands (column header abbreviation).
ENDOENDO = Endodontics (provider specialty column).
ORTHOORTHO = Orthodontics (provider specialty column).
OSOS = Oral Surgery (provider specialty column).
PEDOPEDO = Pediatric Dentistry (provider specialty column).
Regional/provider type rate columns
GP / Neighbor / ENDO / ORTHO / OS / PEDOTable includes columns for GP (general practice; Oahu), Neighbor (Neighbor Islands), and provider-specialty columns ENDO, ORTHO, OS, PEDO for regional/provider-type rates.
GPGP column shown as Oahu general practice rates in the schedule excerpts.
ENDO / ORTHO / OS / PEDOSpecialty columns present to show adjusted rates for Endodontics, Orthodontics, Oral Surgery, and Pediatric Dentistry.
Procedure (CDT/D-code)
DefinitionProcedure = CDT / D-code (example: D5410 shown in schedule).
Coding systemProcedures listed use standard dental CDT D-codes throughout the fee schedule.
ExampleD5410 = Adjust Complete Denture - Maxillary (appears with GP and Neighbor rates).
Oahu / Neighbor (geographic fee columns)
Geographic fee columnsOahu and Neighbor (Neighbor Islands) indicate separate geographic fee columns; many procedures list both Oahu and Neighbor Island amounts (e.g., D5410 GP Oahu $51.30, Neighbor $55.58).
Billing implicationSelect the appropriate Oahu or Neighbor column when billing to ensure correct regional rate applied.
Neighbor label'Neighbor' in headers refers to Neighbor Islands (Island rates).
Provider specialty columns
ORTHO / ENDO / GP / OS / PEDOSchedule includes provider specialty columns labeled ORTHO (Orthodontics), ENDO (Endodontics), GP (General Practice), OS (Oral Surgery), PEDO (Pediatric Dentistry).
Specialty-specific ratesEach specialty column may list different rates or N/A for a given procedure (see D9110, D9230, D9920 examples).
N/A usageSpecialty columns sometimes show N/A indicating the procedure is not applicable or not paid for that specialty/region.
Neighbor Islands
Neighbor Islands'Neighbor' denotes Neighbor Islands (the non-Oahu geographic column used throughout the schedule).
Example valuesMany Neighbor Island rates differ from Oahu (e.g., D2394 Oahu $192.44, Neighbor $208.47; Neighbor values shown elsewhere like $1,311.05).
Billing noteUse Neighbor column for services performed on Neighbor Islands to apply appropriate fee.
Pediatric Dentistry (PEDO) column
PEDO = Pediatric DentistryPEDO column indicates Pediatric Dentistry provider-type rates (appears in column headers and rate rows).
Example PEDO ratesPEDO rates are shown for multiple procedures (e.g., D5410 Neighbor PEDO $64.55; D9110 PEDO.Oahu $59.28).
ApplicabilityPEDO column used when billing a pediatric dentistry provider to apply the specialty-adjusted pediatric rate.
Policy Summary
PayerHawaii Department of Human Services | Med-QUEST Division
PolicyChildren and Adult Dental Fee Schedule
Policy CodePolicy N/A
Change TypeNo material change
Effective DateApr 1, 2026
Next Review DateN/A
Key ActionConsult Medicaid Provider Manual Chapter 14 for specific coverage, limitations, and prior authorization requirements.
SourceLink
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