CurrentHawaii Department of Human Services | Med-QUEST DivisionPolicy N/A

Children and Adult Dental Fee Schedule — Med-QUEST Division

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Provides the Med-QUEST Division fee schedule for dental services for children and adults, listing procedure codes, descriptions, and reimbursement rates by region/provider type; coverage details and prior authorization requirements are specified in Medicaid Provider Manual Chapter 14.

Policy Summary

PayerHawaii Department of Human Services | Med-QUEST Division

PolicyChildren and Adult Dental Fee Schedule

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionPlease see Medicaid Provider Manual Chapter 14 for specific coverage details.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

04/01/2026effective service date

Chapter 14referenced manual chapter

coverage pointersprocedures covered

~200+unique procedure lines

$5,044orthodontic adult fee

Coverage summary and applicability

inv-01: Coverage stance and referral

This fee schedule provides reimbursement rates; coverage specifics, limitations, and prior authorization requirements are governed by the Medicaid Provider Manual (Chapter 14).

This document lists reimbursement rates (fee schedule) for dental procedures effective 04/01/2026.

Coverage specifics, limitations, medical necessity criteria, and prior authorization requirements are defined in the Medicaid Provider Manual Chapter 14 and govern payment and coverage decisions.

inv-02: Coverage summary

Document provides fee amounts but defers coverage specifics to the Medicaid Provider Manual.

The schedule enumerates procedure codes, descriptions, coverage indicators (e.g., 'Covered = x'), and fee amounts by provider type and geography.

Detailed coverage determinations, limitations, and medical necessity criteria for listed procedures are specified in Medicaid Provider Manual Chapter 14; refer to that chapter for adjudication and authorization guidance.

inv-03: Fee schedule coverage summary

Coverage indicators and fee amounts for listed procedures; consult Provider Manual Chapter 14 for detailed coverage criteria and limitations.

Procedure entries include code, description, 'Covered' indicator (shown as 'x' where applicable), and fee amounts across provider/region columns (e.g., GP, ENDO, ORTHO, OS, PEDO; Oahu and Neighbor Islands).

Fees for sample entries (e.g., D5410, D5411 denture adjustments) are listed per provider type and region; these fee amounts determine reimbursement but do not replace coverage rules in the Provider Manual.

inv-04: Fee schedule coverage guidance

Coverage and billing are governed by the fee schedule values and additional details in the Medicaid Provider Manual Chapter 14.

Use the fee schedule values for billing and reimbursement calculations (examples include orthodontic fees and entries marked N/A where not applicable).

For procedures with 'N/A' entries or specialty/geography-specific rates (for example, comprehensive orthodontic rates listed under ORTHO.Oahu and ORTHO.Neighbor Island), follow the Provider Manual Chapter 14 for coverage eligibility, limits, and prior authorization procedures.

Representative procedure codes and rate entries

example diagnostic and evaluation codesCPTCovered

D0120	Periodic Oral Evaluation - Established Patient / Limited Oral Evaluation - Problem Focused
D0140	Limited Oral Evaluation - Problem Focused / Oral Evaluation for patient under 3 and counseling
D0150	Comprehensive Oral Evaluation - New or Established Patient
D0210	Intraoral - Complete Series
D0220	Intraoral - Periapical First Radiographic Image
D0230	Intraoral - Periapical Each Additional Radiographic Image

example restorative and prosthetic codesCPTCovered

D2330	Resin - One Surface, Anterior
D2391	Resin-based Composite - One Surface, Posterior
D2740	Crown - Porcelain/Ceramic
D2750	Crown - Porcelain Fused to High Noble Metal

Restorative / Crown codes (sample)CPTCovered

D2394	Resin-based Composite - Four or More Surfaces, Posterior
D2740	Crown - Porcelain/Ceramic
D2750	Crown - Porcelain Fused to High Noble Metal
D2751	Crown - Porcelain Fused to Predominantly Base Metal

Endodontic codes (sample)CPTCovered

D3310	Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)
D3320	Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration)
D3330	Endodontic Therapy, Molar Tooth (Excluding Final Restoration)

Prosthodontics codes (sample)CPTCovered

D5110	Complete Denture - Maxillary
D5120	Complete Denture - Mandibular
D5130	Immediate Denture - Maxillary
D5140	Immediate Denture - Mandibular

D54xx denture adjustmentsCPTCovered

D5410	Adjust Complete Denture - Maxillary (listed with fee amounts)
D5411	Adjust Complete Denture - Mandibular (listed with fee amounts)

Oral surgery (extractions/impactions)CPTCovered

D7140	Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth
D7210	Removal of Impacted Tooth - Soft Tissue / surgical codes D7220-D7241 listed

Orthodontics - adult comprehensiveCPTCovered

D8080	Comprehensive Orthodontic Treatment of the Adult Dentition
D8090	Comprehensive Orthodontic Treatment of the Adult Dentition (alternate)

Comprehensive orthodontic treatment codesCPTCovered

D8080	Comprehensive Orthodontic Treatment of the Adolescent
D8090	Comprehensive Orthodontic Treatment of the Adult Dentition

Pain management and sedation codesCPTCovered

D8660	Development Palliative Treatment of Dental Pain - per visit
D9110	Palliative Treatment of Dental Pain - per visit
D9230	Inhalation of Nitrous Oxide/Analgesia, Anxiolysis
D9239	Inhalation of Nitrous Oxide/Analgesia, Anxiolysis (alternate)

Consultation, facility call, behavior, teledentistryCPTCovered

D9310	Consultation - Physician other than Requesting Dentist or Physician
D9420	Hospital/Ambulatory Surgical Center Call
D9920	Behavior Management
D9995	Teledentistry - synchronous; real-time encounter
D9996	Teledentistry - asynchronous; store and forward

N/A entries for CBCT codes (D0364–D0367)

CBCT codes with N/A entriesD0364–D0367 display 'N/A' for multiple provider types and regions (Oahu, Neighbor Islands, Neighbor ENDO/ORTHO in many cells)

Exception for Neighbor OSD0364 shows Neighbor OS listed with a fee of $139.60 while many other provider/region columns are N/A

PEDO and many specialtiesFor D0364–D0367 PEDO and several specialty columns are marked N/A in the schedule

Adult comprehensive orthodontic fee range

Adult comprehensive orthodontic fee range (summary)ORTHO.Oahu listed at $5,044.00; ORTHO.Neighbor Island range listed $5,352.46 - $5,415.09

Procedure codesD8080 and D8090 (Comprehensive Orthodontic Treatment of the Adult Dentition)

OS/PEDO columnsOS and PEDO columns for these codes are marked N/A

Columns, status markers, and entry format

Geographic / provider-type rate columns (definitions)

Geographic and provider-type rate columnsOahu / Neighbor Islands / Neighbor ENDO / Neighbor ORTHO / Neighbor OS / Neighbor PEDO

Examples of regional columns used on linesMany procedure lines show separate Oahu and Neighbor Islands columns and additional Neighbor specialty columns (e.g., Neighbor ENDO, Neighbor ORTHO)

Specialty-specific neighbor columnsNeighbor ENDO, Neighbor ORTHO, Neighbor OS, Neighbor PEDO appear across fee entries for specialty pricing differences

Provider-type column abbreviations

Column abbreviationsGP / ENDO / ORTHO / OS / PEDO

MeaningGP = General Practice; ENDO = Endodontics; ORTHO = Orthodontics; OS = Oral Surgery; PEDO = Pediatric Dentistry

Usage exampleFee entries show GP.Oahu, GP.Neighbor Islands and corresponding ENDO/ORTHO/OS/PEDO columns

Covered marker definition

Covered marker meaningCovered = x indicates the procedure is covered as shown throughout the schedule

Location in schedule'Covered = x' appears on fee lines (e.g., denture adjustment entries) to denote coverage status

Relationship to Provider ManualCoverage indicators in the schedule reference Medicaid Provider Manual Chapter 14 for specific coverage details

Procedure entry format

Procedure entry componentsEach procedure entry includes the procedure code, a description, and fee amounts by provider category or island (Oahu / Neighbor Islands and specialty columns)

Example formatLines show 'Procedure = D0120', 'Description = Periodic Oral Evaluation', followed by GP.Oahu, Neighbor Islands, ENDO, ORTHO, OS, PEDO fee columns

Coverage indicator inclusionMany procedure rows also include coverage markers (e.g., 'Covered = x') alongside fees

ORTHO.Oahu vs ORTHO.Neighbor Island reimbursement rates

ORTHO.Oahu rateORTHO.Oahu reimbursement for comprehensive adult orthodontics: $5,044.00

ORTHO.Neighbor Island rate rangeORTHO.Neighbor Island reimbursement for comprehensive adult orthodontics: $5,352.46 - $5,415.09

Specialty column differencesORTHO columns list orthodontic-specific rates distinct from GP/ENDO/OS/PEDO columns

Provider-type abbreviations used in the fee schedule

PEDOPediatric Dentistry

GPGeneral Practice

ENDOEndodontics

OSOral Surgery

Procedure entry format (reference)

Standard entry elementsProcedure code, description, then fee columns broken out by Oahu and Neighbor Islands and by provider type/specialty

Coverage markers and notesEntries may include 'Covered = x' or 'N/A' indicators in the fee cells

Specialty neighbor columnsNeighbor ENDO/ORTHO/OS/PEDO columns mirror the same code/description but provide alternative regional/specialty fees

What providers must do / where to confirm coverage

Documentation Required

Refer to Medicaid Provider Manual Chapter 14

Please see Medicaid Provider Manual Chapter 14 for specific coverage details.

Documentation Required

Refer to Medicaid Provider Manual Chapter 14

Please see Medicaid Provider Manual Chapter 14 for specific coverage details.

Documentation Required

Refer to Medicaid Provider Manual Chapter 14

Please see Medicaid Provider Manual Chapter 14 for specific coverage details.

Documentation Required

Refer to Medicaid Provider Manual Chapter 14

Please see Medicaid Provider Manual Chapter 14 for specific coverage details.

Documentation Required

Refer to Medicaid Provider Manual Chapter 14

Please see Medicaid Provider Manual Chapter 14 for specific 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 changes

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionPlease see Medicaid Provider Manual Chapter 14 for specific coverage details.

SourceLink

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Children and Adult Dental Fee Schedule — Med-QUEST Division

Customize your policy alerts

Sign up for all Hawaii Department of Human Services policy alerts

Know when Hawaii Department of Human Services releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage summary and applicability

inv-01: Coverage stance and referral

This fee schedule provides reimbursement rates; coverage specifics, limitations, and prior authorization requirements are governed by the Medicaid Provider Manual (Chapter 14).

This document lists reimbursement rates (fee schedule) for dental procedures effective 04/01/2026.

Coverage specifics, limitations, medical necessity criteria, and prior authorization requirements are defined in the Medicaid Provider Manual Chapter 14 and govern payment and coverage decisions.

inv-02: Coverage summary

Document provides fee amounts but defers coverage specifics to the Medicaid Provider Manual.

The schedule enumerates procedure codes, descriptions, coverage indicators (e.g., 'Covered = x'), and fee amounts by provider type and geography.

inv-03: Fee schedule coverage summary

Coverage indicators and fee amounts for listed procedures; consult Provider Manual Chapter 14 for detailed coverage criteria and limitations.

inv-04: Fee schedule coverage guidance

Coverage and billing are governed by the fee schedule values and additional details in the Medicaid Provider Manual Chapter 14.

Use the fee schedule values for billing and reimbursement calculations (examples include orthodontic fees and entries marked N/A where not applicable).

Representative procedure codes and rate entries

example diagnostic and evaluation codesCPTCovered

D0120	Periodic Oral Evaluation - Established Patient / Limited Oral Evaluation - Problem Focused
D0140	Limited Oral Evaluation - Problem Focused / Oral Evaluation for patient under 3 and counseling
D0150	Comprehensive Oral Evaluation - New or Established Patient
D0210	Intraoral - Complete Series
D0220	Intraoral - Periapical First Radiographic Image
D0230	Intraoral - Periapical Each Additional Radiographic Image

example restorative and prosthetic codesCPTCovered

D2330	Resin - One Surface, Anterior
D2391	Resin-based Composite - One Surface, Posterior
D2740	Crown - Porcelain/Ceramic
D2750	Crown - Porcelain Fused to High Noble Metal

Restorative / Crown codes (sample)CPTCovered

D2394	Resin-based Composite - Four or More Surfaces, Posterior
D2740	Crown - Porcelain/Ceramic
D2750	Crown - Porcelain Fused to High Noble Metal
D2751	Crown - Porcelain Fused to Predominantly Base Metal

Endodontic codes (sample)CPTCovered

D3310	Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)
D3320	Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration)
D3330	Endodontic Therapy, Molar Tooth (Excluding Final Restoration)

Prosthodontics codes (sample)CPTCovered

D5110	Complete Denture - Maxillary
D5120	Complete Denture - Mandibular
D5130	Immediate Denture - Maxillary
D5140	Immediate Denture - Mandibular

D54xx denture adjustmentsCPTCovered

D5410	Adjust Complete Denture - Maxillary (listed with fee amounts)
D5411	Adjust Complete Denture - Mandibular (listed with fee amounts)

Oral surgery (extractions/impactions)CPTCovered

D7140	Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth
D7210	Removal of Impacted Tooth - Soft Tissue / surgical codes D7220-D7241 listed

Orthodontics - adult comprehensiveCPTCovered

D8080	Comprehensive Orthodontic Treatment of the Adult Dentition
D8090	Comprehensive Orthodontic Treatment of the Adult Dentition (alternate)

Comprehensive orthodontic treatment codesCPTCovered

D8080	Comprehensive Orthodontic Treatment of the Adolescent
D8090	Comprehensive Orthodontic Treatment of the Adult Dentition

Pain management and sedation codesCPTCovered

D8660	Development Palliative Treatment of Dental Pain - per visit
D9110	Palliative Treatment of Dental Pain - per visit
D9230	Inhalation of Nitrous Oxide/Analgesia, Anxiolysis
D9239	Inhalation of Nitrous Oxide/Analgesia, Anxiolysis (alternate)

Consultation, facility call, behavior, teledentistryCPTCovered

D9310	Consultation - Physician other than Requesting Dentist or Physician
D9420	Hospital/Ambulatory Surgical Center Call
D9920	Behavior Management
D9995	Teledentistry - synchronous; real-time encounter
D9996	Teledentistry - asynchronous; store and forward

N/A entries for CBCT codes (D0364–D0367)

CBCT codes with N/A entriesD0364–D0367 display 'N/A' for multiple provider types and regions (Oahu, Neighbor Islands, Neighbor ENDO/ORTHO in many cells)

Exception for Neighbor OSD0364 shows Neighbor OS listed with a fee of $139.60 while many other provider/region columns are N/A

PEDO and many specialtiesFor D0364–D0367 PEDO and several specialty columns are marked N/A in the schedule

Adult comprehensive orthodontic fee range

Adult comprehensive orthodontic fee range (summary)ORTHO.Oahu listed at $5,044.00; ORTHO.Neighbor Island range listed $5,352.46 - $5,415.09

Procedure codesD8080 and D8090 (Comprehensive Orthodontic Treatment of the Adult Dentition)

OS/PEDO columnsOS and PEDO columns for these codes are marked N/A

Columns, status markers, and entry format

Geographic / provider-type rate columns (definitions)

Geographic and provider-type rate columnsOahu / Neighbor Islands / Neighbor ENDO / Neighbor ORTHO / Neighbor OS / Neighbor PEDO

Examples of regional columns used on linesMany procedure lines show separate Oahu and Neighbor Islands columns and additional Neighbor specialty columns (e.g., Neighbor ENDO, Neighbor ORTHO)

Specialty-specific neighbor columnsNeighbor ENDO, Neighbor ORTHO, Neighbor OS, Neighbor PEDO appear across fee entries for specialty pricing differences

Provider-type column abbreviations

Column abbreviationsGP / ENDO / ORTHO / OS / PEDO

MeaningGP = General Practice; ENDO = Endodontics; ORTHO = Orthodontics; OS = Oral Surgery; PEDO = Pediatric Dentistry

Usage exampleFee entries show GP.Oahu, GP.Neighbor Islands and corresponding ENDO/ORTHO/OS/PEDO columns

Covered marker definition

Covered marker meaningCovered = x indicates the procedure is covered as shown throughout the schedule

Location in schedule'Covered = x' appears on fee lines (e.g., denture adjustment entries) to denote coverage status

Relationship to Provider ManualCoverage indicators in the schedule reference Medicaid Provider Manual Chapter 14 for specific coverage details

Procedure entry format

Procedure entry componentsEach procedure entry includes the procedure code, a description, and fee amounts by provider category or island (Oahu / Neighbor Islands and specialty columns)

Example formatLines show 'Procedure = D0120', 'Description = Periodic Oral Evaluation', followed by GP.Oahu, Neighbor Islands, ENDO, ORTHO, OS, PEDO fee columns

Coverage indicator inclusionMany procedure rows also include coverage markers (e.g., 'Covered = x') alongside fees

ORTHO.Oahu vs ORTHO.Neighbor Island reimbursement rates

ORTHO.Oahu rateORTHO.Oahu reimbursement for comprehensive adult orthodontics: $5,044.00

ORTHO.Neighbor Island rate rangeORTHO.Neighbor Island reimbursement for comprehensive adult orthodontics: $5,352.46 - $5,415.09

Specialty column differencesORTHO columns list orthodontic-specific rates distinct from GP/ENDO/OS/PEDO columns

Provider-type abbreviations used in the fee schedule

PEDOPediatric Dentistry

GPGeneral Practice

ENDOEndodontics

OSOral Surgery

Procedure entry format (reference)

Standard entry elementsProcedure code, description, then fee columns broken out by Oahu and Neighbor Islands and by provider type/specialty

Coverage markers and notesEntries may include 'Covered = x' or 'N/A' indicators in the fee cells

Specialty neighbor columnsNeighbor ENDO/ORTHO/OS/PEDO columns mirror the same code/description but provide alternative regional/specialty fees

What providers must do / where to confirm coverage

Documentation Required

Refer to Medicaid Provider Manual Chapter 14

Please see Medicaid Provider Manual Chapter 14 for specific coverage details.

Documentation Required

Refer to Medicaid Provider Manual Chapter 14

Please see Medicaid Provider Manual Chapter 14 for specific coverage details.

Documentation Required

Refer to Medicaid Provider Manual Chapter 14

Please see Medicaid Provider Manual Chapter 14 for specific coverage details.

Documentation Required

Refer to Medicaid Provider Manual Chapter 14

Please see Medicaid Provider Manual Chapter 14 for specific coverage details.

Documentation Required

Refer to Medicaid Provider Manual Chapter 14

Please see Medicaid Provider Manual Chapter 14 for specific coverage details.