HFS Dental Program Fee Schedule — CDT codes, maximum allowances, and prior approval indicators (effective July 1, 2026)
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Fee schedule listing dental procedure codes, descriptions, maximum allowances, and prior approval requirements for child, adult, and pregnant beneficiaries under the Illinois HFS Dental Program (effective July 1, 2026). Applies to billing and reimbursement for covered dental services.
No material clinical or coverage changes in this revision.
Coverage rules and per-code conditions
Coverage criteria by code
Coverage and billing rules extracted from the fee schedule (partial document):
ALL of the following
- Children (age 0–20): Maximum Allowance $29.40; Prior Approval Required = N
- Adults (21+): Maximum Allowance $28.00; Prior Approval Required = N
- Pregnant women: Maximum Allowance $28.00; Prior Approval Required = N
ALL of the following
- D1120 (Child): Maximum Allowance $43.05; Prior Approval Required = N
- D1110 (Adult / Pregnant): Maximum Allowance $48.38; Prior Approval Required = N
ALL of the following
- Children, Adults, Pregnant Women: Maximum Allowance $0.00; Prior Approval Required = N
ALL of the following
- Onlays (D2542–D2644): Maximum Allowance $235.20 across beneficiary groups; Prior Approval Required = Y
- Crowns (e.g., D2740, D2750): Maximum Allowance $272.83 across beneficiary groups; Prior Approval Required = Y
Fee schedule coverage rules (excerpt)
Selected CDT codes and their coverage attributes from the HFS dental fee schedule in this document portion:
ALL of the following
- Maximum Allowance (Children/Adults/Pregnant) = $444.09
- Prior Approval Required = Y
ALL of the following
- Maximum Allowance — Children = $155.25; Adults = $158.22 (as listed)
- Prior Approval Required — Children = N (per schedule entries)
ALL of the following
- Maximum Allowance = $122.00
- Prior Approval Required = Y (children entry shown)
ALL of the following
- Maximum Allowance = By Report (children/adults/pregnant)
- Prior Approval Required = Y
Per-procedure criteria (examples)
Per-code payment and authorization rules (sample from section):
ALL of the following
- Population: Children / Adults / Pregnant Women
- Maximum Allowance: By Report
- Prior Approval Required = Y
ALL of the following
- Population: Children: Maximum Allowance = $178.80
- Prior Approval Required = Y
ALL of the following
- Population: Children / Adults / Pregnant Women: Maximum Allowance = $53.55
- Prior Approval Required = N for Children and Adults (per schedule)
covered_with_criteria (partial)
Coverage status and constraints by code (partial list):
ALL of the following
- Children / Adults / Pregnant Women: Maximum Allowance = $74.24
- Prior Approval Required = Y
ALL of the following
- Children / Adults / Pregnant Women: Maximum Allowance = $231.54
- Prior Approval Required = Y
ALL of the following
- Children / Adults / Pregnant Women: Maximum Allowance = $824.65
- Prior Approval Required = Y
ALL of the following
- Children: Maximum Allowance = $900.00; Prior Approval Required = Y
- Adults / Pregnant: Maximum Allowance = N/A; Prior Approval = N/A (per extract)
ALL of the following
- Children / Adults / Pregnant Women: Maximum Allowance — D9995 $13.19; D9996 $9.24
- Prior Approval Required = N
CDT codes, descriptions, and maximum allowances
| D0120 | Periodic Oral Exam - Ages 0 thru 20 / Ages 21 and older and Pregnant Women (separate entries with beneficiary-specific maximum allowances and prior approval flags) |
| D0210 | Intraoral-Complete Series (including bitewings) |
| D1120 | Prophylaxis - Child |
| D1110 | Prophylaxis - Adult/pregnant |
| D2542-D2644 | Onlays (metallic and porcelain/ceramic) — uniform maximum allowance shown and flagged Y for prior approval |
| D2740-D2792 | Crowns of various materials — maximum allowances (e.g., $272.83 for many crown codes) and prior approval flags |
| D3220 | Partial pulpotomy (entries for pulpal therapy / prior approval entries present) |
| D3222 | Partial pulpotomy (listed with children allowance $61.13 and prior approval flags) |
| D3320 | Bicuspid Root Canal (Excluding Final Restoration) — Maximum Allowance Children = $155.25; Adults = $158.22 |
| D3330 | Molar Root Canal (Excluding Final Restoration) — Maximum Allowance Children = $234.67 |
| D4260 | Osseous Surgery - 4+ Teeth, Per Quadrant — Maximum Allowance Children = $277.60; Prior Approval Required Children = Y |
| D4261 | Osseous Surgery - 1 to 3 Teeth, Per Quadrant — Maximum Allowance Children = $138.80; Prior Approval Required Children = Y |
| D4341 | Periodontal Scaling and Root Planing - 4+ Teeth, Per Quadrant — Maximum Allowance Children = $122.00; Prior Approval Required Children = Y |
| D5110 | Complete Denture - Maxillary — Maximum Allowance Children = $444.09; Prior Approval Required Children = Y |
| D5120 | Complete Denture - Mandibular — Maximum Allowance Children = $444.09; Prior Approval Required Children = Y |
| D5211 | Maxillary Partial Denture -- Resin Base — Maximum Allowance Children = $376.35; Prior Approval Required Children = Y |
| D5911 | Facial Moulage - sectional — Maximum Allowance = By Report; Prior Approval Required = Y |
| D5912 | Facial Moulage - complete — Maximum Allowance = By Report; Prior Approval Required = Y |
| D5913 | Nasal Prosthesis — Maximum Allowance = By Report; Prior Approval Required = Y |
| D5761 | Facial moulage - sectional; shows prior approval required and adult allowance $117.60 |
| D6210 | Pontic crown - metal high noble — Maximum Allowance Children = $178.80; Prior Approval Required Children = Y |
| D6251 | Pontic - Resin/Base Metal — Maximum Allowance Children = $103.50; Prior Approval Required Children = Y |
| D7140 | Extraction - Erupted Tooth or Exposed Root — Maximum Allowance Children = $53.55; Prior Approval Required Children = N |
| D7210 | Surgical Removal of Erupted Tooth — Maximum Allowance Children = $78.57; Prior Approval Required Children = N |
| D7240 | Removal of Impacted Tooth -- Completely Bony — Maximum Allowance Children = $116.81; Prior Approval Required Children = Y |
| D7310 | Alveoloplasty in Conjunction with Extractions -- per quadrant |
| D7450 | Removal of Odontogenic Cyst or Tumor up to 1.25cm |
| D7630 | Mandible-Open Reduction, Teeth Immobilized |
| D8080 | Initial Orthodontic Appliance Placement |
| D9110 | Palliative (emergency) Treatment of Dental Pain - Minor Procedures |
| D9222 | Deep Sedation / General Anesthesia - first 15 minute increment |
| D9230 | Inhalation of nitrous oxide/anxiolysis, analgesia |
| D9243 | Intravenous Moderate (conscious) Sedation / Analgesia - Each 15 minute increment |
| D9995 | Teledentistry, Synchronous, Real-Time Encounter |
| D9996 | Teledentistry, Asynchronous, Info Stored & Forward To Dentist |
Prior authorization and billing actions required of providers
Obtain prior authorization for specified onlay and crown codes
Prior authorization is required for multiple restorative and prosthetic CDT codes listed on the fee schedule. Examples flagged Y for children, adults, and pregnant women include onlay codes D2542–D2644 and crown codes D2740–D2792; providers must obtain prior approval before billing these services when the schedule indicates Prior Approval Required = Y.
- Onlays: D2542–D2644 — Prior Approval Required = Y for Children, Adults, Pregnant Women (see D2542–D2644 entries).
- Crowns: D2740–D2753, D2790 etc. — Prior Approval Required = Y for Children, Adults, Pregnant Women (see crown entries).
Check per-line prior approval indicators on the fee schedule
The fee schedule includes Prior Approval Required (Y/N) indicators on each procedure line for beneficiary categories; providers must check the schedule line for the prior approval flag applicable to children, adults, and pregnant women before providing or billing a service.
- Prior Approval.Required appears per-code and per-beneficiary group (Children, Adults, Pregnant Women).
- Example: D3320 shows Prior Approval.Required Children = N; D3352 shows Prior Approval.Required Children = Y.
Submit report and obtain prior approval for 'By Report' prosthetics
Several prosthetic and maxillofacial procedure lines show Maximum Allowance = 'By Report' and are flagged Y for prior approval; when a 'By Report' allowance appears (for example D5911–D5919 and D6999), providers must submit the required report and secure prior approval per the schedule.
- Facial prosthetics (D5911–D5919): Maximum Allowance = By Report and Prior Approval.Required = Y.
- Unspecified fixed prosthodontic procedure D6999: Maximum Allowance = By Report and Prior Approval.Required = Y.
Obtain prior approval where code line indicates 'Y'
Many individual CDT codes in the schedule are explicitly marked Prior Approval Required = Y for one or more beneficiary groups; providers must obtain prior authorization for those listed services prior to billing.
- Examples of codes with Prior Approval.Required = Y include D5110 (complete denture), D7310 (alveoloplasty), and D9222 (deep sedation/general anesthesia).
- Review each code line for the Y/N prior approval flag for the relevant beneficiary group before performing the procedure.
No prior approval required for some extraction/surgery codes when flagged 'N'
Some extraction and oral surgery codes are marked Prior Approval Required = N for certain populations; providers may proceed without prior authorization for those codes when the schedule shows N.
- D7140 (Extraction - Erupted Tooth or Exposed Root): Prior Approval Required Children = N (also N for Adults and Pregnant Women).
- D7210 (Surgical removal) entries in the schedule show specific prior approval flags—confirm the per-line value before billing.
Follow the procedure-specific prior approval indicator (Y/N)
Across the schedule, prior approval indicators (Y/N) are specified per procedure and beneficiary category; providers must use those indicators to determine if preauthorization is required for the procedure code being billed.
- Codes such as D7310 and D7311 show Prior Approval Required = Y for Children, Adults, Pregnant Women.
- Codes such as D3320 and D3330 show Prior Approval Required = N for Children in the listed entries.
No prior approval required for teledentistry (D9995/D9996)
Teledentistry codes are reimbursed and do not require prior approval; providers may bill D9995 (synchronous) and D9996 (asynchronous) without obtaining prior authorization when the schedule shows Prior Approval Required = N.
- D9995: Maximum Allowance Adults = $13.19; Prior Approval Required Adults = N (same for Children and Pregnant Women).
- D9996: Maximum Allowance Children/Adults/Pregnant Women = $9.24; Prior Approval Required = N.
Key terms and schedule field definitions
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