CurrentPennsylvania Insurance DepartmentPolicy N/A

Medical Assistance Program Dental Fee Schedule (Dental services and rates)

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This document lists Pennsylvania Medical Assistance dental procedure codes (D and select CPT codes), provider types/places of service, fees, prior authorization flags, limits, and reporting requirements effective August 1, 2025; it affects providers billing Pennsylvania Medical Assistance for dental services.

Policy Summary

PayerPennsylvania Insurance Department

PolicyMedical Assistance Program Dental Fee Schedule (Dental services and rates)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionUse the listed MA Fee and frequency limits when billing Pennsylvania Medical Assistance for dental services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiple hundred+procedure entries listed

variedfrequency/limit rules

fees shownMA Fee amounts provided

presentprior authorization flags

$2,410highest listed fee (excerpt)

Coverage and Service-specific Limits

inv-01: Coverage with service-specific limits

Coverage entries list whether services are covered and applicable limits; many codes show 'No' under prior authorization and include explicit frequency limits.

D0120 — Periodic oral evaluation (established patient): Limits: 1 per 180 days.

D0140 — Limited oral evaluation (problem focused): Limits: 1 per day (must be initiated by patient).

D0210 — Intraoral comprehensive radiographic series: Limits: 1 per 5 years.

D0340 — Panoramic radiographic image: Limits: 1 per 3 years (under 21) or 1 per 5 years general.

D1110/D1120 — Prophylaxis (adult/child): typical limits: 1 per 180 days (age-specific rules apply).

D1206 — Topical fluoride varnish: Limits: 6 per 365 days (under 21).

D1351 — Sealant (per tooth): Limits: up to 4 per 365 days (under 21) with specified tooth rules.

D2150 (amalgam) and similar restorative codes: Limits: 1 per 180 days; document shows T-flag indicators where applicable.

Prior Authorization: a Prior Authorization column is present for procedure entries; many entries are 'No' or blank (no routine prior authorization).

inv-02: Example coverage node (endodontics)

Coverage stance and limits for listed CDT codes in this excerpt:

D3310 — Endodontic therapy, anterior/premolar: Fee listed ($275.00); Prior Authorization flag: Yes in excerpt; Frequency: 1 per lifetime (under 21 years of age).

D3320 — Endodontic therapy, premolar: Fee listed ($375.00); Prior Authorization flag: Yes; Frequency: 1 per lifetime (under 21).

D3330 — Endodontic therapy, molar: Fee listed ($500.00); Prior Authorization: (entry indicates 'No' in part of the table but shows endodontics with explicit prior auth flags in this section); Frequency: 1 per lifetime (under 21).

inv-03: Denture coverage node

Denture services coverage examples:

D5110 — Complete denture, maxillary: Covered; Fee: $525.00; Prior Authorization: Yes; Frequency: 1 per lifetime.

D5120 — Complete denture, mandibular: Covered; Fee: $525.00; Prior Authorization: Yes; Frequency: 1 per lifetime.

D5130/D5140 — Immediate dentures (maxillary/mandibular): Covered; Fee: $525.00 each; Prior Authorization: Yes; Frequency: 1 per lifetime.

Adjustments/Repairs (e.g., D5410, D5411, D5421): Adjustment fee examples $20.00; Limits: up to 4 per 365 days starting 180 days after insertion (per rules shown); some adjustment codes specify 'starting 180 days after insertion'.

inv-04: Per-code coverage entries (selected examples)

Per-code coverage details (examples from this section):

D9947 — Custom sleep apnea appliance fabrication and placement: Covered; Fee: $2,410.00; Prior Authorization: Yes; Frequency: 1 per lifetime.

D9230 — Inhalation of nitrous oxide/analgesia, anxiolysis: Covered; Fee: $44.00; Prior Authorization: No; Frequency: 1 per day (under 21 as specified).

D9222 — Deep sedation/general anesthesia — first 15 minutes: Covered; Fee: $122.00; Prior Authorization: No; Frequency: typically 1 per day.

21076 — Mileage (additional allowance for home, SNF and ICF visits): Covered; Rate: $0.10 per mile; Maximum: 300 miles per day; Frequency: 1 appliance per day (applies to appliance-related visits as listed).

Procedure Codes, Fees and Frequency Rules

Endodontics (selected)CPTCovered

D3310	Endodontic therapy, anterior/premolar (excl final restoration) — fee listed
D3320	Endodontic therapy, premolar/molar (excl final restoration) — fee listed
D3330	Endodontic therapy, molar (excl final restoration) — fee listed

Periodontics (selected)CPTCovered

D4341	Periodontal scaling and root planing - four or more teeth per quadrant
D4342	Periodontal scaling and root planing - one to three teeth per quadrant
D4346	Scaling in presence of generalized moderate or severe gingival inflammation - full mouth

Complete/Immediate DenturesCPTCovered

D5110	Complete denture - maxillary
D5120	Complete denture - mandibular
D5130	Immediate denture - maxillary
D5140	Immediate denture - mandibular

Partial DenturesCPTCovered

D5211	Maxillary partial denture - resin base
D5212	Mandibular partial denture - resin base
D5213	Maxillary partial denture - cast metal framework

Relines/RepairsCPTCovered

D5731	Reline complete maxillary denture (direct)
D5750	Reline complete maxillary denture (indirect)
D6930	Re-cement or re-bond fixed partial denture

sample codes in this sectionCPTCovered

D7260	Removal of residual tooth roots (cutting procedure)
D7270	Tooth re-implantation and/or stabilization
D7280	Exposure of an unerupted tooth
D7450	Removal of benign odontogenic cyst or tumor - lesion ≤1.25 cm
D7451	Removal of benign odontogenic cyst or tumor - lesion >1.25 cm
D7472	Removal of torus palatinus
D7510	Incision and drainage of abscess - intraoral soft tissue - complicated
D7961	Buccal/labial Frenectomy
D8080	Orthodontic related code (adolescent dentition)
D8660	Pre-orthodontic treatment examination

1–10 of 13

1/2

Common service limits

Typical short-term visit limits1 per day for select diagnostics and radiographs (e.g., D0140, D0220; some radiographs have per-day caps like D0230 = 10 per day)

Routine prophylaxis and restorative intervals1 per 180 days for prophylaxis and many restorations (example: D0120, D1110, D2150)

Annual screening and imaging limits1 per 365 days for screening (D0190); 1 per 5 years for comprehensive intraoral series (D0210) or as specified for some radiographs (D0340 exceptions for <21)

Multi-per-day caps for radiographic imagingCertain imaging codes list per-day maximums (e.g., D0230 = 10 per day; D0373 = 4 per day; D0374 = 11 per day)

Periodontal scaling frequency

D4341 / D4342 frequency1 per 2 years (D4341: maximum of 2 quadrants per day; D4342: maximum of 4 quadrants per day)

D4346 frequency1 per 180 days

Periodontal maintenance (D4910)1 per 90 days

Denture frequency

Complete and immediate dentures (D5110–D5140)1 per lifetime; MA Fee listed $525.00 per denture

Partial dentures (e.g., D5211)Typically 1 per lifetime for partial denture entries (fee examples shown, e.g., D5211 = $375.00)

Denture adjustments/relinesAdjustments allowed starting 180 days after insertion; example: 4 per 365 days starting 180 days after insertion for some adjustment codes

D9947 frequency limit

D9947 frequency1 per lifetime

D9947 coverage indicatorYes (coverage indicated)

D9947 MA Fee$2,410.00

Anesthesia/sedation frequency limits

First-unit per-day limit for deep sedation/general anesthesia (D9222) and inhalation (D9230)D9222: 1 per day (first 15 minutes); D9230: 1 per day (under 21) — first unit per day is limited

Subsequent increments per dayD9223, D9243 list additional increments allowed (e.g., D9223 = 2 per day; D9243 = 2 per day)

Per-day caps across anesthesia codesMany anesthesia/sedation codes specify 1 per day for first unit with limited additional increments for subsequent units

Mileage maximum

Mileage rate$0.10 per mile for additional allowance to home, skilled nursing facility, and ICF visits

Daily mileage cap300 miles per day

Applies to specific appliance and prosthesis visitsListed for codes 21076–21088; shows same $0.10 rate and 300 miles/day rule

Prior Authorization, Billing and Documentation Requirements

Prior Authorization

Check prior authorization flag on each procedure

The fee schedule includes a Prior Authorization column for procedure entries; most listed procedures show either "No" or a blank entry under prior authorization. Providers should check the prior authorization indicator on each code line before billing and obtain prior authorization when the column shows "Yes."

Verify the Prior Authorization column on each code line prior to submitting claims.
Obtain prior authorization when a code’s prior authorization flag is "Yes"; many codes explicitly show "No" or blank.

Documentation Required

Adhere to periodontal frequency and documentation requirements

Periodontal service entries include explicit frequency and procedural requirements: D4341/D4342 are limited to 1 per 2 years with quadrant limits; D4346 is limited to 1 per 180 days; D4355 requires a post‑operative review and is limited to 1 per 365 days. Providers must follow these frequency limits and the per‑day quadrant maximums when billing periodontal procedures.

D4341: 1 per 2 years — maximum of 2 quadrants per day; flagged Yes.
D4342: 1 per 2 years — maximum of 4 quadrants per day; flagged Yes.
D4346: 1 per 180 days; flagged No.
D4355: requires post‑operative review; 1 per 365 days.

Billing Rule

Follow denture lifetime limits and adjustment timing

Denture codes carry lifetime limits and adjustment timing rules: complete and immediate dentures (D5110–D5140 and many partial denture codes) are limited to 1 per lifetime; denture adjustments and relines are limited to specified counts starting 180 days after insertion.

D5110–D5140: 1 per lifetime; flagged Yes; fee shown $525.00.
Partial denture codes (e.g., D5211): commonly 1 per lifetime.
Adjustment codes (e.g., D5410/D5411 and other adjust/relines): up to 4 per 365 days starting 180 days after insertion; typical adjustment fee $20.00.

Billing Rule

Bill custom sleep apnea appliance and follow lifetime/adjustment limits

Custom sleep apnea appliance D9947 is covered, shows a reimbursement of $2,410.00, and is limited to 1 per lifetime; related adjustment and repair codes have separate lifetime limits and timing rules.

D9947: $2,410.00; Coverage flag Yes; frequency 1 per lifetime.
D9948 (adjustment): $50.00; 2 per lifetime starting 180 days after insertion.
D9949 (repair) and D9953 (reline): 2 per lifetime starting 180 days after insertion; fees shown ($100.00 for repair, $100.00 for reline).

Billing Rule

Use correct anesthesia/sedation codes and observe per‑day limits

Anesthesia and sedation codes specify provider/place restrictions, reimbursement amounts, and per‑day frequency caps; billers must use the correct anesthesia codes and observe the per‑day unit limits.

D9222 (deep sedation/general anesthesia — first 15 min): $122.00; 1 per day.
D9223 (each subsequent 15‑min increment): $122.00; 2 per day.
D9230 (nitrous oxide): $44.00; 1 per day (under 21).
D9239/D9243 (IV moderate sedation first/subsequent increments): $128.50; first unit 1 per day, subsequent up to 2 per day as indicated.
D9248 (non‑IV conscious sedation): $184.00; 1 per day.

Key Terms and Fee-related Definitions

MA Fee (Medical Assistance fee)

MA Fee definitionMA Fee = the Medical Assistance reimbursement amount shown for each procedure (specific fee listed in the MA Fee column for each code)

Examples of MA FeesD0340: $19.50 (example shown in radiographs); D2150: $55.00; D5110: $525.00; D9947: $2,410.00

Fees shown per code lineEach procedure row includes an MA Fee value where applicable (many codes include an explicit dollar amount)

Service frequency limits

Per-day limitsMultiple diagnostic and procedure codes limit services to 1 per day (examples: D0140, D0220, many anesthesia codes) or list specific per-day maxima for imaging (e.g., D0230 = 10 per day)

Short-interval limits (days/months)Examples include 1 per 90 days (D4910), 1 per 180 days (prophylaxis/restoratives), and 1 per 365 days (D0190 or annual services)

Multi-year and lifetime limitsSome services limited to 1 per 5 years (D0210/D0340 in some cases) or 1 per lifetime (many denture codes, D5110–D5140, and D9947)

Quarter-based frequency flag

Quarter-based flag 'Q'Q flag used on periodontal scaling entries (e.g., D4341 and D4342 list Q indicating quarter-based tracking alongside 1 per 2 years limits)

Usage contextFlag appears in the periodontal code rows to indicate quarter-based frequency/reference in the limits column

Treatment or billing flag shown in multiple code lines

'T' treatment/billing flagT appears in multiple restorative and procedure code lines (example: T shown on D2150 and other restorative entries) indicating a document-specific treatment/billing flag

Flag appears across categoriesT is present in restorative entries and may appear where treatment-type annotations are required

Document-specific usageThe flag is shown repeatedly across code rows in this fee schedule and should be interpreted per the schedule's legend/context

Mileage - additional allowance for home, skilled nursing facility and ICF visits

Mileage rate for home/SNF/ICF visits$0.10 per mile (applies to codes 21076, 21079–21088 and others)

Per-day mileage maximum300 miles per day stated for these mileage allowance codes

Applies to appliance/prosthesis servicesMileage entries accompany appliance/prosthesis procedure lines (e.g., impressions, custom preparation) for home, skilled nursing, and ICF visits

1 per lifetime (example: D9947 custom sleep apnea appliance)

Example 1-per-lifetime codeD9947 (Custom sleep apnea appliance) = 1 per lifetime

Related lifetime limitsMany denture and custom appliance codes in the schedule also carry 1 per lifetime limits (see D5110–D5140 and partial denture entries)

Adjustment/repair exceptionsSome related appliance adjustment and repair codes allow limited per-lifetime or per-post-insertion allowances (e.g., D9948/D9949 = 2 per lifetime starting 180 days after insertion)

Policy Summary

PayerPennsylvania Insurance Department

PolicyMedical Assistance Program Dental Fee Schedule (Dental services and rates)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionUse the listed MA Fee and frequency limits when billing Pennsylvania Medical Assistance for dental services.

SourceLink

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