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Ryan White Part B Allowable Services (2025-2026) Fee Schedule: Oral Health Services

*No preauth or treatment plan needed. The Ryan White Part B rate for 2025-2026 is based on the 2025 Medicaid fee schedule rate x 40%. The $3500 cap is calculated on the Ryan White Part B grant year that begins on April 1 and ends on March 31.

Service Code - 27.10 Office Visits

ADA Code Description Medicaid Rate Ryan White Rate Notes
*D0120 PERIODIC ORAL EXAM $33.56 $46.98  
*D0140 LIMITED ORAL EVALUATION - PROBLEM FOCUSED $43.15 $60.41  
*D0150 COMPREHENSIVE ORAL EVALUATION $50.35 $70.49  
*D0160 DETAILED AND EXTENSIVE SPECIALIST EVALUATION Not covered $98.35  
*D0180 COMPREHENSIVE PERIODONTAL EVALUATION $50.35 $70.49  
*D9995 TELEDENTISTRY- SYNCHRONOUS; REAL-TIME ENCOUNTER Not covered $31.61  
*D9996 TELEDENTISTRY- ASYNCHRONOUS; INFO STORED AND FORWARDED TO DENTIST FOR SUBSEQUENT REVIEW Not covered $31.61  

Service Code - 27.20 Dental Cleaning

ADA Code Description Medicaid Rate Ryan White Rate Notes
*D1110 ADULT PROPHYLAXIS $65.22 $91.31  

Service Code - 27.60 Dental X-rays

ADA Code Description Medicaid Rate Ryan White Rate Notes
*D0210 INTRAORAL - COMPLETE SERIES (INCLUDING BITE WINGS) $117.90 $165.06  
*D0220 INTRAORAL- PERIAPICAL SINGLE, FIRST FILM $9.83 $13.76  
*D0230 INTRAORAL- PERIAPICAL EACH ADDITIONAL FILM $9.83 $13.76  
*D0240 INTRAORAL-OCCLUSAL $22.93 $32.10  
*D0250 EXTRAORAL FIRST FIRM $14.81 $20.73  
*D0270 BITEWING, SINGLE FILM $5.50 $7.70  
*D0272 BITEWINGS, TWO FILMS $19.65 $27.51  
*D0273 BITEWINGS, THREE FILMS $28.09 $39.33  
*D0274 BITEWINGS, FOUR FILMS $39.30 $55.02  
*D0330 PANORAMIC- MAXILLA AND MANDIBLE FILM $88.52 $123.93  

Service Code - 27.35 Restorative

ADA Code Description Medicaid Rate Ryan White Rate Notes
D1354 INTERIM CARIES ARRESTING MED APPLICATION $29.48 $41.27 Preauth and Tx plan.
D2140 AMALGAM- ONE SURFACE, PRIMARY OR PERMANENT $78.60 $110.04 Preauth and Tx plan.
D2150 AMALGAM- TWO SURFACES, PRIMARY OR PERMANENT $103.19 $144.47 Preauth and Tx plan.
D2160 AMALGAM- THREE SURFACES, PRIMARY OR PERMANENT $124.22 $173.91 Preauth and Tx plan.
D2161 AMALGAM, FOUR OR MORE SURFACES, PRIMARY OR PERMANENT $146.27 $204.78 Preauth and Tx plan.
D2330 COMPOSITE RESIN- ONE SURFACE, ANTERIOR $97.86 $137.00 Preauth and Tx plan.
D2331 RESIN RESTORATION, TWO SURFACE, ANTERIOR $121.33 $169.86 Preauth and Tx plan.
D2332 RESIN RESTORATION, THREE SURFACES, ANTERIOR $146.42 $204.99 Preauth and Tx plan.
D2335 COMP RESIN 4 OR MORE SURFACES INVOLVING INCISAL ANGLE (ANTERIOR) $181.45 $254.03 Preauth and Tx plan.
D2390 ANT RESIN-BASED CMPST CROWN $181.45 $254.03 Preauth and Tx plan.
D2391 RESIN RESTORATION - ONE SURFACE POSTERIOR $97.86 $137.00 Preauth and Tx plan.
D2392 RESIN RESTORATION - TWO SURFACES POSTERIOR $103.19 $144.47 Preauth and Tx plan.
D2393 RESIN RESTORATION - THREE SURFACES POSTERIOR $124.22 $173.91 Preauth and Tx plan.
D2394 RESIN RESTORATION – FOUR OR MORE SURFACE POSTERIOR $146.27 $204.78 Preauth and Tx plan.
D2740 CROWN PORCELAIN/CERAMIC SUBSTRATE $816.55 $1,143.17 Preauth and Tx plan; Medicaid covered service for anterior teeth only.
D2750 CROWN PORCELAIN FUSED TO HIGH NOBLE METAL Not covered $658.03 Preauth and Tx plan.
D2751 CROWN PORCELAIN FUSED W/ NOBLE METAL $470.02 $658.03 Preauth and Tx plan; Medicaid covered service for anterior teeth only.
D2752 CROWN PORCELAIN W/ NOBLE METAL $470.02 $658.03 Preauth and Tx plan; Medicaid covered service for anterior teeth only.
D2920 DENTAL RECEMENT CROWN $49.50 $69.30 Preauth and Tx plan.
D2928 PREFAB PORCELAIN/CERAMIC CROWN, ANTERIOR $194.77 $272.68 Preauth and Tx plan.
D2929 PREFAB PORCELAIN/CERAMIC, POSTERIOR $194.77 $272.68 Preauth and Tx plan.
D2930 PREFAB STNLSS STEEL CROWN PRIMARY $200.27 $280.38 Preauth and Tx plan.
D2931 PREFAB STAINLESS STEEL CROWN-PERM. TOOTH $222.65 $311.71 Preauth and Tx plan.
D2933 PREFAB STAINLESS STEEL CROWN $292.38 $409.33 Preauth and Tx plan.
D2934 PREFAB STEEL CROWN PRIMARY $300.65 $420.91 Preauth and Tx plan.
D2940 PROTECTIVE RESTORATION $34.40 $48.16 Preauth and Tx plan.
D2950 CORE BUILDUP $146.27 $204.78 Preauth and Tx plan.
D2951 TOOTH PIN RETENTION $31.51 $44.11 Preauth and Tx plan.
D2952 POST AND CORE CAST + CROWN $260.51 $364.71 Preauth and Tx plan.
D2954 PREFAB POST/CORE + CROWN $260.51 $364.71 Preauth and Tx plan.

Service Code - 27.45 Endodontic Services

ADA Code Description Medicaid Rate Ryan White Rate Notes
D3220 THERAPEUTIC PULPOTOMY $121.81 $170.53 Preauth and Tx plan.
D3310 ROOT CANAL THERAPY, ANTERIOR TOOTH $473.22 $662.51 Preauth and Tx plan.
D3320 ROOT CANAL THERAPY, BICUSPIDS $569.67 $797.54 Preauth and Tx plan.
D3330 ROOT CANAL THERAPY, MOLAR $724.31 $1,014.03 Preauth and Tx plan.
D3346 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY, ANTERIOR TOOTH Not covered $606.58 Preauth and Tx plan.
D3347 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY, BICUSPIDS Not covered $700.00 Preauth and Tx plan.
D3348 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY, MOLAR Not covered $800.00 Preauth and Tx plan.
D3351 APEXIFICATION/RECALC INITIAL $114.66 $160.52 Preauth and Tx plan.
D3352 APEXIFICATION/RECALC INTERIM $76.44 $107.02 Preauth and Tx plan.
D3353 APEXIFICATION/RECALC FINAL $76.44 $107.02 Preauth and Tx plan.
*D9110 PALLIATIVE EMERGENCY TX OF DENTAL PAIN-MINOR PROCEDURE Not covered $61.95 Based on Medicaid reimbursement rates in similar states.

Service Code - 27.50 Dentures

ADA Code Description Medicaid Rate Ryan White Rate Notes
D5110 COMPLETE DENTURE – MAXILLARY (UPPER) – LIMITED TO ONCE EVERY 5 YEARS $764.40 $1,070.16 Preauth and Tx plan.
D5120 COMPLETE DENTURE – MANDIBULAR (LOWER)– LIMITED TO ONCE EVERY 5 YEARS $764.40 $1,070.16 Preauth and Tx plan.
D5130 IMMEDIATE DENTURE- MAXILLARY (UPPER) $764.40 $1,070.16 Preauth and Tx plan.
D5140 IMMEDIATE DENTURE- MANDIBULAR (LOWER) $764.40 $1,070.16 Preauth and Tx plan.
D5211 BASE MAXILLARY PARTIAL DENTURE (UPPER) $391.76 $548.46 Preauth and Tx plan.
D5212 MANDIBULAR PARTIAL DENTURE (LOWER) $391.76 $548.46 Preauth and Tx plan.
D5213 UPPER PARTIAL DENTURE ,CAST METAL BASE ACRYLIC SAD 2 CLASP $1,032.42 $1,445.39 Preauth and Tx plan.
D5214 LOWER PARTIAL DENTURE ,CAST METAL BASE ACRYL. SAD 2 CLASP $1,032.42 $1,445.39 Preauth and Tx plan.
D5225 DENTURES MAXILL PART FLEX, INCL RETEN CLASP REST TEETH $650.00 $910.00 New Code; Preauth and Tx plan.
D5226 DENTURES MAND PART FLEX, INCL RETEN CLASP REST TEETH $650.00 $910.00 New Code; Preauth and Tx plan.
*D5410 DENTURE ADJUSTMENTS- COMPLETE MAXILLARY (UPPER) Not covered $30.00  
*D5411 DENTURE ADJUSTMENTS- COMPLETE MANDIBULAR (LOWER) Not covered $30.00  
*D5421 DENTURES ADJUSTMENTS- PARTIAL MAXILLARY (UPPER) Not covered $30.00  
*D5422 DENTURE ADJUSTMENTS- PARTIAL MANDIBULAR (LOWER) Not covered $30.00  
D5511 REP BROKE COMP DENT BASE MAN $133.77 $187.28 Preauth and Tx plan.
D5512 REP BROKE COMP DENT BASE MAX $133.77 $187.28 Preauth and Tx plan.
D5520 REPLACE MISSING OR BROKEN TOOTH $133.77 $187.28 Preauth and Tx plan.
D5611 REPAIR RESIN PARTIAL DENTURE BASE, MANDIBULAR $133.77 $187.28 Preauth and Tx plan.
D5612 REPAIR RESIN PARTIAL DENTURE BASE, MAXILLARY $133.77 $187.28 Preauth and Tx plan.
D5621 REPAIR CAST PARTIAL FRAMEWORK, MANDIBULAR $156.51 $219.11 Preauth and Tx plan.
D5622 REPAIR CAST PARTIAL FRAMEWORK, MAXILLARY $156.51 $219.11 Preauth and Tx plan.
D5630 REPAIR/REPLACE BROKEN CLASP $148.48 $207.87 Preauth and Tx plan.
D5640 REPLACE BROKEN TOOTH $133.77 $187.28 Preauth and Tx plan.
D5650 ADD TOOTH TO EXISTING PARTIAL DENTURE $77.00 $107.80 Preauth and Tx plan.
D5660 ADD CLASP TO EXISTING PARTIAL DENTURE $81.40 $113.96 Preauth and Tx plan.
D5710 REBASE COMPLETE DENTURE (UPPER) Not covered $495.00 Preauth and Tx plan.
D5711 REBASE COMPLETE DENTURE (LOWER) Not covered $489.00 Preauth and Tx plan.
D5720 REBASE PARTIAL DENTURE (UPPER) Not covered $473.00 Preauth and Tx plan.
D5721 REBASE PARTIAL DENTURE (LOWER) Not covered $473.00 Preauth and Tx plan.
D5750 RELINE COMPLETE (MAXILLARY) DENTURE (INDIRECT) $335.40 $469.56 Preauth and Tx plan.
D5751 RELINE COMPLETE (MANDIBULAR) DENTURE (INDIRECT) $335.95 $470.33 Preauth and Tx plan.
D5760 RELINE PARTIAL (MAXILLARY) DENTURE (INDIRECT) $267.54 $374.56 Preauth and Tx plan.
D5761 RELINE PARTIAL (MANDIBULAR) DENTURE (INDIRECT) $267.54 $374.56 Preauth and Tx plan.
D6930 DENTAL RECEMENT BRIDGE Not covered $134.00 Preauth and Tx plan.

Service Code - 27.55 Periodontic Services

ADA Code Description Medicaid Rate Ryan White Rate Notes
D4210 GINGIVECTOMY/PLASTY 4 OR MORE $376.85 $527.59 Preauth and Tx plan.
D4211 GINGIVECTOMY/PLASTY 1 TO 3 $227.03 $317.84 Preauth and Tx plan.
*D4341 PERIODONTAL SCALING AND ROOT PLANING – FOUR OR MORE TEETH PER QUADRANT $188.62 $264.07  
*D4342 PERIODONTAL SCALING AND ROOT PLANING – ONE TO THREE TEETH PER QUADRANT $127.73 $178.82  
D4355 FULL MOUTH DEBRIDEMENT Not covered $175.00 Preauth and Tx plan.
*D4910 PERIODONTAL MAINTENANCE $67.07 $93.90  

Service Code - 27.65 Oral Surgery

ADA Code Description Medicaid Rate Ryan White Rate Notes
*D7140 EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT $113.36 $158.70  
D7210 SURGICAL EXTRACTION $113.36 $158.70 Preauth and Tx plan.
D7220 SOFT TISSUE IMPACTION REMOVAL $194.92 $272.89 Preauth and Tx plan.
D7230 REMOVAL OF IMPACTED TOOTH, PARTIALLY BONY $297.62 $416.67 Preauth and Tx plan.
D7240 REMOVAL OF IMPACTED TOOTH, COMPLETELY BONY $370.99 $519.39 Preauth and Tx plan.
D7241 REMOVAL OF IMPACTED TOOTH, BONY WITH UNUSUAL SURGICAL IMPLICATIONS $382.20 $535.08 Preauth and Tx plan.
D7250 ROOT RECOVERY, COMPLICATIONS $126.13 $176.58 Preauth and Tx plan.
D7260 ORAL ANTRI FISTULA CLOSURE $269.50 $377.30 Preauth and Tx plan.
D7270 TOOTH REIMPLANTATION AND/OR STABILIZATION $193.13 $270.38 Preauth and Tx plan.
D7280 EXPOSURE IMPACT TOOTH ORTHOD $291.05 $407.47 Preauth and Tx plan.
D7285 BIOPSY OF ORAL TISSUE HARD $165.00 $231.00 Preauth and Tx plan.
D7286 BIOPSY OF ORAL TISSUE SOFT $143.00 $200.20 Preauth and Tx plan.
D7310 ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS- 4 OR MORE TEETH OR TOOTH SPACES, PRE QUADRANT $189.30 $265.02 Preauth and Tx plan.
D7311 ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS- 1-3 TEETH OR TOOTH SPACES, PRE QUADRANT $94.65 $132.51 Preauth and Tx plan.
D7320 ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS- 4 OR MORE TEETH OR TOOTH SPACES, PRE QUADRANT $230.54 $322.76 Preauth and Tx plan.
D7321 ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS- 1-3 TEETH OR TOOTH SPACES, PRE QUADRANT Not covered $101.00 Preauth and Tx plan.
D7450 REM ODONTOGEN CYST TO 1.25 CM $202.16 $283.02 Preauth and Tx plan.
D7451 REM ODONTOGEN CYST GREATER THAN 1.25 CM $440.66 $616.92 Preauth and Tx plan.
D7460 REM NONODONTO CYST TO 1.25 CM $277.10 $387.94 Preauth and Tx plan.
D7461 REM NONODONTO CYST GREATER THAN 1.25 CM $459.19 $642.87 Preauth and Tx plan.
D7471 REMOVAL OF LATERAL EXOSTOSIS (MAXILLA OR MANDIBLE) $242.70 $339.78 Preauth and Tx plan.
D7472 REMOVAL OF TORUS PALATINUS $242.70 $339.78 Preauth and Tx plan.
D7473 REMOVAL OF TORUS MANDIBULARIS $242.70 $339.78 Preauth and Tx plan.
D7510 INCISION AND DRAINAGE OF INTRAORAL ABSCESS (SOFT) $145.24 $203.34 Preauth and Tx plan.
D7520 INCISION AND DRAINAGE OF INTRAORAL ABSCESS (EXTRAORAL) $164.35 $230.09 Preauth and Tx plan.
D7961 BUCCAL/LABIAL FRENECTOMY/FRENULECTOMY $131.04 $183.46 Preauth and Tx plan.
D7962 LINGUAL FRENECTOMY/FRENULECTOMY $131.04 $183.46 Preauth and Tx plan.
D9222 DEEP SEDATION (1ST 15 MINUTES) $229.32 $321.05 Preauth and Tx plan.
D9223 DEEP SEDATION/GENERAL ANESTHESIA (15 MINUTE INCREMENTS) $133.77 $187.28 Preauth and Tx plan.
D9239 INTRAVENOUS MODERATE SEDATION $133.77 $187.28 Preauth and Tx plan.
D9243 INTRAVENOUS CONSCIOUS SEDATION/ANALGESIA $76.44 $107.02 Preauth and Tx plan.