Dental Fee Schedule

The pricing modifier populated on the fee schedule may not be valid for the PT/Spec/POS combination and is only a reference. Please refer to the appropriate MA bulletins for more information about the use of modifiers. Please Note: ** is not a valid modifier. Please use the appropriate modifier as per your MA bulletins. In addition, this fee schedule does not apply to Home and Community Based waiver services or those services approved by the Department under the 1150 Administrative Waiver (Program Exception) process.

Limitations such as age, gender, min/max units, PA requirements and PA min/max age are now available for procedures as a reference on this fee schedule. Please refer to the appropriate MA bulletins and handbooks for more information concerning these limitations.

Note: The length of time to display a fee schedule depends on its size. Large fee schedules may take several minutes to display.

If you notice inconsistencies or inaccuracies within the Medical Assistance Outpatient Online Fee Schedule tool such as incorrect modifiers with procedure codes, incorrect pricing segments, and omitted procedure codes, the issue could be caused by a wildcard feature used at one time within the PROMISe™ system. If you have a question about an inconsistency or inaccuracy with the tool, please contact the Provider Service Center at 1-800-537-8862.

If you do not find your provider type identified, please call the Provider Service Center.