Provider Manual - Chapter 3 - Fee Schedule

The published fee schedule lists the CTDHP payable procedure codes and the associated fees for pediatric Members under age 21) and adult Members (21 years old and older).

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Dental Hygienist Fees and Covered Procedures

Dental hygienists receive 90% of the payment rate of the fees listed on the fee schedule as applicable to the age of the Member.  Claim submission and payment for hygienist services are limited to the following procedures:

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Periapical X-Rays
D0220, D0230
Bite Wings
D0270, D0272, D0274
Caries Risk Assessment
D0601, D0602, D0603
Unspecified Diagnostic
Prophylaxis Adult/Child
D1110, D1120
Topical Fluoride Application
Tobacco Counseling
House/Extended Care Call

The CDT Code and Nomenclature above have been obtained from Current Dental Terminology (including procedure codes; nomenclatures; descriptors and other data contained therein).

How to Use the Fee Schedule

The fee schedule is broken out to show the prior authorization requirements by dental specialty.  To use the fee schedule, locate the procedure code desired and follow the line across to your applicable dental specialty to see if prior authorization is required.  The fee schedule will also note the procedures that require post procedure review.

Procedures which require prior authorization/post procedure review are identified on the fee schedule using the following codes:

PA        Prior Authorization is required prior to providing service for all ages

PR        Post Procedure Review required after the service has been performed and prior to payment being made

PAR     Prior Authorization required for Members over 21 years old and Post review required for under 21 years old

<21      Prior authorization is required for this service when provided for a Member under the age of 21

>21     Prior authorization is required for this service when provided for a Member over the age of 21

21-69   Prior authorization is required for Members 21 years of age and older, but less than 70 years old

An empty box on the fee schedule signifies that no prior authorization is required.

How to Download a Copy of the Fee Schedule

From time to time, updates may be made to the fee schedule.  To view and/or print the most recent version of the fee schedule, go to  Click on the Provider tab on the main menu.  Scroll down to “Fee Schedule Download” and click on the link.    Choose “Accept” in order to view the fee schedules.

This will bring you to a new page which lists all the available fee schedules. Scroll down to “Dental.”  This will display the current dental fee schedule for both adults and children in an Excel-like format.

These updates may also be available on  Fee Schedule – HUSKY Dental (

HUSKY B Fees and Co-Pays

As of July 1, 2010, Husky B members are responsible for co-pays on many dental procedures.  The fee schedule shows the percentage of the fee that the member is responsible to pay as an out of pocket expense.  For example, if the fee shown for a procedure is $100.00 and the HUSKY B co-pay amount is shown as 20%, the member would be responsible for $20.00.  Please note: If a provider bills less than the allowed amount as shown on the fee schedule, the member would only be responsible for the percentage shown on the fee schedule and applied to the billed amount.  When the provider fee is higher than what the Medicaid fee schedules shows, the provider must bill the co-pay percentage against the Medicaid listed fee schedule amount.