D5865 Medicaid reimbursement rate by state (2026)

• Order. States are listed from the highest published rate to the lowest. No single unit is shared by 8 or more states for D5865, so the order is by published amount and is not a like-for-like rank.
• Medicaid rate. The most the state's fee-for-service program pays for one unit, as published. 6 of the 10 states list more than one rate for D5865, by modifier, provider type or setting; the table shows the one that matches the provider level and setting used across states, without add-ons.
• Unit. None of the 10 schedules prints a separate unit for D5865, so each amount is a flat payment for one service as the code defines it.
• Per hour. D5865 is not billed in time units in these states, so no hourly figure is shown.
• Managed-care plans. The rule the state sets for its plans on this rate. What each rule means is explained below.
• % of Medicare. No Medicare physician fee schedule amount is on file for D5865, so there is no percentage.
• Source and date. Each Source link opens the state's own document; “since” is the date the rate took effect.

Published rates for D5865 run from $325.00 in Maryland to $2,027.20 in Missouri, a 6.2x gap in the same unit. Half the states pay more than the median of $596.10 and half pay less. The usual reasons for a spread like this in dental rates:

• Some states publish separate child and adult fees for the same procedure, or pay specialists more than general dentists.
• Federal rules require dental coverage for children through EPSDT, while adult dental benefits are optional and range from emergency-only to comprehensive.
• Many states run dental through a dental benefit administrator, and fee updates are often infrequent compared with medical schedules.

Timing matters too. 1 state set the current rate for D5865 in 2026 or later, while 3 states still pay a rate that took effect in 2022 or earlier. A state that has not updated its rate in years will drift down the ranking as others raise theirs.

No managed-care plan publishes what it pays for D5865. What is public is the rule each state's plan contracts set, and that rule decides how much the published rate matters when you contract with a plan.

In 3 states, the published rate binds plans: a floor, a pass-through or a state-set rate. In 1 state, plans negotiate and the published rate is a benchmark or out-of-network default. In 4 states, the service is paid outside the plans or through a state-directed payment. The rule for the remaining 2 states is not classified yet.

• Paid by the state, outside the plans (4 states). Bill the state's Medicaid program, not the plan, at the published rate. There is no plan contract to negotiate for this service.
• Plans must pay at least the published rate (3 states). The published rate is your floor. Negotiate up from it, and if a plan pays less, the contract provision is the basis for a payment dispute.
• Plans negotiate; the published rate applies out of network (1 state). In-network rates can be above or below the published rate. The published rate is the benchmark both sides know, and the fallback if no contract is signed.

Plan-negotiated rates are never estimated here. To see the rule and its citation for a particular state, open that state's managed-care page, for example Missouri managed care.

D5865 is a CDT dental code in the dental line, billed mostly by general dentists, pediatric dentists, oral surgeons and dental clinics. CDT codes are maintained by the American Dental Association. Each is paid once per procedure, with the tooth number and surfaces on the claim, and many states publish separate child and adult amounts.

Dental codes (CDT, maintained by the American Dental Association) are paid once per procedure, with the tooth number and surfaces on the claim. Frequency limits, such as how often an exam or cleaning is covered, decide whether a service is paid at all, regardless of the fee.

Before billing, confirm the rate, unit and any modifier with the state's current schedule or the plan: the amounts here are as published, not a guarantee of payment.