Cal. Code Regs. tit. 22 § 51506

Current through Register 2024 Notice Reg. No. 23, June 7, 2024
Section 51506 - Dental Services
(a) The reimbursement for dental services shall be in accordance with the maximum reimbursement rates listed below. Billing shall not exceed charges made to the general public.
(1) Maximum reimbursement rates include preparation of necessary forms to cover dental services and appliances as prescribed.
(2) A treatment plan authorized for a beneficiary 17 years of age or younger shall be effective until completion if there is both continuing eligibility and dental necessity, regardless of change in age status.
(3) The maximum reimbursement for By Report (B/R) procedures shall be based upon a review of such procedures to determine their relationship to other procedures for which a maximum reimbursement rate has been established.
(b) Charges for dental service shall be reimbursed in accordance with the Department of Health Services maximum reimbursement rates as follows for the periods indicated.

VISITS--DIAGNOSTIC
(9000-9199)
Maximum Allowances
Procedure NumberJan. 1, 1994July 1, 1995April 10, 1998
9010 Complete examination, initial episode of treatment only $24.48 25.00
9015 Examination, periodic (annual) 9.35
9020 Office visit during regular office hours for treatment and for observation of injuries to the teeth and supporting structures 11.68
9030 Professional visit after regular office hours, or to bedside 17.50
9035 Hospital care 35.02
9040 Specialist consultation 17.50
9045 Pit and Fissure Dental Sealants for Permanent First Molars, to age twenty-one (21)15.00
9046 Pit and Fissure Dental Sealants for Permanent Second Molars, to age twenty-one (21)15.00
9049 Prophylaxis--beneficiaries through age 12 36.95 30.00
9050 Prophylaxis--beneficiaries age 13 years and older 42.90 40.00
9061 Prophylaxis, including topical application of fluoride--beneficiaries age five and under 43.21 30.00
9062 Prophylaxis, including topical application of fluoride--beneficiaries age 6 through 17 45.92 40.00
9080 Emergency treatment, palliative 47.87 45.00
9110 Intraoral periapical, single, first film 13.98 10.00
9111 Intraoral periapical, each additional film 6.38 3.00
9112 Intraoral, complete series consisting of at least 14 periapical films plus bite-wings 46.64 45.00
9113 Intraoral, occlusal, each film 7.00
9114 Extraoral single head or lateral jaw 20.19
9115 Extraoral each additional head or lateral jaw 4.07
9116 Bite-wings, two films 20.35 10.00
9117 Bite-wings, four films 26.77 18.00
9118 Bite-wing, one film 1.50
9119 Photograph or slide, first 6.85
9120 Photograph or slide, each additional (maximum five) 1.50
9125 Panographic-type film, single film 11.94
9150 Biopsy of oral tissue 29.18
9160 Gross and microscopic histopathological report 23.34
ORAL SURGERY
(9200-9299)
9200 Removal of erupted tooth, uncomplicated, first tooth $49.23 45.00
9201 Removal of erupted tooth, uncomplicated, each additional tooth 46.41 38.00
9202 Removal of erupted tooth, surgical 89.25 85.00
9203 Removal of root or root tip, completely covered by bone 40.83
9204 Removal of root or root tip, not completely covered by bone 29.18
9220 Postoperative visit, complications (e.g., osteitis) 7.00
9230 Removal of impacted tooth--soft tissue 113.97100.00
9231 Removal of impacted tooth--partial bony 158.73135.00
9232 Removal of impacted tooth--complete bony 197.45165.00
9250 Alveoloplasty per quadrant, edentulous 40.86
9252 Alveoloplasty per quadrant, in conjunction with extractions 23.34
9255 Vestibuloplasty, submucosal resection (not to include grafts) 312.76
9256 Alveoloplasty with ridge extension secondary epithelialization (per arch) 58.37
9257 Removal of palatal exostosis (torus) 58.37
9258 Removal of mandibular exostosis (torus)--per quadrant 49.04
9259 Excision of hyperplastic tissue (per arch) 46.70
9260 Incision and drainage of abscess, intraoral 17.50
9261 Incision and drainage of abscess, extraoral 29.18
9262 Excision pericoronal gingiva, operculectomy 17.50
9263 Sialolithotomy--intraoral 58.37
9264 Sialolithotomy--extraoral 233.47
9265 Closure of salivary fistula 87.55
9266 Dilation of salivary duct 29.18
9267 Reduction of tuberosity, unilateral 29.18
9269 Excision of benign tumor, up to 1.25 cm 29.18
9270 Excision of benign tumor, larger than 1.25 cm 58.37
9271 Excision of malignant tumor 116.73
9273 Reimplantation and/or stabilization of accidentally avulsed or displaced permanent tooth and/or alveolus 140.08
9275 Transplantation of tooth or tooth bud 116.73
9276 Removal of foreign body from bone--independent procedure 52.52
9277 Radical resection of bone for tumor with bone graft 904.97
9278 Maxillary sinusotomy for removal of tooth fragment or foreign body 116.73
9279 Oral-antral fistula closure 99.23
9280 Excision of cyst, up to 1.25 cm 40.86
9281 Excision of cyst over 1.25 cm 87.55
9282 Sequestrectomy 46.70
9285 Condylectomy of mandible, unilateral 703.71
9289 Meniscectomy of temporomandibular joint, unilateral 703.71
9290 Excision of foreign body from soft tissue 23.34
9291 Frenectomy, or frenotomy, separate procedure 40.86
9292 Suture of soft tissue wound or injury 24.52
9294 Injection of sclerosing agent into temporomandibular joint 35.02
9295 Injection of trigeminal nerve branches for destruction 58.37
9296 Surgical exposure of impacted or unerupted tooth to aid eruption, soft tissues 23.34
9297 Surgical exposure of impacted or unerupted tooth to aid eruption, partial bony 35.02
9298 Surgical exposure of impacted or unerupted tooth to aid eruption, complete bony or ectopic eruption 52.52
9299 Unlisted surgical service or procedureBy Report
DRUGS AND ANESTHESIA
(9300-9449)
9300 Injectable drugs $5.83
9301 Conscious sedation relative analgesia, Nitrous oxide (N2O2, oxygen), per visit 11.68
9400 General anesthesia 33.16
PERIODONTICS
(9450-9499)
9451 Emergency treatment: (periodontal abscess, acute periodontitis, etc.) $57.18 55.00
9452 Subgingival curettage and root planing per treatment 189.98200.00
9453 Occlusal adjustment (limited), per quadrant (minor spot grinding) 23.34
9472 Gingivectomy or gingivoplasty, per quadrant 81.70
9473 Osseous and mucogingival surgery, per quadrant 99.23
9474 Gingivectomy or gingivoplasty treatment, per tooth (fewer than six teeth) 17.50
ENDODONTICS
(9500-9599)
9501 Therapeutic pulpotomy $17.50
9502 Vital pulpotomy 17.50
9503 Recalcification, includes temporary restoration, per tooth 16.34
9511 Anterior root canal therapy 217.26215.00
9512 Bicuspid root canal therapy 263.94260.00
9513 Molar root canal therapy 333.58330.00
9530 Apicoectomy--surgical procedure in conjunction with root canal filling 134.25
9531 Apicoectomy (separate surgical procedure), per tooth 72.38
9534 Apexification (therapeutic apical closure), per treatment 13.65
RESTORATIVE DENTISTRY
(9600-9699)
Amalgam Restorations
9600 One surface, primary tooth $37.95 33.00
9601 Two surfaces, primary tooth 46.49 41.00
9602 Three surfaces, primary tooth 56.00 48.00
9603 Four or more surfaces, primary tooth (maximum) 63.68 55.00
9611 One surface, permanent tooth 43.86 39.00
9612 Two surfaces, permanent tooth 53.15 48.00
9613 Three surfaces, permanent tooth 62.77 57.00
9614Four or more surfaces, permanent tooth (maximum) 73.53 60.00
Silicate, Composite, Plastic Restorations
9640 Silicate cement restoration $51.28 0.00
9641 Silicate restorations, two or more in a single tooth (maximum) 79.05 0.00
9645 Composite or plastic restoration 62.58 55.00
9646 Composite or plastic restorations, two or more in a single tooth (maximum) 98.77 80.00
9648 Pin retention, (per pin) maximum three pins per tooth 31.06 31.00
Crowns
9650 Crown, plastic (laboratory processed)$105.06
9651 Crown, plastic with metal 134.25
9652 Crown, porcelain 140.08
9653 Crown, porcelain fused to metal 397.53330.00
9660 Crown, cast, full 388.49340.00
9663 Crown, cast, three-fourths 116.73
9670 Crown, stainless steel, primary 87.87 75.00
9671 Crown, stainless steel, permanent 104.84 90.00
9672 Cast metal dowel post 103.35 75.00
PROSTHETICS
(9680-9799)
Pontics
9680 Fixed bridge pontic, cast metal$105.06
9681 Fixed bridge pontic, slotted facing 105.06
9682 Fixed bridge pontic, slotted pontic 110.90
9692 Fixed bridge pontic, porcelain fused to metal 157.58
9693 Fixed bridge pontic, plastic processed to metal 122.57
Recementing
9685 Recement inlay, facing, pontic $42.83 30.00
9686 Recement crown 39.29 30.00
9687 Recement bridge 52.34 50.00
Repairs, Crown And Bridge
9690 Repair fixed bridgesBy Report
9694 Replace broken tru-pontic $17.50
9695 Replace broken facing, post intact 14.01
9696 Replace broken facing, post backing broken 23.34
Removable Prosthodontics
9700 Complete maxillary denture 484.77400.00
9701 Complete mandibular denture 484.77400.00
9702 Partial upper or lower denture with two assembled chrome cobalt wrought or cast chrome cobalt clasps with occlusal rests and necessary teeth, acrylic base 191.28
9703 Partial upper or lower denture with cast chrome cobalt skeleton, two cast clasps, and necessary teeth 493.93400.00
9704 Clasps, third and each additional clasp for procedure 9703 48.27 35.00
9705 Stress breakers, extra 29.18
9706 Partial upper or lower stayplate, acrylic (base fee, teeth and clasps extra) 191.10150.00
9708 Partial upper or lower denture, all acrylic, with two assembled chrome cobalt wrought clasps having two clasp arms, but no rests, and necessary teeth 175.11
9709 Clasp third and each additional for Procedure 9708 14.01
9712 Clasp third and each additional for Procedure 9702 17.50
9716 Clasp or teeth, each for Procedure 9706 29.68 23.00
9720 Denture adjustment, per visit 11.68
9721 Reline--office, cold cure 44.28
9722 Reline--laboratory processed 158.70140.00
9723 Tissue conditioning, per denture 35.02
9724 Denture duplication ("jump," "reconstruction") denture base including necessary tooth replacement, per denture 268.19150.00
Repairs, Dentures, Acrylic
9750 Repair broken denture base only (complete or partial) 62.78 45.00
9751 Repair broken denture and replace one broken denture tooth 74.71 65.00
9752 Each additional denture tooth replaced on 9751 repair (maximum two) 18.95 15.00
9753 Replace one broken denture tooth only (complete or partial) 57.09 50.00
9754 Each additional denture tooth replaced on 9753 repair (maximum two) 18.95 15.00
9755 Adding first tooth to partial denture to replace newly extracted natural tooth 45.66
9756 Each additional natural tooth replaced on 9755 repair (maximum two) 15.17
9757 Add a new or replace a broken chrome cobalt assembled wrought clasp with two clasp arms and rest to an existing 9702 partial denture 48.38
9758 Each additional new or replacement clasp for repair 9757 (maximum two) 48.38
9759 Add a new or replace a broken chrome cobalt assembled wrought clasp with two clasp arms and no rest to an existing 9708 partial denture 38.36
9760 Each additional new or replacement clasp for repair 9759 (maximum two) 38.36
9761 Reattaching clasp on partial denture, clasp intact, each (maximum two) 29.18
9762 Add a new or replace a broken cast chrome cobalt clasp with two clasp arms and rest to an existing 9703 partial denture 52.52
9763 Each additional new or replacement clasp for repair 9762 (maximum two) 52.52
SPACE MAINTAINERS
(9800-9899)
9800 Fixed, unilateral band type (including band) 58.37
9801 Removable plastic with two stainless steel round wire clasps or rests 64.20
9802 Each additional clasp or rest (for 9801 only) 11.68
9811 Fixed, unilateral stainless steel crown type (including crown, Procedure 9670 or 9671) 81.70
9812 Fixed, bilateral lingual or palatal bar type 145.93
9832 Fixed or removable appliance to control harmful habit 70.05
FRACTURES AND DISLOCATIONS
(9900-9999)
(Includes Usual Follow-up Care)
9900 Maxilla, open reduction, simple$469.14
9901 Maxilla, closed reduction, simple 273.66
9902 Mandible, open reduction, simple 625.53
9903 Mandible, closed reduction, simple 312.76
9904 Maxilla, closed reduction, compound 371.40
9905 Maxilla, open reduction, compound 625.53
9906 Mandible, closed reduction, compound 371.40
9907 Mandible, open reduction, compound 625.53
9913 Reduction of dislocation of temporomandibular joint 62.55
9915 Treatment of malar fracture, simple, closed reduction 195.18
9916 Treatment of malar fracture, simple or compound depressed, open reduction 371.40
UNLISTED PROCEDURES
9999 Fees to be determinedBy Report

Cal. Code Regs. Tit. 22, § 51506

1. Amendment filed 8-7-89 as an emergency; operative 8-7-89 (Register 89, No. 32). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 12-5-89. For prior history, see Register 85, No. 52.
2. Certificate of Compliance transmitted to OAL 12-1-89 and filed 1-2-90 (Register 90, No. 2).
4. Amendment of subsection (b) refiled 12-26-91 as an emergency; operative 12-26-91 (Register 92, No. 12). A Certificate of Compliance must be transmitted to OAL 4-24-92 or emergency language will be repealed by operation of law on the following day.
5. Amendment of subsection (b) refiled and amendment of NOTE filed 4-24-92 as an emergency; operative 4-24-92 (Register 92, No. 18). A Certificate of Compliance must be transmitted to OAL 8-24-92 or emergency language will be repealed by operation of law on the following day.
6. Certificate of Compliance as to 4-24-92 order including amendment of subsection (b) [9760] transmitted to OAL 8-21-92 and filed 10-5-92 (Register 92, No. 41).
7. Amendment of subsection (b) filed 12-24-92 as an emergency; operative 12-24-92 (Register 92, No. 52). A Certificate of Compliance must be transmitted to OAL 4-23-93 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 12-24-92 order transmitted to OAL 4-19-93 and filed 5-18-93 (Register 93, No. 21).
9. Amendment of subsection (b) filed 6-29-93 as an emergency; operative 6-29-93 (Register 93, No. 27). A Certificate of Compliance must be transmitted to OAL by 10-27-93 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 6-29-93 order transmitted to OAL 10-22-93 and filed 12-7-93 (Register 93, No. 50).
11. Amendment of subsection (b) and NOTE filed 10-27-95 as an emergency; operative 10-27-95 (Register 95, No. 43). A Certificate of Compliance must be transmitted to OAL by 2-24-96 or emergency language will be repealed by operation of law on the following day.
12. Certificate of Compliance as to 10-27-95 order including editorial corrections to subsection (b) transmitted to OAL 2-6-96 and filed 3-13-96 (Register 96, No. 11).
13. Amendment of subsection (b) (amending Procedure Numbers 9045 and 9046 and repealing Procedure Number 9047) filed 4-10-98 as an emergency; operative 4-10-98 (Register 98, No. 15). A Certificate of Compliance must be transmitted to OAL by 8-10-98 or emergency language will be repealed by operation of law on the following day.
14. Editorial correction of subsection (b) (Register 98, No. 16).
15. Certificate of Compliance as to 4-10-98 order transmitted to OAL 7-27-98 and filed 9-4-98 (Register 98, No. 36).

Note: Authority cited: Sections 10725, 14105 and 14124.5, Welfare and Institutions Code; Clark v. Kizer (Coye) (October 15, 1992) S 871700 [nonpub. opn.]; Order Modifying Judgment, Clark v. Kizer (Coye) (October 15, 1992) S 871700 [non pub. opn.], filed on June 21, 1995. Reference: Section 14105, Welfare and Institutions Code; Statutes of 1989, Chapter 93, Items 4260-106-001 and 890; and 42 U.S.C., Section 1396a(a)(30)(A).

1. Amendment filed 8-7-89 as an emergency; operative 8-7-89 (Register 89, No. 32). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 12-5-89. For prior history, see Register 85, No. 52.
2. Certificate of Compliance transmitted to OAL 12-1-89 and filed 1-2-90 (Register 90, No. 2).
4. Amendment of subsection (b) refiled 12-26-91 as an emergency; operative 12-26-91 (Register 92, No. 12). A Certificate of Compliance must be transmitted to OAL 4-24-92 or emergency language will be repealed by operation of law on the following day.
5. Amendment of subsection (b) refiled and amendment of Note filed 4-24-92 as an emergency; operative 4-24-92 (Register 92, No. 18). A Certificate of Compliance must be transmitted to OAL 8-24-92 or emergency language will be repealed by operation of law on the following day.
6. Certificate of Compliance as to 4-24-92 order including amendment of subsection (b) [9760] transmitted to OAL 8-21-92 and filed 10-5-92 (Register 92, No. 41).
7. Amendment of subsection (b) filed 12-24-92 as an emergency; operative 12-24-92 (Register 92, No. 52). A Certificate of Compliance must be transmitted to OAL 4-23-93 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 12-24-92 order transmitted to OAL 4-19-93 and filed 5-18-93 (Register 93, No. 21).
9. Amendment of subsection (b) filed 6-29-93 as an emergency; operative 6-29-93 (Register 93, No. 27). A Certificate of Compliance must be transmitted to OAL by 10-27-93 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 6-29-93 order transmitted to OAL 10-22-93 and filed 12-7-93 (Register 93, No. 50).
11. Amendment of subsection (b) and Note filed 10-27-95 as an emergency; operative 10-27-95 (Register 95, No. 43). A Certificate of Compliance must be transmitted to OAL by 2-24-96 or emergency language will be repealed by operation of law on the following day.
12. Certificate of Compliance as to 10-27-95 order including editorial corrections to subsection (b) transmitted to OAL 2-6-96 and filed 3-13-96 (Register 96, No. 11).
13. Amendment of subsection (b) (amending Procedure Numbers 9045 and 9046 and repealing Procedure Number 9047) filed 4-10-98 as an emergency; operative 4-10-98 (Register 98, No. 15). A Certificate of Compliance must be transmitted to OAL by 8-10-98 or emergency language will be repealed by operation of law on the following day.
14. Editorial correction of subsection (b) (Register 98, No. 16).
15. Certificate of Compliance as to 4-10-98 order transmitted to OAL 7-27-98 and filed 9-4-98 (Register 98, No. 36).