Cal. Code Regs. tit. 22 § 51506
Current through Register 2024 Notice Reg. No. 24, June 14, 2024
| VISITS--DIAGNOSTIC | |||
| (9000-9199) | |||
| Maximum Allowances | |||
| Procedure Number | Jan. 1, 1994 | July 1, 1995 | April 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 | 113.97 | 100.00 | |
| 9231 Removal of impacted tooth--partial bony | 158.73 | 135.00 | |
| 9232 Removal of impacted tooth--complete bony | 197.45 | 165.00 | |
| 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 procedure | By 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 | 189.98 | 200.00 | |
| 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 | 217.26 | 215.00 | |
| 9512 Bicuspid root canal therapy | 263.94 | 260.00 | |
| 9513 Molar root canal therapy | 333.58 | 330.00 | |
| 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 | 397.53 | 330.00 | |
| 9660 Crown, cast, full | 388.49 | 340.00 | |
| 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 bridges | By 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 | 484.77 | 400.00 | |
| 9701 Complete mandibular denture | 484.77 | 400.00 | |
| 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 | 493.93 | 400.00 | |
| 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) | 191.10 | 150.00 | |
| 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 | 158.70 | 140.00 | |
| 9723 Tissue conditioning, per denture | 35.02 | ||
| 9724 Denture duplication ("jump," "reconstruction") denture base including necessary tooth replacement, per denture | 268.19 | 150.00 | |
| 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 determined | By Report |
Cal. Code Regs. Tit. 22, § 51506
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).
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).