Cal. Code Regs. tit. 22, § 51506
(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.
(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 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
Note: Authority cited: Sections 10725, 14105 and 14124.5, Welfare and Institutions Code; Clark v. Kizer (Coye) (October 15, 1992) S871700 [nonpub. opn.]; Order Modifying Judgment, Clark v. Kizer (Coye) (October 15, 1992) S871700 [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).