California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51506.1 - Maxillofacial Dental Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Reimbursement for maxillofacial dental
					 services shall be the usual charge to the general public, not to exceed the
					 maximum reimbursement rates listed in this section.
(b) Maximum Allowances
Code
Maximum
								Allowances
DIAGNOSTIC SERVICES
9950
Clinical Examination and Consultation,
								Including Study Models
$51.99
9952
Prosthetic Evaluation and Treatment
								Plan, Including Study Models
74.33
9955
TMJ Series
								radiographs
81.34
9956
Cephalometric Head Film, single, first
								film, Including tracing
22.48
9957
Cephalometric Head Film, Each
								Additional film, Including tracing
4.56
MAXILLOFACIAL PROSTHETIC SERVICES
9960
Speech appliance transitional with or
								without pharyngeal extension
$593.76
9962
Speech appliance, permanent,
								edentulous, with or without pharyngeal extension
1,115.78
9964
Speech appliance, permanent, partially
								edentulous, cast framework, with or without pharyngeal
								extension
1,190.11
9966
Palatal lift,
								interim
595.07
9968
Palatal lift, permanent, cast
								framework
1,115.78
9970
Obturator immediate surgical,
								routine
669.52
9971
Obturator immediate surgical,
								complex
892.66
9972
Obturator permanent,
								complex
1,190.11
9973
Resection prosthesis, permanent
								edentulous, complex
1,190.11
9974
Resection prosthesis, permanent
								edentulous, routine
1,041.46
9975
Resection prosthesis, permanent,
								partially edentulous, complex
1,338.92
9976
Repositioner, mandibular, two
								piece
1,785.33
9977
Removal facial prosthesis
By
								Report
9978
Splints and stents
By
								Report
9979
Radiation therapy fluoride
								carrier
59.00
9980
Repairs, maxillofacial
								prosthesis
By Report
9981
Rebase laboratory processed,
								maxillofacial prosthesis
By Report
9982
Balancing (opposing) maxillofacial
								prosthesis
By Report
MAXILLOFACIAL SURGICAL PROCEDURES
9985
Maxillofacial surgical
								procedures
By Report
TEMPOROMANDIBULAR JOINT DYSFUNCTION MANAGEMENT
9990
Occlusal analysis, including report
								and/or models
$89.81
9992
Occlusal adjustments, limited centric
								and excursive adjustments including records and/or models
44.96
9994
Occlusal balancing, altering centric
								relation, including records and/or models
238.59
9995
Orthopedic stabilizing appliance,
								disocclusion splint
210.49
9996
Postoperative visits, symptomatic care
								and counseling
36.52
9998
Unlisted therapeutic
								service
By Report
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).
Note: Authority cited: Sections
						  10725,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14105,
						  Welfare and Institutions Code; and Statutes of 1989, Chapter 93, Items
						  4260-106-001 and 890.