Transcription
Medi-Cal Dental Schedule of Maximum AllowancesFees payable to providers by Medi-Cal Dental for covered services shall be the LESSER of:a. provider’s billed amountb. the maximum allowance set forth in the schedule below2. Refer to your Medi-Cal Dental Program Provider Handbook for specific procedure instructionsand program limitations.1.Benefit: Dental or medical health care services covered by the Medi-Cal programNot a Benefit: Dental or medical health care services not covered by the Medi-Cal programTGlobal: Treatment performed in conjunction with another procedure which is not payable separatelyBy Report: Payment amount determined from submitted documentationMaximum AllowanceAFCDTCodesProcedure Code DescriptionEffective DateDiagnostic ProceduresPeriodic oral evaluation - established patientLimited oral evaluation – problem focusedD0145Oral evaluation for a patient under three years of ageand counseling with primary 0D0191D0210D0220D0230D0240Comprehensive oral evaluation – new or establishedpatientDetailed and extensive oral evaluation – problemfocused, by reportRe-evaluation – limited, problem focused(established patient; not post-operative visit)Re-evaluation post-operative office visitComprehensive periodontal evaluation – new orestablished patientScreening of a patientAssessment of a patientIntraoral - complete series of radiographic imagesIntraoral - periapical first radiographic imageIntraoral - periapical each additional radiographic imageIntraoral - occlusal radiographic imageEffective March 14, 2020 15.00 35.00Global 20.00October 6, 2016 25.00October 6, 2016October 6, 2016 100.00 75.00GlobalMarch 14, 2020GlobalNot A BenefitNot A Benefit 40.00 10.00 3.00 10.00June 1, 2019Schedule of Maximum Allowances
D0321D0322D0330DRD0340Extra-oral - first 2D projection radiographic imagescreated using a stationary radiation source, and detectorExtra-oral posterior dental radiographic imageExtraoral - each additional radiographic imageBitewing - single radiographic imageBitewings - two radiographic imagesBitewings - three radiographic imagesBitewings - four radiographic imagesVertical bitewings - 7 to 8 radiographic imagesPosterior - anterior or lateral skull and facial bone surveyradiographic imageSialographyTemporomandibular joint arthrogram, including injectionOther temporomandibular joint radiographic images, byreportTomographic surveyPanoramic radiographic image2D Cephalometric radiographic image - acquisition,measurement and analysis2D Oral/Facial photographic images obtained intra-orallyor extra orally3D photographic imageCone beam - three dimensional image reconstructionusing existing data, includes multiple imagesCone beam CT capture and interpretation with limitedfield of view - less than one whole jawCone beam CT capture and interpretation with limitedfield of view of one full dental arch - mandibleCone beam CT capture and interpretation with field ofview of one full dental arch - maxilla, with or withoutcraniumCone beam CT capture and interpretation with field ofview of both jaws with or without craniumCone beam CT capture and interpretation for tmj seriesincluding two or more ffective Date 22.00Not a Benefit 5.00 5.00 10.00Global 18.00GlobalMarch 14, 2020March 14, 2020 35.00March 14, 2020TD0250Procedure Code DescriptionMaximum AllowanceAFCDTCodesEffective March 14, 2020 100.00 76.00Not A Benefit 100.00 25.00 50.00June 1, 2019 6.00Not A BenefitMarch 14, 2020Not A BenefitMarch 14, 2020Not A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitSchedule of Maximum Allowances
Procedure Code DescriptionD0369D0370D0371Maxillofacial MRI capture and interpretationMaxillofacial ultrasound capture and interpretationSialoendoscopy capture and interpretationCone beam CT image capture with limited field of view less than one whole jawCone beam CT image capture with field of view of onefull dental arch - mandibleCone beam CT image capture with field of view of onefull dental arch - maxilla with or without craniumCone beam CT image capture with field of view of bothjaws, with or without craniumCone beam CT image capture for TMJ series includingtwo or more exposuresMaxillofacial MRI image captureMaxillofacial ultrasound image captureInterpretation of diagnostic image by a practitioner notassociated with capture of the image, including reportTreatment simulation using 3d image volumeDigital subtraction of two or more images or imagevolumes of the same modalityFusion of two or more 3d image volumes of one or moremodalitiesHBA1C in-office point of service testingBlood glucose level test in-office using a glucose meterLaboratory processing of microbial specimen to includeculture and sensitivity studies, preparation andtransmission of written reportCollection of microorganisms for culture and sensitivityViral CultureCollection and preparation of saliva sample forlaboratory diagnostic testingAnalysis of saliva sampleGenetic test for susceptibility to oral diseasesCollection and preparation of genetic sample material forlaboratory analysis and 422Effective DateNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitAFD0380Maximum AllowanceTCDTCodesEffective March 14, 2020Not A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitMarch 14, 2020Not A BenefitMarch 14, 2020Not A BenefitMarch 14, 2020Not a BenefitNot A BenefitMarch 14, 2020March 14, 2020Not A BenefitMarch 14, 2020Not A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitMarch 14, 2020Not A BenefitMarch 14, 2020Schedule of Maximum Allowances
77D0478D0479Genetic test for susceptibility to diseases- specimenanalysisCaries susceptibility testsAdjunctive pre-diagnostic test that aids in detection ofmucosal abnormalities including premalignant andmalignant lesions, not to include cytology or biopsyproceduresPulp vitality testsDiagnostic castsAccession of tissue, gross examination, preparation andtransmission of written reportAccession of tissue, gross and microscopic examination,preparation and transmission of written reportAccession of tissue, gross and microscopic examination,including assessment of surgical margins for presence ofdisease, preparation and transmission of written reportDecalcification procedureSpecial stains for microorganismsSpecial stains not for microorganismsImmunohistochemical stainsTissue in-situ hybridization, including interpretationAccession of exfoliative cytologic smears, microscopicexamination, preparation and transmission of writtenreportElectron microscopyDirect immunofluorescenceIndirect immunofluorescenceConsultation on slides prepared elsewhereConsultation, including preparation of slides from biopsymaterial supplied by referring sourceAccession of transepithelial cytologic sample,microscopic examination, preparation and transmissionof written reportOther oral pathology procedures, by reportNon-ionizing diagnostic procedure capable ective DateNot A BenefitMarch 14, 2020Not A BenefitNot A BenefitGlobal 75.00TD0423Procedure Code DescriptionMaximum AllowanceNot A BenefitAFCDTCodesEffective March 14, 2020Not A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitBy ReportNot A BenefitMarch 14, 2020Schedule of Maximum Allowances
CDTCodesProcedure Code DescriptionMaximum AllowanceEffective Datequantifying, monitoring, and recording changes instructure of enamel, dentin, and cementumD0602D0603D0999Caries risk assessment and documentation, with a finding Not A Benefitof low risk(Benefit in DTI)Caries risk assessment and documentation, with a finding Not A Benefitof moderate risk(Benefit in DTI)Caries risk assessment and documentation, with a finding Not A Benefitof high risk(Benefit in DTI)Unspecified diagnostic procedure, by report 46.00 40.00 30.00 18.00 8.00 6.00July 15, 2016July 15, 2016June 1, 2019June 1, 2019June 1, 2019 18.00June 1, 2019 8.00June 1, 2019DRAFPreventive ProceduresD1110 Prophylaxis – adultD1120 Prophylaxis – childD1206 Topical application of fluoride varnish - child 0 to 5D1206 Topical application of fluoride varnish - child 6 to 20D1206 Topical application of fluoride varnish - adult 21 and overTopical application of fluoride - excluding varnish - childD12080-5Topical application of fluoride - excluding varnish - childD12086-20D1208 Topical application of fluoride - excluding varnish - adultD1310Nutritional counseling for control of dental diseaseD1320Tobacco counseling for the control and prevention oforal diseaseD1330D1351D1352D1353D1354D1510D1515March 14, 2020(January 1, 2017)March 14, 2020(January 1, 2017)March 14, 2020(January 1, 2017)May 16, 2020TD0601 6.00June 1, 2019Global(January 1, 2017)(Benefit in DTI)GlobalJune 1, 2019 10.00Global 22.00Oral hygiene instructionsSealant – per toothPreventive resin restoration in a moderate to high caries 22.00risk patient - permanent toothSealant repair- per toothNot A BenefitNot A BenefitInterim caries arresting medicament application-per(Benefit fortoothDTI)Space maintainer-fixed – unilateral 120.00Space maintainer-fixed – bilateral 200.00Effective March 14, 2020March 14, 2020March 14, 2020(January 1, 2017)June 1, 2019March 14, 2020Schedule of Maximum Allowances
CDTCodesProcedure Code DescriptionSpace maintainer - fixed – bilateral, maxillarySpace maintainer - fixed – bilateral, mandibularD1520Space maintainer-removable – unilateralD1525D1526D1527D1550D1555D1575D1999Space maintainer-removable – bilateralSpace maintainer - removable – bilateral, maxillarySpace maintainer - removable – bilateral, mandibularRe-cementation or re-bond of space maintainerRemoval of fixed space maintainerDistal shoe space maintainer- fixed- unilateralUnspecified preventive procedure, by reportEffective Date 200.00 200.00 230.00Not A Benefit 230.00 230.00 230.00 30.00 30.00 120.00 46.00March 14, 2020March 14, 2020 39.00 48.00 57.00 60.00 55.00 60.00 65.00January 13, 2016January 13, 2016January 13, 2016January 13, 2016January 13, 2016January 13, 2016January 13, 2016 85.00January 13, 2016 75.00 39.00 48.00 57.00January 13, 2016January 13, 2016January 13, 2016January 13, 2016 60.00January 13, 2016March 14, 2020March 14, 2020March 14, 2020March 14, 2020AFTD1516D1517Maximum AllowanceDRRestorative ProceduresD2140 Amalgam – one surface, primary or permanentD2150 Amalgam – two surfaces, primary or permanentD2160 Amalgam – three surfaces, primary or permanentD2161 Amalgam – four or more surfaces, primary or permanentD2330 Resin-based composite – one surface, anteriorD2331 Resin-based composite – two surfaces, anteriorD2332 Resin-based composite – three surfaces, anteriorResin-based composite – four or more surfaces orD2335involving incisal angle (anterior)D2390 Resin-based composite crown, anteriorD2391 Resin-based composite – one surface, posteriorD2392 Resin-based composite – two surfaces, posteriorD2393 Resin-based composite – three surfaces, posteriorResin-based composite – four or more surfaces,D2394posteriorD2410 Gold foil – one surfaceD2420 Gold foil – two surfacesD2430 Gold foil – three surfacesD2510 Inlay – metallic – one surfaceD2520 Inlay – metallic – two surfacesD2530 Inlay – metallic – three surfacesEffective March 14, 2020May 16, 2020March 14, 2020Not A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitSchedule of Maximum Allowances
Procedure Code 3D2790D2791D2792D2794D2799Onlay – metallic – two surfacesOnlay – metallic – three surfacesOnlay – metallic – four or more surfacesInlay – porcelain/ceramic – one surfaceInlay – porcelain/ceramic – two surfacesInlay – porcelain/ceramic – three or more surfacesOnlay – porcelain/ceramic – two surfacesOnlay – porcelain/ceramic – three surfacesOnlay – porcelain/ceramic – four or more surfacesInlay – resin-based composite – one surfaceInlay – resin-based composite – two surfacesInlay – resin-based composite – three or more surfacesOnlay – resin-based composite – two surfacesOnlay – resin-based composite – three surfacesOnlay – resin-based composite – four or more surfacesCrown – resin - based composite (indirect)Crown - 3/4 resin-based composite (indirect)Crown – resin with high noble metalCrown – resin with predominantly base metalCrown – resin with noble metalCrown – porcelain/ceramic substrateCrown – porcelain fused to high noble metalCrown – porcelain fused to predominantly base metalCrown – porcelain fused to noble metalCrown – 3/4 cast high noble metalCrown – 3/4 cast predominantly base metalCrown – 3/4 cast noble metalCrown – 3/4 porcelain/ceramicCrown – full cast high noble metalCrown – full cast predominantly base metalCrown – full cast noble metalCrown - titaniumProvisional crown - further treatment or completion ofMaximum AllowanceNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A Benefit 150.00 150.00Not A Benefit 220.00Not A Benefit 340.00Not A Benefit 340.00Not A BenefitNot A Benefit 340.00Not A Benefit 340.00Not A Benefit 340.00Not A BenefitNot A BenefitNot A BenefitEffective DateDRAFTCDTCodesEffective March 14, 2020March 1, 2019March 1, 2019March 1, 2019March 1, 2019March 1, 2019March 1, 2019March 1, 2019March 1, 2019Schedule of Maximum Allowances
CDTCodesProcedure Code DescriptionD2929Prefabricated porcelain/ceramic crown - primary toothD2930D2931D2932D2933Prefabricated stainless steel crown – primary toothPrefabricated stainless steel crown – permanent toothPrefabricated resin crownPrefabricated stainless steel crown with resin windowPrefabricated esthetic coated stainless steel crown primary toothProtective restorationInterim therapeutic restoration- primary dentitionRestorative foundation for an indirect restorationCore buildup, including any pins when requiredPin retention – per tooth, in addition to restorationPost and core in addition to crown, indirectly fabricatedEach additional indirectly fabricated post – same toothPrefabricated post and core in addition to crownPost removalEach additional prefabricated post -same toothLabial veneer (resin laminate) – chairsideLabial veneer (resin laminate) – laboratoryLabial veneer (porcelain laminate) – laboratoryTemporary crown (fractured tooth)Additional procedures to construct new crown underexisting partial denture frameworkCopingCrown repair, necessitated by restorative material 2980 30.00Global 30.00Not a Benefit 75.00Not A Benefit 75.00 90.00 75.00 75.00AFD2910Effective DateMarch 14, 2020TD2920D2921diagnosis necessary prior to final impressionRecement inlay or re-bond, onlay, veneer or partialcoverage restorationRecement or re-bond indirectly fabricated cast orprefabricated post and coreRecement or re-bond crownReattachment of tooth permanent, incisal edge or cuspMaximum AllowanceEffective March 14, 2020March 14, 2020January 13, 2016January 13, 2016January 13, 2016January 13, 2016Not A Benefit 45.00 45.00GlobalGlobal 80.00 75.00Global 75.00GlobalGlobalNot A BenefitNot A BenefitNot A Benefit 45.00March 14, 2020March 14, 2020March 14, 2020March 14, 2020GlobalNot A Benefit 60.00Schedule of Maximum Allowances
CDTCodesProcedure Code DescriptionEffective DateNot A BenefitNot A BenefitNot A BenefitNot A Benefit 50.00GlobalGlobalTD2981 Inlay repair necessitated by restorative material failureD2982 Onlay repair necessitated by restorative material failureD2983 Veneer repair necessitated by restorative material failureD2990 Resin infiltration of incipient smooth surface lesionsD2999 Unspecified restorative procedure, by reportEndodontic ProceduresD3110 Pulp cap – direct (excluding final restoration)D3120 Pulp cap – indirect (excluding final restoration)Therapeutic pulpotomy (excluding final restoration) –D3220 removal of pulp coronal to the dentinocemental junctionapplication of medicamentD3221 Pulpal debridement, primary and permanent teethPartial pulpotomy for apexogenesis - permanent toothD3222with incomplete root developmentPulpal therapy (resorbable filling) – anterior, primaryD3230tooth (excluding final restoration)Pulpal therapy (resorbable filling) – posterior, primaryD3240tooth (excluding final restoration)Endodontic therapy, anterior tooth (excluding finalD3310restoration)Endodontic therapy, premolar bicuspid tooth (excludingD3320final restoration)Endodontic therapy, molar tooth (excluding finalD3330restoration)D3331 Treatment of root canal obstruction; non-surgical accessIncomplete endodontic therapy; inoperable,D3332unrestorable or fractured toothD3333 Internal root repair of perforation defectsD3346 Retreatment of previous root canal therapy – anteriorRetreatment of previous root canal therapy – bicuspidD3347premolarD3348 Retreatment of previous root canal therapy – molarApexification/Recalcification/Pulpal regeneration - initialD3351 visit (apical closure/calcific repair of perforations, rootresorption, pulp space disinfection etc.)Maximum AllowanceDRAF 71.00Effective March 14, 2020 45.00 71.00 71.00 71.00 216.00March 15, 2017 261.00March 15, 2017 331.00March 15, 2017GlobalNot A BenefitGlobal 216.00March 15, 2017 261.00March 15, 2017 331.00March 15, 2017 100.00Schedule of Maximum Allowances
DRD3428Apexification/Recalcification/Pulpal regeneration interim medication replacementApexification/Recalcification - final visit (includescompleted root canal therapy - apical closure/calcificrepair of perforations, root resorption, etc.)Pulpal regeneration - (completion of regenerativetreatment in an immature permanent tooth with anecrotic pulp); does not include final restorationPulpal regeneration- initial visitPulpal regeneration- interim medication replacementPulpal regeneration- completion of treatmentApicoectomy/Periradicular surgery – anteriorApicoectomy/Periradicular surgery – bicuspid (first root)Apicoectomy/Periradicular surgery – molar (first root)Apicoectomy/Periradicular surgery – (each additionalroot)Periradicular surgery without apicoectomyBone graft in conjunction with periradicular surgery- pertooth, single siteBone graft in conjunction with periradicular surgeryeach additional contiguous tooth in the same surgicalsiteRetrograde filling – per rootBiologic materials to aid in soft and osseous tissueregeneration in conjunction with periradicular surgeryGuided tissue regeneration, resorbable barrier, per site,in conjunction with periradicular surgeryRoot amputation – per rootEndodontic endosseous implantIntentional reimplantation (including necessary splinting)Surgical procedure for isolation of tooth with rubber damHemisection (including any root removal), not includingroot canal therapyCanal preparation and fitting of preformed dowel or postUnspecified endodontic procedure, by 0D3950D3999Effective Date 100.00Not A BenefitNot A BenefitMarch 14, 2020TD3352Procedure Code DescriptionMaximum AllowanceNot A BenefitNot A BenefitNot A Benefit 100.00 100.00 100.00AFCDTCodesEffective March 14, 2020March 14, 2020March 14, 2020March 14, 2020 100.00 100.00March 14, 2020Not A BenefitMarch 14, 2020Not A BenefitMarch 14, 2020GlobalNot A BenefitMarch 14, 2020Not A BenefitMarch 14, 2020Not A BenefitNot A BenefitNot A BenefitGlobalNot A BenefitNot A Benefit 42.00Schedule of Maximum Allowances
CDTCodesProcedure Code DescriptionEffective Date 185.00 110.00Not A BenefitTPeriodontal ProceduresGingivectomy or gingivoplasty – four or more contiguousD4210teeth or tooth bound spaces per quadrantGingivectomy or gingivoplasty – one to three contiguousD4211teeth or tooth bounded spaces per quadrantGingivectomy or gingivoplasty to allow access forD4212restorative procedure, per toothAnatomical crown exposure - four or more contiguousD4230teeth or tooth bounded spaces per quadrantAnatomical crown exposure - one to three teeth or toothD4231bounded spaces per quadrantGingival flap procedure, including root planing – four orD4240 more contiguous teeth or tooth bounded spaces perquadrantGingival flap procedure, including root planing – one toD4241 three contiguous teeth or tooth bounded spaces perquadrantD4245 Apically positioned flapD4249 Clinical crown lengthening – hard tissueOsseous surgery (including elevation of a full thicknessD4260 flap entry and closure) – four or more contiguous teethor tooth bounded spaces per quadrantOsseous surgery (including elevation of a full thicknessD4261 flap entry and closure) – one to three contiguous teethor tooth bounded spaces, per quadrantBone replacement graft – retained natural tooth- firstD4263site in quadrantBone replacement graft – retained natural tooth- eachD4264additional site in quadrantBiologic materials to aid in soft and osseous tissueD4265regenerationD4266 Guided tissue regeneration – resorbable barrier, per siteGuided tissue regeneration – nonresorbable barrier, perD4267site (includes membrane removal)D4268 Surgical revision procedure, per toothMaximum AllowanceNot A BenefitDRAFNot A BenefitEffective March 14, 2020Not A BenefitNot A BenefitNot A BenefitGlobal 350.00 245.00Not A BenefitNot A BenefitGlobalNot A BenefitNot A BenefitNot A BenefitSchedule of Maximum Allowances
Procedure Code DescriptionD4270Pedicle soft tissue graft procedureAutogenous Subepithelial connective tissue graftprocedures (including donor and recipient surgical sites),per first tooth, implant, or edentulous tooth position ingraftMesial/distal or proximal wedge procedure, single tooth(when not performed in conjunction with surgicalprocedures in the same anatomical area)Non-Autogenous connective soft tissue allograft(including recipient site and donor material) first tooth,implant, or edentulous tooth position in graftCombined connective tissue and double pedicle graft,per toothFree soft tissue graft procedure (including recipient anddonor surgical sites surgery), first tooth, implant, oredentulous tooth position in graftFree soft tissue graft procedure (including recipient anddonor surgery surgical sites surgery), each additionalcontiguous tooth, implant or edentulous tooth positionin same graft siteAutogenous connective tissue graft procedure (includingdonor and recipient surgical sites) - each additionalcontiguous tooth, implant or edentulous tooth positionin same graft siteNon-autogenous connective tissue graft procedure(including donor and recipient surgical sites) - eachadditional contiguous tooth, implant or edentulous toothposition in same graft siteProvisional splinting – intracoronalProvisional splinting – extracoronalPeriodontal scaling and root planing – four or more teethper quadrant (for beneficiaries in a SNF or ICF)Periodontal scaling and root planing – four or more teethper quadrantPeriodontal scaling and root planing – one to threeteeth, per quadrant (for beneficiaries in a SNF or 1D4341D4341D4342Effective DateNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitAFD4273Maximum AllowanceTCDTCodesEffective March 14, 2020Not A BenefitNot A BenefitNot A BenefitMarch 14, 2020Not A BenefitMarch 14, 2020Not A BenefitNot A Benefit 70.00 50.00 50.00Schedule of Maximum Allowances
CDTCodesD4342D4346D4355Procedure Code DescriptionPeriodontal scaling and root planing – one to threeteeth, per quadrantScaling in presence of generalized moderate or severegingival inflammation- full mouth, after oral evaluationFull mouth debridement to enable comprehensiveevaluation and diagnosis on a subsequent visitMaximum Allowance 30.00GlobalMay 16, 2020Global 75.00July 15, 2016Localized delivery of antimicrobial agents via a controlledGlobalrelease vehicle into diseased crevicular tissue, per tooth 130.00D4910 Periodontal maintenance 55.00Unscheduled dressing change (by someone other thanD4920 45.00treating dentist or their staff)D4921 Gingival irrigation- per quadrantGlobalD4999 Unspecified periodontal procedure, by reportBy ReportProsthodontic (Removable) ProceduresD5110 Complete denture – maxillary 450.00D5120 Complete denture – mandibular 450.00D5130 Immediate denture – maxillary 450.00D5140 Immediate denture – mandibular 450.00Maxillary partial denture – resin base (including anyD5211 conventional clasps, retentive/clasping materials, rests 250.00and teeth)Mandibular partial denture – resin base (including anyD5212 conventional clasps, retentive/clasping materials, rest 250.00and teeth)Maxillary partial denture – cast metal framework withD5213 resin denture bases (including any conventional clasps, 470.00rest and teeth)Mandibular partial denture – cast metal framework withD5214 resin denture bases (including any conventional clasps, 470.00rest and teeth)Immediate maxillary partial denture –resin baseD5221Not A Benefit(including any conventional clasps, rests and teeth)Immediate mandibular partial denture –resin baseD5222Not A Benefit(including any conventional clasps, rests and teeth)DRAFTD4381Effective DateEffective March 14, 2020May 16, 2018March 14, 2020July 10, 2019July 10, 2019March 14, 2020March 14, 2020Schedule of Maximum Allowances
22D5510D5511D5512Immediate maxillary partial denture –cast metalframework with resin denture bases (including anyconventional clasps, rests and teeth)Immediate mandibular partial denture –cast metalframework with resin denture bases (including anyconventional clasps, rests and teeth)Maxillary partial denture - flexible base (including anyconventional clasps, rests, and teeth)Mandibular partial denture - flexible base (including anyconventional clasps, rests, and teeth)Removable unilateral partial denture – one piece castmetal (including clasps and teeth)Removable unilateral partial denture – one piece castmetal (including clasps and teeth), maxillaryRemovable unilateral partial denture – one piece castmetal (including clasps and teeth), mandibularAdjust complete denture – maxillaryAdjust complete denture – mandibularAdjust partial denture – maxillaryAdjust partial denture – mandibularRepair broken complete denture baseRepair broken complete denture base, mandibularRepair broken complete denture base, maxillaryReplace missing or broken teeth – complete denture(each tooth)Repair resin denture baseRepair resin partial denture base, mandibularRepair resin partial denture base, maxillaryRepair cast frameworkRepair cast partial denture framework, mandibularRepair cast partial denture framework, maxillaryRepair or replace broken clasp- retentive/claspingmaterials per toothReplace broken teeth – per Effective DateNot A BenefitMarch 14, 2020Not A BenefitMarch 14, 2020Not A BenefitTD5223Procedure Code DescriptionMaximum AllowanceNot A BenefitNot A BenefitAFCDTCodesEffective March 14, 2020March 14, 2020Not A BenefitMarch 14, 2020Not A BenefitMarch 14, 2020 25.00 25.00 25.00 25.00 50.00 50.00 50.00March 14, 2020March 14, 2020March 14, 2020 50.00 60.00 60.00 60.00 230.00 230.00 230.00March 14, 2020March 14, 2020March 14, 2020March 14, 2020March 14, 2020March 14, 2020 100.00 50.00Schedule of Maximum Allowances
CDTCodesProcedure Code DescriptionAdd tooth to existing partial dentureAdd clasp to existing partial denture- per toothReplace all teeth and acrylic on cast metal frameworkD5670(maxillary)Replace all teeth and acrylic on cast metal frameworkD5671(mandibular)D5710 Rebase complete maxillary dentureD5711 Rebase complete mandibular dentureD5720 Rebase maxillary partial dentureD5721 Rebase mandibular partial dentureD5730 Reline complete maxillary denture (chairside)D5731 Reline complete mandibular denture (chairside)D5740 Reline maxillary partial denture (chairside)D5741 Reline mandibular partial denture (chairside)D5750 Reline complete maxillary denture (laboratory)D5751 Reline complete mandibular denture (laboratory)D5760 Reline maxillary partial denture (laboratory)D5761 Reline mandibular partial denture (laboratory)D5810 Interim complete denture (maxillary)D5811 Interim complete denture (mandibular)D5820 Interim partial denture (maxillary)D5821 Interim partial denture (mandibular)D5850 Tissue conditioning, maxillaryD5851 Tissue conditioning, mandibularD5860 Overdenture – complete, by report[D5861 Overdenture – partial, by reportD5862 Precision attachment, by reportD5863 Overdenture – complete maxillaryD5864 Overdenture – partial maxillaryD5865 Overdenture – complete mandibularD5866 Overdenture – partial mandibularReplacement of replaceable part of semi-precision orD5867precision attachment (male or female component)Effective Date 60.00 100.00Not A BenefitNot A BenefitNot A BenefitNot A BenefitNot A BenefitNot A Benefit 70.00 70.00 70.00 70.00 140.00 140.00 140.00 140.00Not A BenefitNot A BenefitNot A BenefitNot A Benefit 50.00 50.00 450.00Not A BenefitGlobal 450.00Not A Benefit 450.00Not A BenefitDRAFTD5650D5660Maximum AllowanceEffective March 14, 2020March 14, 2020March 14, 2020March 14, 2020March 14, 2020March 14, 2020March 14, 2020Not A BenefitSchedule of Maximum Allowances
CDTCodesProcedure Code DescriptionModification of removable prosthesis following implantsurgeryD5876 Add metal substructure to acrylic full denture (per arch)Unspecified removable prosthodontic procedure, byD5899reportMaxillofacial Prosthetic ProceduresD5911 Facial moulage (sectional)D5912 Facial moulage (complete)D5913 Nasal prosthesisD5914
Medi-Cal Dental Schedule of Maximum Allowances 1. Fees payable to providers by Medi-Cal Dental for covered services shall be the LESSER of: a. provider's billed amount b. the maximum allowance set forth in the schedule below 2. Refer to your Medi -Cal Dental Program Provider Handbook for specific procedure instructions and program limitations .
