Maxillofacial Dental Services.

22 CCR 51506.1

§ 51506.1. Maxillofacial Dental Services. Code Maximum Allowances DIAGNOSTIC SERVICES 9950 Clinical Examination and Consultation, Including Study Models $51.99 9952 Prosthetic Evaluation and Treatment Plan, Including Study Models 9955 TMJ Series radiographs 9956 Cephalometric Head Film, single, first film, Including tracing 9957 Cephalometric Head Film, Each Additional film, Including tracing 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 9968 Palatal lift, permanent, cast framework 1,115.78 9970 Obturator immediate surgical, routine 9971 Obturator immediate surgical, complex 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 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 9994 Occlusal balancing, altering centric relation, including records and/or models 9995 Orthopedic stabilizing appliance, disocclusion splint 9996 Postoperative visits, symptomatic care and counseling 9998 Unlisted therapeutic service By Report