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Insured Dental Services Tariff Regulations

made under clause 13(1)(c) and subsection 17(2) of the

Health Services and Insurance Act

R.S.N.S. 1989, c. 197

O.I.C. 2022-132 (effective June 1, 2022), N.S. Reg. 98/2022

amended to O.I.C. 2023-167 (effective July 4, 2023), N.S. Reg. 109/2023



Table of Contents


Please note: this table of contents is provided for convenience of reference and does not form part of the regulations.
Click here to go to the text of the regulations.

 

 

Citation

Definitions

Tariff of fees

Insurance of last resort for certain programs

Services must be provided in the Province

 

Schedule A—Cleft Palate/Craniofacial Program

 

Part 1: Diagnostic—01000–09999

Examinations

Radiographs

Tests and Laboratory Examinations

Photographs, Diagnostic

Casts, Diagnostic

Case Presentation

 

Part 2: Endodontics—30000-39999

Pulp Chamber, Treatment of (excluding final restoration)

Root Canal Therapy

Periapical Services

Endodontic, Procedures, Miscellaneous

 

Part 3: Oral and Maxillofacial Surgery—70000–79999

Removals (Extractions), Erupted Teeth

Removals (Extractions), Surgical

Surgical Incisions

Treatment of Fractures

Maxillofacial Deformities, Treatment of

Hemorrhage, Control of

Grafts, Surgical

Post-Surgical Care

Implantology

 

Part 4: Orthodontics—80000-89999

Orthodontic Services, Observations and Adjustments

Appliances, Active, for Tooth Guidance or Minor Tooth Movement

Comprehensive Orthodontic Treatment

 

Part 5: Periodontics—40000–49999

Desensitization

Periodontal Services, Surgical

Periodontal Procedures, Adjunctive

Occlusion

Root planing, Periodontal

Chemotherapeutic and/or Antimicrobial Agents

Appliances

Periodontal Services, Miscellaneous

 

Part 6: Preventive—10000–19999

Preventive Services, Other

Space Maintainers

 

Part 7: Prosthetics—Removable—50000–59999

Dentures, Complete

Dentures, Partial, Acrylic

Dentures, Partial, Cast with Acrylic Base

Dentures, Adjustments

Dentures, Repairs/Additions

Dentures, Duplication, Relining, Rebasing, and Remaking

Dentures, Tissue Conditioning

Dentures, Miscellaneous Services

 

Part 8: Prosthodontics—Fixed—60000–69999

Fixed Bridges

Fixed Bridge Retainers

Fixed Prosthodontics, Abutments/Retainers, Miscellaneous Services

Fixed Prosthetics, Other Services

 

Part 9: Restorative Services—20000–29999

Caries, Trauma and Pain Control (permanent teeth only)

Restorations, Amalgam

Restorations, Prefabricated, Full Coverage

Restorations, Tooth-coloured

Restorations, tooth-coloured, permanent posteriors—bonded

Posts

Crowns

Copings, Metal/Plastic, Transfer (Thimble Type)

Veneer, Laboratory Processed

Repairs

Restorative Procedures, Overdentures

Restorative Services, Other

 

Schedule B—Children’s Oral Health Program

 

Part 1: Diagnostic—01000–09999

Examinations

Radiographs

Tests and Laboratory Examinations

Casts, Diagnostic

 

Part 2: Preventive Services—10000–19999

Scaling

Topical Fluoride Applications

Preventive Services, Other

Space Maintainers

 

Part 3: Restorative Services—20000–29999

Caries, Trauma and Pain Control (permanent teeth only)

Restorations, Amalgam

Restorations, Prefabricated, Full Coverage

Restorations, Tooth-coloured

Crowns

Endodontics

Root Canal Therapy

Periapical Services

 

Part 4: Periodontics—40000–49999

Desensitization

Periodontal Procedures, Adjunctive

 

Part 5: Prosthetics—Removable—50000–59999

 

Part 6: Oral and Maxillofacial Surgery—70000–79999

Removals (Extractions), Erupted Teeth

Removals (Extractions), Surgical

Surgical Incisions

Treatment of Fractures

Hemorrhage, Control of

Post-Surgical Care

 

Part 7: Adjunctive General Services—90000–99999

Anesthesia, Conscious Sedation

 

Schedule C—Oral and Maxillofacial Surgery

 

Part 1: Diagnostic—01000–09999

 

Part 2: Oral and Maxillofacial Surgery—70000–79999

Removals

Removals (Extractions), Surgical

Apicoectomy

Remodeling and Recontouring Oral Tissues

Surgical Excision

Surgical Incisions

Fractures, Treatment of

Maxillofacial Deformities, Treatment of

Temporomandibular Joint Dysfunctions, Treatment of

Oral Surgery Procedures, Other

Hemorrhage, Control of

Post-Surgical Care

Emergency Office Procedures

 

Schedule D—Maxillofacial Prosthodontics Program

 

Part 1: Examination and Diagnosis

 

Part 2: Prosthetics, Removable—50000–59999

Dentures, Complete

Dentures, Partial, Acrylic

Dentures, Partial, Cast with Acrylic Base

Dentures, Adjustments

Dentures, Repairs/Additions

Dentures, Duplication, Relining and Rebasing

Dentures, Tissue Conditioning

Dentures, Miscellaneous Services

Prostheses

 

Schedule E—Individuals with Special Needs Oral Health Program

 

Part 1: Diagnostic—01000–09999

Examinations

Radiographs (including radiographic examinations and interpretation)

Tests and Laboratory Examinations

Casts, Diagnostic

 

Part 2: Preventive Services—10000–19999

Preventive Scaling

Topical Fluoride Applications

Preventive Services, Other

Space Maintainers

 

Part 3: Restorative Services—20000–29999

Caries, Trauma and Pain Control (permanent teeth only)

Restorations, Amalgam

Restorations, Prefabricated, Full Coverage

Restorations, Tooth-Coloured

Crowns

Endodontics

Root Canal Therapy

Periapical Services

Open and drain (separate emergency procedures)

Opening through artificial crown (in addition to procedures)

Bleaching, non-vital

 

Part 4: Periodontics—40000–49999

Desensitization

Periodontal Procedures, Adjunctive

 

Part 5: Prosthetics–Removable—50000–59999

Dentures, partial, acrylic, with wrought/cast clasps and/or rests

 

Part 6: Oral and Maxillofacial Surgery—70000–79999

Removals (Extractions), Erupted Teeth

Removals (Extractions), Surgical

Surgical Incisions

Treatment of Fractures

Hemorrhage, Control of

Post-surgical Care

 

Part 7: Adjunctive General Services—90000–99999

Anesthesia, Conscious Sedation

 


 


Citation

1        These regulations may be cited as the Insured Dental Services Tariff Regulations.


Definitions

2        (1)    In these regulations, the following definitions apply:

 

“+ E” means additional material expenses;

 

“+ L” means laboratory services;

 

“Dentists Guide” means the Dentists Guide published by the Department of Health and Wellness;

 

“GP” means general practitioner;

 

“IC” means independent consideration;

 

“insured dental services” means the insured dental services referred to in Section 10 of the MSI Regulations and prescribed in these regulations;

 

“MSI Regulations” means the regulations respecting insured professional services and the MSI plan made under subsection 17(2) of the Act;

 

“PA” means pre-approval;

 

“SP” means specialist practitioner.

 

          (2)    A term defined in Section 1 of the MSI Regulations has the same meaning when used in these regulations.


Tariff of fees

3        (1)    The tariff of fees for insured dental services is as set out in the following schedules to these regulations:

 

                   (a)      Schedule A—Cleft Palate/Craniofacial Program;

 

                   (b)     Schedule B—Children’s Oral Health Program;

 

                   (c)      Schedule C—Oral and Maxillofacial Surgery;

 

                   (d)     Schedule D—Maxillofacial Prosthodontics Program;

 

                   (e)      Schedule E—Individuals with Special Needs Oral Health Program.

 

          (2)    The tariff of fees for insured dental services must be administered in accordance with the Dentists Guide.


Insurance of last resort for certain programs

4        (1)    Coverage under the following programs is insurance of last resort and no amount is payable for any services under those programs if rendered to a resident to whom or for whom a benefit in respect of those services has been paid or would be payable if claimed under any contract or plan of insurance that applies to that resident:

 

                   (a)      Schedule A—Cleft Palate/Craniofacial Program;

 

                   (b)     Schedule B—Children’s Oral Health Program;

 

                   (c)      Schedule E—Individuals with Special Needs Oral Health Program.

 

          (2)    If a partial benefit for a service under a program listed in subsection (1) has been paid or would be payable for a resident if claimed under any contract or plan of insurance that applies to that resident, any outstanding costs are billable directly to the Province and are payable by the Province.


Services must be provided in the Province

5        Services performed outside of the Province are not insured dental services and no coverage is provided for these services under these regulations.


 ________________________________________________________________ 

Schedule A—Cleft Palate/Craniofacial Program


The Cleft Palate/Craniofacial Program provides insured dental services for residents with craniofacial anomalies that directly influence the growth and development of the dentoalveolar and craniofacial structures.


These residents are eligible for insured coverage for basic dental services through the Children’s Oral Health Program (Schedule B) and other services under this Schedule as considered necessary as a result of the anomaly, so long as they meet the eligibility requirements for those services.



Part 1: Diagnostic—01000–09999

 

 

GP

Fee

SP

Fee

Examinations

 

1. Examinations and diagnosis, complete oral

(Including: history, medical and dental clinical examination and diagnosis of hard and soft tissues, including carious lesions, missing teeth, determination of pocket depth and location of periodontal pockets, gingival contours, mobility of teeth, interproximal tooth contact relationships, occlusion of teeth, pulp vitality tests, if necessary, and any other pertinent factors.

Radiographs extra as required.)

1101

Examination and diagnosis, complete, primary dentition, including extended examination and diagnosis on primary dentition, recording history, charting, treatment planning and case presentation, including above description

36.12

68.04

1102

Examination and diagnosis, complete, mixed dentition

47.04

97.44

1103

Examination and diagnosis, complete, permanent dentition

63.84

132.72

 

2. Examinations and diagnosis, limited oral

1201

Examination and diagnosis, limited, oral, new patient: examination with mirror and explorer of hard and soft tissues, including checking occlusion and appliances, but not including specific tests as for 01101, 01102, 01103

30.36

37.26

1202

Examination and diagnosis, limited oral, previous patient (recall): examination and diagnosis with mirror and explorer of hard and soft tissues, including checking occlusion and appliances, but not including specific tests, as for 01101, 01102, 01103

23.18

29.37

 

3. Specific oral examinations

1204

Examination and diagnosis, specific: examination, diagnosis and evaluation of a specific situation in a localized area (includes x-rays)

36.24

49.29

 

4. Emergency oral examinations

1205

Examination and diagnosis, emergency: examination to investigate discomfort and/or infection in a localized area (includes x-rays)

36.24

49.29

5201

Consultation, specialist—in office

PA

81.81

5202

2 units of time

PA

155.40

5209

Each additional unit of time over 2

PA

77.70

 

5. Examinations and diagnosis, prosthodontic

1701

Examination and diagnosis, prosthodontic, edentulous: extended examination of the edentulous mouth, including detailed medical and dental history (incl. prosthetic history), visual and digital examination of the oral structures, head and neck (incl. TMJ), lips, oral mucosa, tongue, oral pharynx, salivary glands and lymph nodes, and including evaluation for implant-supported or retained prosthesis.

 


154.40

1702

Examination and diagnosis, prosthodontic, specific

 

60.98

1703

Examination prosthodontic, fixed oral rehabilitation, to include: (a) history, medical and dental; (b) clinical examination of hard and soft tissues, including carious lesions, missing teeth, location of periodontal pockets and determination of pocket depth, gingival contours, mobility of teeth, interproximal tooth contact relationships, occlusion of teeth, pulp vitality tests, where necessary, and any other pertinent factors; (c) evaluation of specific sites for implant-supported or retained prosthesis; (d) radiographs extra, as required.

 

176.18

Radiographs

(includes radiographic examination and interpretation)

 

1. Radiographs, intra-oral

 

 

2101

Radiographs, intra-oral, pedodontic, complete series
(minimum of 12 films including bitewings)

104.97

107.07

2102

Radiographs, intra-oral, adult, complete series
(minimum of 16 films including bitewings)

104.97

107.07

 

2. Radiographs, intra-oral, periapical

 

 

2111

Single film

12.87

13.14

2112

2 films

16.91

17.24

2113

3 films

24.86

25.36

2114

4 films

29.70

30.30

2115

5 films

34.53

35.23

2116

6 films

39.51

40.30

2117

7 films

44.27

45.15

2118

8 films

49.18

50.17

2119

9 films

54.01

55.09

2120

10 films

58.93

60.10

2121

11 films

64.23

65.51

2122

12 films

69.98

71.38

2123

13 films

76.29

77.82

2124

14 films

83.15

84.81

2125

15 films

88.13

89.89

 

3. Radiographs, intra-oral, occlusal

 

 

2131

Single film

31.47

32.10

2132

2 films

49.18

50.17

2133

3 films

66.89

60.90

2134

4 films

84.53

73.50

 

4. Radiographs, intra-oral, bitewing

 

 

2141

Single film

12.87

13.14

2142

2 films

16.91

17.24

2143

3 films

24.86

25.36

2144

4 films

29.70

30.30

 

5. Radiographs, extra-oral

 

 

2201

Single film

31.47

32.10

2202

2 films

49.18

50.17

2203

3 films

66.89

68.22

2204

4 films

84.53

86.22

 

6. Radiographs, postero-anterior and lateral skull and facial bone

 

2301

Single film

PA

32.10

2302

2 films

PA

50.17

2303

3 films

PA

68.22

2304

Sinus examination: minimum 4 films identified as: (1) Waters (2) Calwell (3) Lateral Skull (4) Basal

PA

86.22

 

7. Radiographs, sialography

 

 

2401

Single film

PA

PA

2402

2 films

PA

PA

2409

Each additional film over 2

PA

PA

 

8. Radiopaque dyes, use of, to demonstrate lesions

 

 

2411

1 unit of time

PA

PA

2412

2 units of time

PA

PA

2419

Each additional unit of time over 2

PA

PA

 

9. Radiographs, temporomandibular joint

 

 

2501

Single film

PA

32.10

2502

2 films

PA

50.17

2503

3 films

PA

68.22

2504

4 films (minimum examination closed and open each side)

PA

86.22

2509

Each additional film over 4 

PA

PA

 

10. Radiographs, panoramic

 

 

2601

Single film

54.09

55.17

 

11. Radiographs, cephalometric

 

 

2701

Single film

54.09

55.17

2702

2 films

88.06

89.83

 

12. Radiographs, cephalometric, tracing and interpretation

 

2751

1 unit of time

PA

PA

2752

2 units of time

PA

PA

2759

Each additional unit of time over 2

PA

PA

 

13. Radiographs, interpretation

 

 

2801

(MSI: for radiographs exposed on hospital equipment)
MSI: paid at 1/2 regular fee

 

 

 

14. Radiographs, hand and wrist

 

 

2801

Radiographs, hand and wrist (as a duplicate aid for dental treatment), per case

PA

PA

 

15. Radiographs, tomography

 

 

2931

Single view

PA

PA

2932

2 views

PA

PA

2933

3 views

PA

PA

2934

4 views

PA

PA

2939

Each additional view over 4

PA

PA

 

16. Radiographic guide (includes diagnostic wax-up with radio-opaque markers for pre-surgical assessment of alveolar bone and vital structures as potential osseo-integrated implant site(s))

 

2951

Maxillary guide + L + E

 

160.00 + L

2952

Mandibular guide + L + E

 

160.00 + L

 

17. Template, surgical (includes diagnostic wax-up. Also used to locate and orient osseo-integrated implants)

 

3001

Maxillary Template + L + E

 

320.00

incl lab

3002

Mandibular Template + L + E

 

320.00

incl lab

Tests and Laboratory Examinations

 

1. Tests, microbiological

 

 

4101

Microbiological test for the determination of pathological agents + L

32.52

33.17

 

2. Tests, caries susceptibility

 

 

4201

Bacteriological test for the determination of dental caries susceptibility + L

31.80

32.45

 

3. Tests, histological

 

 

 

Test, histological, soft tissue

 

 

4311

Biopsy, soft oral tissue—by puncture + L

75.98

85.05

4312

Biopsy, soft oral tissue—by incision + L

75.98

85.05

4313

Biopsy, soft oral tissue—by aspiration + L

75.98

85.05

 

Tests, histological, hard tissue

 

 

4321

Biopsy, hard oral tissue—by puncture + L 

87.50

89.25

4322

Biopsy, hard oral tissue—by incision + L 

87.50

89.25

4323

Biopsy, hard oral tissue—by aspiration + L

87.50

89.25

 

4. Tests, cytological

 

 

4401

Cytological smear from the oral cavity + L

31.80

32.45

 

5. Tests, pulp vitality

 

 

4501

1 unit of time

26.89

27.43

4509

Each additional unit of time

26.89

27.43

 

6. Reports, laboratory

 

 

4601

Report, microbiological by oral microbiologist

PA

PA

4602

Report, histological by oral pathologist

PA

PA

4603

Report, cytological by oral pathologist

PA

PA

4604

Reports, other

PA

PA

 

7. Tests and laboratory examinations, miscellaneous (equilibration, casts, diagnostic (pilot equilibration) for extensive or complicated restorative dentistry + L)

 

4711

1 unit of time

PA

PA

4712

2 units of time

PA

PA

4713

3 units of time

PA

PA

4714

4 units of time

PA

PA

4719

Each additional unit of time over 4

PA

PA

 

Wax up, diagnostic (to evaluate cosmetic and/or preparation design and/or occlusal considerations) (gnathological wax up) + L

 

 

4721

1 unit of time

PA

PA

4722

2 units of time

PA

PA

4723

3 units of time

PA

PA

4724

4 units of time

PA

PA

4729

Each additional unit of time over 4

PA

PA

 

Split cast mounting, diagnostic + L

 

 

4731

1 unit of time

PA

PA

4732

2 units of time

PA

PA

4733

3 units of time

PA

PA

4734

4 units of time

PA

PA

4739

Each additional unit of time over 4

PA

PA

 

Interpretation of models from another source

 

 

4741

First unit of time

PA

PA

4749

Each additional unit of time

PA

PA

Photographs, Diagnostic

4801

Single photograph

16.67

17.01

4802

2 photographs

33.33

33.60

4803

3 photographs

50.01

38.85

4809

Each additional photograph over 3

16.67

17.85

Casts, Diagnostic

 

1. Cast, diagnostic, unmounted

 

 

4911

Cast, diagnostic, unmounted + L 

32.52

45.62

4912

Cast, diagnostic, unmounted, duplicate + L

 

 

 

2. Cast, diagnostic, mounted

 

 

4921

Cast, diagnostic, mounted + L 

40.95

PA

4922

Cast, diagnostic, mounted using face bow transfer + L

67.20

PA

4923

Cast, diagnostic, mounted, using face bow + occlusal records + L

91.50

PA

4924

Cast, diagnostic, mounted using fully adjustable articulator + L (used with 04942)

PA

PA

 

3. Casts, diagnostic, orthodontic

 

 

4931

Cast, diagnostic, orthodontic (unmounted, angle trimmed and soaped) + L

PA

45.62

Case Presentation

 

1. Treatment planning (This service is only for extra time spent on unusually complicated cases or where the patient demands unusual time in explanation or where diagnostic material is received from another source. Usual case presentation time and usual treatment planning time are implicit in the examination and diagnosis fee and in the radiographic interpretation fee.)



 

5101

1 unit of time

 

86.40

5102

2 units of time

 

172.80

 

2. Radiographs, cone beam computerized tomography (CBCT)

 

 

Radiographs, CBCT, acquisition

 

7011

Small field of view (e.g. sextant or part of; isolated temporomandibular joint)

 

174.40

7012

Large field of view (1 arch)

 

IC

7013

Large field of view (2 arches)

 

IC

 

Radiographs, CBCT, image processing

 

7021

1 unit of time

 

IC

7022

2 units

 

IC

7027

One half unit

 

IC

7029

Each additional unit over 2

 

IC

 

Radiographs, CBCT, interpretation

 

 

7031

1 unit of time

 

71.92

7032

2 units

 

143.84

7037

One half unit

 

36.00

7039

Each additional unit over 2

 

71.92

 

Radiographs, CBCT, acquisition, processing and interpretation

 

 

7041

Small field of view (e.g., sextant or part of; isolated temporomandibular joint) 

 

285.60

7042

Large field of view (1 arch)

 

359.20

7043

Large field of view (2 arches)

 

423.20

 


Part 2: Endodontics—30000-39999

 

 

Pulp Chamber, Treatment of (excluding final restoration)

 

1. Pulpotomy

 

 

 

Pulpotomy vital, permanent teeth (as a separate emergency procedure)

 

 

32221

Anterior and bicuspid teeth 

75.33

92.13

32222

Molar teeth

75.33

92.13

 

Pulpotomy, vital, primary teeth

 

 

32231

Primary tooth as a separate procedure

60.54

76.78

32232

Primary tooth, concurrent with restorations (but excluding final restoration)

60.54

75.27

 

2. Pulpectomy (as a separate emergency procedure)

 

 

 

Pulpectomy, permanent teeth/retained primary teeth

 

 

32311

1 canal

86.77

89.17

32312

2 canals

134.22

137.11

32313

3 canals

PA

PA

32314

4 canals or more

PA

PA

 

Pulpectomy, primary teeth

 

 

32321

Anterior tooth

78.75

88.50

32322

Posterior tooth

116.55

128.47

Root Canal Therapy

(includes treatment plan, clinical procedures (e.g., pulpectomy, biomechanical preparation, chemotherapeutic treatment and obturation), with appropriate radiographs)

 

1. Root canals, permanent teeth, retained primary teeth (including clinical procedures with appropriate radiographs, excluding final restoration)

 

33111

1 canal

342.74

419.55

33121

2 canals

502.03

604.10

33131

3 canals

674.30

825.29

33141

4 canals or more

837.14

988.39

 

2. Root canals, primary teeth

 

 

33401

1 canal

117.71

PA

33402

2 canals

177.68

PA

33403

3 canals or more

238.02

294.30

 

3. Apexification/apical closure/induction of hard tissue repair (including biomechanical preparation and placement of dentogenic media)

 

33601

1 canal

130.55

159.77

33602

2 canals

172.85

230.56

33603

3 canals

220.13

302.33

33604

4 canals or more

395.47

455.60

 

4. Re-insertion of dentogenic media per visit

 

 

33611

1 canal

58.19

68.59

33612

2 canals

58.19

68.59

33613

3 canals

58.19

68.59

33614

4 canals or more

58.19

68.59

Periapical Services

 

1. Apicoectomy/apical curettage

 

 

 

Maxillary anterior

 

 

34111

1 root

179.03

219.16

34112

2 roots

255.79

298.23

 

Maxillary bicuspid

 

 

34121

1 root

239.40

311.24

34122

2 roots

318.15

371.60

34123

3 roots or more

397.95

431.80

 

Maxillary molar

 

 

34131

1 root

254.37

PA

34132

2 roots

336.64

PA

34133

3 roots

401.76

PA

34134

4 roots or more

452.37

482.77

 

Mandibular anterior

 

 

34141

1 root

179.03

219.16

34142

2 roots or more

255.79

284.03

 

Mandibular bicuspid

 

 

34151

1 root

240.45

311.24

34152

2 roots

318.15

371.60

34153

3 roots or more

400.05

431.80

 

Mandibular molar

 

 

34161

1 root

254.37

311.24

34162

2 roots

336.64

371.60

34163

3 roots

401.76

431.80

34164

4 roots or more

452.37

482.77

 

2. Retrofilling

 

 

34211

1 canal

71.17

87.11

34212

2 or more canals

86.24

108.60

 

Maxillary bicuspid

 

 

34221

1 canal

71.17

87.11

34222

2 canals

86.24

108.60

34223

3 canals

104.34

135.77

34234

4 or more canals

116.97

152.71

 

Maxillary molar

 

 

34321

1 canal

73.22

87.11

34322

2 canals

90.36

108.60

34323

3 canals

104.34

142.55

34324

4 or more canals

116.97

152.71

 

Mandibular anterior

 

 

34241

1 canal

71.17

87.11

34242

2 or more canals

86.24

108.60

 

Mandibular bicuspid

 

 

34251

1 canal

71.17

87.11

34252

2 canals

86.24

108.60

34253

3 canals

104.34

135.77

34254

4 or more canals

116.97

152.71

 

Mandibular molar

 

 

34261

1 canal

73.22

87.11

34262

2 canals

90.36

108.60

34263

3 canals

104.34

135.77

34264

4 or more canals

116.97

152.71

 

3. Enlargement, canal and/or pulp chamber (preparation of post space)

 

34601

Enlargement, canal and/or pulp chamber (preparation of post space)

PA

PA

34602

In calcified canals

PA

PA

Endodontic, Procedures, Miscellaneous

 

1. Isolation of endodontic tooth/teeth for asepsis

 

 

39101

Banding of tooth/teeth and/or contouring of tissue surrounding teeth to maintain aseptic operating field (per tooth)

86.45

105.72

 

Open and drain (separate emergency procedures)

 

 

39201

Anteriors and bicuspids

69.30

75.04

39202

Molars

69.30

75.04

 

Opening through artificial crown (in addition to procedures)

 

 

39211

Anteriors and bicuspids

85.65

87.36

39212

Molars

85.65

87.36

 

2. Bleaching, non-vital

 

 

 

Bleaching endodontically treated tooth/teeth

 

 

39311

1 unit of time

56.50

PA

39312

2 units of time

97.25

PA

39313

3 units of time

137.98

140.74

39319

Each additional unit of time (to a maximum of 3)

40.73

41.55

 


Part 3: Oral and Maxillofacial Surgery—70000–79999

 

 

Removals (Extractions), Erupted Teeth

 

1. Removals, erupted teeth, uncomplicated

 

 

 

Unless directly related to a developmental anomaly (supply details with claim) uncomplicated extractions are insured only in the case of
(1) pain, infection, trauma (2) ankylosis and (3) supernumerary teeth.

 

71101

Single tooth, uncomplicated

67.94

65.90

71109

Each additional tooth, same quadrant, same appointment

45.52

34.65

 

2. Removals, erupted teeth, complicated

 

 

71201

Odontectomy, (extraction), erupted tooth, surgical approach, requiring surgical flap and/or sectioning of tooth

146.65

178.48

71209

Each additional tooth, same quadrant

89.71

89.25

Removals (Extractions), Surgical

 

1. Removals, impactions, soft tissue coverage

 

 

 

Removals, impaction, requiring incision of overlying soft tissue and removal of the tooth

 

 

72111

Single tooth

146.65

178.48

72119

Each additional tooth, same quadrant

90.36

89.25

 

2. Removals, impactions, involving tissue and/or bone coverage

 

 

Removals, impaction, requiring incision of overlying soft tissue, elevation of a flap and either removal of bone and tooth or sectioning and removal of tooth

 

 

72211

Single tooth

177.68

294.09

72219

Each additional tooth, same quadrant

108.83

147.53


 

Removals, impaction, requiring incision of overlying soft tissue, elevation of a flap, removal of bone and sectioning of tooth for removal

 

 

72221

Single tooth

243.58

327.05

72229

Each additional tooth, same quadrant

151.05

163.54

 

3. Removals (extractions), residual roots

 

 

 

Removals, residual roots, erupted

 

 

72311

First tooth

53.85

65.90

72319

Each additional tooth, same quadrant

34.95

32.98

 

Removals, residual roots, soft tissue coverage

 

 

72321

First tooth

100.94

123.55

72329

Each additional tooth, same quadrant

63.33

128.45

 

Removals, residual roots, bone tissue coverage

 

 

72331

First tooth

209.93

256.89

72339

Each additional tooth, same quadrant

129.95

128.45

 

4. Post extraction bone preservation

 

 

 

Simple ridge preservation, alloplastic material
(+ E—not payable by MSI)

 

 

72411

First tooth

PA

PA

 

5. Surgical exposure of teeth

 

 

 

Surgical exposure, unerupted, uncomplicated, soft tissue coverage (includes operculectomy)

 

 

72511

Single tooth

185.68

237.03

72519

Each additional tooth, same quadrant

92.86

118.53

 

Surgical exposure, complex, hard tissue coverage

 

 

72521

Single tooth

185.68

237.03

72529

Each additional tooth, same quadrant

92.86

118.53

 

Surgical exposure, unerupted tooth, with orthodontic attachment

 

 

72531

Single tooth

204.56

250.51

72539

Each additional tooth, same quadrant

102.26

125.24

 

Surgical exposure, unerupted tooth, soft tissue coverage with positioning of attached gingivae

 

 

72541

Single tooth

PA

PA

 

Surgical exposure, unerupted tooth, hard tissue coverage with positioning of attached gingivae

 

 

72551

Single tooth

PA

PA

 

6. Surgical movement of teeth

 

 

 

Transplantation of erupted tooth

 

 

72611

First tooth

PA

PA

 

Transplantation of unerupted tooth

 

 

72621

First tooth

PA

PA

 

Repositioning, surgical

 

 

72631

First tooth

PA

PA

Surgical Incisions

 

1. Surgical incision and drainage and/or exploration, intra-oral soft tissue

 

75111

Intra-oral, surgical exploration, soft tissue

75.33

101.64

75112

Intra-oral, abscess, soft tissue

75.33

101.64

75113

Intra-oral, abscess, in major anatomical area with drain

75.33

101.64

 

2. Surgical incision and drainage and/or exploration, intra-oral hard tissue

 

75121

Intra-oral, abscess, hard tissue, trephination and drainage

PA

PA

Treatment of Fractures

It is understood that the majority of fractures will be treated in hospital and covered under Schedule C—Oral and Maxillofacial Surgery. However, independent consideration will be given for fractures treated in a dental office.

 

1. Replantation, avulsed tooth/teeth (including splinting)

 

 

76941

Replantation, first tooth

217.68

226.12

76949

Each additional tooth

110.82

113.10

 

2. Repositioning of traumatically displaced teeth

 

 

76951

1 unit of time

52.11

49.59

76952

2 units of time

104.22

99.18

76959

Each additional unit of time over 2

52.11

49.59

Maxillofacial Deformities, Treatment of

 

1. Osteotomy/ostectomy, ramus of the mandible

 

 

77101

Osteotomy, subcondylar, closed + L (virtual surgical planning)

 

3058.40 + L

77102

Osteotomy, subcondylar, open + L (virtual surgical planning)

 

4575.20 + L

77103

Osteotomy, ramus of the mandible, oblique, extra-oral + L (virtual surgical planning)

 

4575.20 + L

77104

Osteotomy, ramus of the mandible, oblique, intra-oral + L (virtual surgical planning)

 

4575.20 + L

77105

Osteotomy/ostectomy, body of the mandible + L (virtual surgical planning)

 

4575.20 + L

77106

Osteotomy, coronoidectomy + L (virtual surgical planning)

 

4575.20 + L

77107

Osteotomy, condylar neck + L (virtual surgical planning)

 

IC

77108

Osteotomy, sagittal split + L (virtual surgical planning)

 

4575.20 + L

 

2. Osteotomy, miscellaneous

 

 

77201

Osteotomy, oblique with bone graft + L (virtual surgical planning)

 

5346.40 + L

77202

Osteotomy, inverted “L” + L (virtual surgical planning)

 

4579.20 + L

77203

Osteotomy, “C” + L (virtual surgical planning)

 

4579.20 + L

77205

Osteotomy of the Ramus of the Mandible for Distraction Osteogenesis—Bilateral + L (virtual surgical planning)

 

1881.34 + L

77207

Activation of Distraction Device—Bilateral

 

140.00

77209

Removal of Distraction Device—Bilateral

 

286.16

 

3. Osteotomy, maxilla

 

 

77301

Osteotomy, maxilla, total + L (virtual surgical planning)

 

5346.40 + L

77302

Osteotomy, maxilla, total with bone graft + L (virtual surgical planning)

 

5346.40 + L

77303

Osteotomy, maxilla, Le Fort II with bone graft + L (virtual surgical planning)

 

IC

77304

Osteotomy, maxilla, Le Fort III + L (virtual surgical planning)

 

IC

77313

Osteotomy, Maxillary, LeFort I—for Distraction Osteogenesis + L (virtual surgical planning)

 

1881.34 + L

77316

Activation of Distraction Device—LeFort I Level

 

140.00

77319

Removal of Maxillary Distraction Device

 

286.16

 

4. Cleft surgery

 

 

77912

Secondary Unilateral Cleft Lip Repair

 

984.43

77914

Secondary Bilateral Cleft Lip Repair

 

1476.62

77916

Complex Reconstruction of Revision of Cleft Lip

 

2900.00

Hemorrhage, Control of

79403

Hemorrhage control, using compression and hemostatic agent

52.48

64.30

79404

Hemorrhage control, using hemostatic substance and sutures (including removal of bony tissue, if necessary)

52.48

64.30

Grafts, Surgical

 

Harvesting of Intraoral Tissue for Grafting to Operative Site

79511

Bone

 

581.12

Post-Surgical Care

(required by complications and unusual circumstances)

79605

Post-surgical care, alveolitis, treatment of (without anaesthesia)

44.44

54.53

79606

Post-surgical care, alveolitis, treatment of (with anaesthesia)

44.44

54.53

Implantology

(includes placement of implant, post-surgical care, uncovering

and placement of attachment but not prosthesis)

 

1. Implants, endosseous, integrated cylindrical

 

 

79951

First stage surgical placement, maxilla per implant (+ E—not covered)

PA

PA

79952

First stage surgical placement, mandible per implant (+ E—not covered)

PA

PA

79953

Second stage exposure and temporization, maxilla per implant (+ E—not covered)

PA

PA

79954

Second stage exposure and temporization, mandible per implant (+ E—not covered)

PA

PA

 

2. Implants, removal of

 

 

79991

First implant (uncomplicated)

PA

PA

79992

First implant (complicated)

PA

PA


Part 4: Orthodontics—80000-89999

Orthodontic Services, Observations and Adjustments

 

Recementation of fixed appliances, not including brackets

 

 

80651

1 unit of time

47.17

57.48

Appliances, Active, for Tooth Guidance or Minor Tooth Movement

 

1. Appliances, removable

 

 

 

Appliances, removable, space regaining

 

 

81113

Appliance, maxillary, bilateral + L

517.50

675.78

81114

Appliance, mandibular, bilateral + L

517.50

675.78

 

Appliances, removable, cross-bite correction

 

 

81121

Appliance, maxillary, simple + L

PA

1239.36

81122

Appliance, mandibular, simple + L

PA

1239.36

 

Appliances, removable, dental arch expansion

 

 

81131

Appliance, maxillary, simple + L

PA

PA

81132

Appliance, mandibular, simple + L

PA

PA

 

Appliances, removal, closure of diastemas

 

 

81141

Appliance, maxillary, simple + L

PA

PA

81142

Appliance, mandibular, simple + L

PA

PA

 

Appliances, removable, alignment of anterior teeth

 

 

81151

Appliance, maxillary, simple + L

PA

PA

81152

Appliance, mandibular, simple + L

PA

PA

 

2. Appliances, fixed or cemented

 

 

 

Appliance, fixed, space regaining (e.g., lingual or labial arch with molar bands, tubes, locks)

 

 

81211

Appliance, maxillary + L

PA

675.78

81212

Appliance, mandibular + L 

PA

675.78

 

Appliance, fixed, space regaining, unilateral

 

 

81221

Appliance, maxillary + L

PA

471.60

81222

Appliance, mandibular + L 

PA

471.60

 

Appliance, fixed, cross-bite correction—anterior
(as Phase I treatment)

 

 

81231

Appliance, maxillary + L

PA

1239.36

81232

Appliance, mandibular + L 

PA

1239.36

 

Appliance, fixed, cross-bite correction—posterior
(as Phase I treatment)

 

 

81241

Appliance, maxillary + L

PA

1239.36

81242

Appliance, mandibular + L 

PA

1239.36

81243

Appliance, two-molar band, hooked and elastics + L

PA

1239.36

 

Appliance, fixed, dental arch expansion

 

 

81251

Appliance, maxillary + L

PA

PA

81253

Appliance, maxillary, rapid expansion + L 

PA

PA

 

Appliance, fixed, closure of diastemas

 

 

81261

Appliance, maxillary, simple + L

PA

PA

81262

Appliance, mandibular, simple + L

PA

PA

 

Appliance, fixed, alignment of incisor teeth

 

 

81271

Appliance, maxillary, simple + L 

PA

PA

81272

Appliance, mandibular, simple + L 

PA

PA

 

Appliances, fixed, mechanical eruption tooth/teeth

 

 

81291

Appliance, maxillary + L

PA

PA

81292

Appliance, mandibular + L

PA

PA

 

3. Appliances, retention, orthodontic retaining appliances

 

 

 

Appliances, removable, retention

 

 

83101

Appliance, maxillary + L ($60.00 lab maximum)

PA

328.24

83102

Appliance, mandibular + L ($60.00 lab maximum)

PA

328.24

83103

Appliance, tooth positioner + L ($60.00 lab maximum)

PA

328.24

 

Appliances, fixed/cemented, retention

 

 

83201

Appliance, maxillary + L ($60.00 lab maximum)

PA

328.24

83202

Appliance, mandibular + L ($60.00 lab maximum)

PA

328.24

Comprehensive Orthodontic Treatment

 

1. Fixed appliance (includes formal full banded treatment and retention)

 

 

Permanent dentition

 

 

84101

Class I malocclusion (non-surgical case)

PA

5397.47

84101

Class I malocclusion (surgical case)

PA

5930.67

84201

Class II malocclusion (non-surgical case)

PA

6305.52

84201

Class II malocclusion (surgical case)

PA

6680.39

84301

Class III malocclusion (non-surgical case)

PA

7748.22

84301

Class III malocclusion (surgical case)

PA

9138.69

84401

Malocclusions not requiring complete banding

PA

PA

 

2. Removable appliance (includes removable appliance therapy and retention; e.g., functional appliances for mixed and primary dentition)

 

 

Permanent dentition

 

 

87101

Class I malocclusion + L 

PA

PA

87201

Class II malocclusion + L

PA

PA

87301

Class III malocclusion + L 

PA

PA

 

Mixed dentition

 

 

88101

Class I malocclusion + L 

PA

PA

88201

Class II malocclusion + L

PA

PA

88301

Class III malocclusion + L 

PA

PA


Part 5: Periodontics—40000–49999

Desensitization

This may involve application and burnishing of medicinal aids on the root or the use of a variety of therapeutic procedures. More than 1 appointment may be necessary.

41301

1 unit of time

33.10

33.76

41302

2 units of time

66.18

67.50

41309

Each additional unit of time over 2

33.10

33.76

Periodontal Services, Surgical

Includes local anesthetic, suturing and placing and removing initial surgical dressing.

A surgical site is an area that lends itself to 1 or more procedures.

 

1. Periodontal surgery, gingival curettage

 

 

 

Surgical curettage, including definitive root planing

 

 

42111

Per sextant

117.04

143.46

 

2. Periodontal surgery, gingivoplasty

 

 

42201

Per sextant

PA

205.14

 

3. Periodontal surgery, gingivectomy (the procedure by which gingival deformities are reshaped and reduced to create normal and functional form, when the pocket is uncomplicated by extension into the underlying bone; does not include limited re-contouring to facilitate restorative services)

 

 

Gingivectomy, uncomplicated

 

 

42311

Per sextant

PA

147.22

 

Gingivectomy, with curettage

 

 

42321

Per sextant

PA

161.95

 

Gingival fiber incision (supra crestal fibrotomy)

 

 

42331

Per tooth

PA

27.38

42339

Each additional tooth

PA

27.38

 

Soft tissue recontouring for crown lengthening

 

 

42341

Limited recontouring of tissue, per tooth

PA

76.56

 

4. Periodontal surgery, flap approach

 

 

 

Flap approach, with osteoplasty/ostectomy

 

 

42411

Per sextant

PA

300.75

 

Flap approach, with curettage of osseous defect

 

 

42421

Per sextant

PA

300.75

 

Flap approach, with curettage of osseous defect and osteoplasty

 

 

42431

Per sextant

PA

336.78

 

Flap approach, exploratory (for diagnosis)

 

 

42441

Per site

PA

74.10

 

Flap approach, with osteoplasty/ostoectomy for crown lengthening

 

 

42451

Per site

PA

300.75

 

5. Periodontal surgery, grafts

 

 

 

Grafts, soft tissue, pedicle (including apically or coronally positioned, lateral sliding and rotated flaps)

 

 

42511

Per site

PA

334.23

42512

Periosteal stimulation in addition to 42511

PA

367.65

 

Grafts, soft tissue, pedicle (coronally positioned)

 

 

42521

Per site

PA

334.23

42522

Periosteal stimulation in addition to 42521

PA

367.65

 

Grafts, free soft tissue

 

 

42531

Per site

PA

334.23

 

Grafts, soft tissue, pedicle, with free graft placed in pedicle donor site

 

 

42541

Per site

PA

334.23

 

Grafts, free connective tissue (for root coverage)

 

 

42551

Per site

PA

334.23

 

Grafts, free connective tissue (for ridge augmentation)

 

 

42561

Per site

PA

334.23

 

Grafts, connective tissue, pedicle with free graft for root coverage

 

 

42571

Per site

PA

334.23

 

Grafts, gingival onlay, for ridge augmentation

 

 

42581

Per site

PA

334.23

 

6. Periodontal surgery, grafts, osseous tissue

 

 

 

Grafts, osseous, autograft (including flap entry and closure)

 

 

42611

Per site (+ E—not covered)

PA

288.58

 

Grafts, osseous, allograft (including flap entry and closure)

 

 

42621

Per site (+ E—not covered)

PA

PA

 

7. Periodontal surgery, miscellaneous procedure

 

 

 

Guided tissue regeneration (including re-entry)

 

 

42711

Per site (+ E—not covered)

PA

PA

 

8. Periodontal surgery, miscellaneous procedures

 

 

 

Proximal wedge procedure (as a separate procedure)

 

 

42811

With flap curettage, per site

PA

PA

42819

With flap curettage and ostectomy/ostoplasty, per site

PA

PA

 

Post-Surgical periodontal treatment visit per dressing change

 

 

42821

1 unit of time

PA

PA

42822

2 units of time

PA

PA

42823

3 units of time

PA

PA

42829

Each additional unit of time over 3

PA

PA

 

Periodontal abscess or pericoronitis, may include 1 or more of the following procedures: lancing, scaling, curettage, surgery or medication

 

 

42831

1 unit of time

PA

PA

42832

2 units of time

PA

PA

42833

3 units of time

PA

PA

42834

4 units of time

PA

PA

42839

Each additional unit of time over 4

PA

PA

Periodontal Procedures, Adjunctive

When per joint is designated, the corresponding tooth code is represented by the mesial

of the tooth involved, except at the midline, where the tooth to the right is utilized.

 

1. Periodontal splinting or ligation, provisional, intra-coronal

 

 

“A” splint (acrylic, composite or amalgam, plus knurled wire)

 

 

43111

Per joint

PA

48.43

 

2. Periodontal splinting or ligation, provisional, extra-coronal

 

 

Acid etch joint restorations (per joint)

 

 

43211

Per joint

PA

63.46

 

Acid etch, interproximal enamel splint

 

 

43221

Per joint

PA

63.46

 

Wire ligation

 

 

43231

Per joint

PA

63.46

 

Wire ligation, acrylic covered

 

 

43241

Per joint

PA

63.46

 

Dental floss ligation

 

 

43251

Per joint

PA

63.46

 

Orthodontic band splint

 

 

43261

Per band

PA

63.46

 

Orthodontic band splint

 

 

43271

Per abutment + L

PA

63.46

 

Removal of fixed periodontal splints

 

 

43281

1 unit of time

PA

PA

43289

Each additional unit of time

PA

PA

Occlusion







 

Occlusal adjustment/equilibration:

(a) may require several sessions;

(b) may be used in conjunction with basic restorative treatment only when occlusal adjustment/equilibration is not required as a result of that restoration;

(c) is not to be used in conjunction with the delivery and post-insertion care of fixed or removable prosthesis (5000 and 6000 code series) by the same dentist for a period of 3 months.







 

16511

1 unit of time

51.91

63.46

16512

2 units of time

103.85

126.93

16513

3 units of time

155.77

190.40

16514

4 units of time

207.70

253.91

16517

One half unit of time

25.97

31.74

16519

Each additional unit of time over 4

51.91

63.46

Root planing, Periodontal

43421

1 unit of time

51.91

63.46

43422

2 units of time

103.85

126.93

43423

3 units of time

155.77

190.40

43424

4 units of time

207.70

253.91

43425

5 units of time

259.63

338.63

43426

6 units of time

311.55

380.80

43427

One half unit of time

25.97

31.74

43429

Each additional unit of time

51.91

63.46

Chemotherapeutic and/or Antimicrobial Agents

 

1. Chemotherapeutic and/or antimicrobial agents, topical application

 

43511

1 unit of time

PA

PA

43519

Each additional unit of time

PA

PA

 

2. Chemotherapeutic and/or antimicrobial agents, intra-sulcular

 

43521

1 unit of time

PA

PA

43529

Each additional unit of time

PA

PA

Appliances

 

 1. Appliances, periodontal
(See separate codes for TMJ (43700–codes))

 

 

 

Appliances, periodontal (including bruxism appliance): includes impression, insertion and adjustment

 

 

14611

Maxillary appliance + L

PA

PA

14612

Mandibular appliance + L

PA

PA

 

Appliances, maintenance, adjustments, repair (including bruxism appliances)

 

 

14621

1 unit of time + L

PA

PA

14622

2 units of time + L

PA

PA

14623

3 units of time + L

PA

PA

14629

Each additional unit of time over 3

PA

PA

 

2. Appliances, reline (including bruxism appliances)

 

 

 

Appliance, TMJ, diagnostic

 

 

14711

Maxillary appliance + L 

PA

PA

14712

Mandibular appliance + L

PA

PA

 

Appliance, TMJ intra-oral repositioning

 

 

14721

Maxillary appliance + L

279.65

341.96

14722

Mandibular appliance + L

279.65

341.96

 

Appliance, TMJ, periodic maintenance, adjustments, repairs

 

 

14731

1 unit of time + L

47.13

57.73

14732

2 units of time + L

94.27

115.45

14733

3 units of time + L

141.38

173.16

14739

Each additional unit of time over 3

47.13

57.73

 

Appliance, TMJ, relines

 

 

14741

Reline, direct

PA

PA

14742

Reline, processed + L

PA

PA

 

3. Appliances, myofascial pain syndrome (conditions that originate outside the temporomandibular joint), including models, gnathological determinants,

 

14801

Maxillary appliance + L 

PA

PA

14802

Mandibular appliance + L

PA

PA

 

Appliance, myofascial pain syndrome, periodic maintenance, adjustment and repairs

 

 

14811

1 unit of time + L

PA

PA

14812

2 units of time + L

PA

PA

14813

3 units of time + L

PA

PA

14819

Each additional unit of time over 3

PA

PA

Periodontal Services, Miscellaneous

 

1. Periodontal re-evaluation

 

 

49101

1 unit of time

PA

PA

49102

2 units of time

PA

PA

49109

Each additional unit of time over 2

PA

PA

 

2. Periodontal irrigation, subgingival

 

 

49211

1 unit of time

PA

PA

49219

Each additional unit of time

PA

PA

 

3. Provisional non-coded services

 

 

 

Root separation

PA

PA

 

Forced eruption—1 tooth

PA

PA

 

Forced eruption—more than 1 tooth

PA

PA

 

Rapid extrusion—1 tooth

PA

PA

 

Rapid extrusion—more than 1 tooth

PA

PA


Part 6: Preventive—10000–19999

 

Any procedure carried out by an auxiliary is paid at the General Practitioner level. To qualify for a specialist’s fee, the procedure must be carried out personally.
The fees for preventive services assume a 1-to-1 relationship between patient and dentist. If service is provided to a group at the same time, only one fee is payable.

 

 

1. Scaling

 

 

11111

1 unit of time

31.80

32.45

11112

2 units of time

63.59

64.86

11113

3 units of time

95.36

97.27

11114

4 units of time

127.16

129.70

11115

5 units of time

159.03

162.21

11116

6 units of time

190.50

194.31

11117

One half unit of time

15.90

16.21

11119

Each additional unit of time

31.80

32.45

 

2. Fluoride treatments

 

 

12112

Fluoride treatment, gel or foam

15.75

16.95

12113

Fluoride treatment, varnish

15.75

16.95

Preventive Services, Other

 

1. Nutritional dietary counselling (including recording and analysis of 7-day dietary intake and consultation (maximum payable per lifetime is 1)

 

13101

1 unit of time

26.25

32.45

 

2. Caries prevention service

(Oral hygiene instruction/plaque control, including brushing and/or flossing and/or embrasure cleaning)

 

13211

1 unit of time

31.80

32.45

 

3. Sealants, pit and fissure (acid etch preparation included)

 

13401

Each tooth

21.00

29.56

 

4. Disking of teeth, interproximal (maximum 3 units per lifetime)

 

16201

1 unit of time

39.46

39.46

16202

2 units of time

78.92

78.92

16203

3 units of time

118.38

118.38

 

5. Recontouring of teeth for functional reasons (not associated with delivery of a single or multiple prosthesis)

 

16301

1 unit of time

PA

PA

16309

Each additional unit of time

PA

PA

Space Maintainers

(includes design, separation, fabrication, insertion and,

if applicable, initial cementation and removal)

 

1. Space maintainers, band type

 

 

15101

Space maintainer, band type, fixed, unilateral + L

130.55

178.08

15103

Space maintainer, band type, fixed, bilateral (soldered lingual arch) + L

156.45

270.94

15105

Space maintainer, band type, fixed, bilateral tubes and locking wires + L

190.05

296.31

 

2. Space maintainers, stainless steel crown type

 

 

15201

Space maintainer, stainless steel crown type, fixed + L

167.00

206.25

 

3.  Space maintainers, maintenance of

 

 

15601

Maintenance, space maintainer appliance, including adjustment and/or recementation after 30 days post-insertion

55.65

62.24


Part 7: Prosthetics—Removable—50000–59999

Dentures, Complete

(includes impressions, initial and final jaw relation records, try-in evaluation and

check records, insertion and adjustments, including 3 months post insertion care)

 

1. Dentures, complete, equilibrated (involves remounted equilibration on a semi-adjustable articulator)

 

51201

Maxillary + L

PA

1305.70

51202

Mandibular + L

PA

1361.00

51204

Liners, resilient in addition to above + L

PA

64.42

 

2. Dentures, surgical, standard (immediate) (includes tissue conditioner, but does not include hard reline. Does not include 3 months post insertion care.)

 

51301

Maxillary + L

590.84

1520.00 + L

51302

Mandibular + L

590.84

1840.00 + L

51303

Maxillary plus Mandibular (combined) + L

 

3229.60

 

3. Dentures, surgical, complex (immediate) (includes first tissue conditioner but not a processed reline)

 

51401

Maxillary + L

 

2149.83

51402

Mandibular + L

 

2488.44

51403

Maxillary plus Mandibular (combined) + L

 

4398.69

 

4. Dentures, complete, gnathological (cast base and metal occlusals)

 

51501

Maxillary + L

 

1843.17

51502

Mandibular + L

 

1843.17

51503

Maxillary plus Mandibular (combined) + L

 

3400.97

 

5. Dentures, complete, transitional (temporary)

 

 

51601

Maxillary + L

PA

896.25

51602

Mandibular + L

PA

896.25

51603

Maxillary plus Mandibular (combined) + L

 

3400.97

 

6. Dentures, complete, surgical (immediate), provisional (includes first tissue conditioner, but not a processed reline)

 

51611

Maxillary + L

 

1520.00 + L

51612

Mandibular + L

 

1840.00 + L

51613

Maxillary plus Mandibular (combined) + L

 

3229.60

 

7. Dentures, complete, overdentures, tissue borne, supported by natural teeth or implants with or without coping crowns, no attachments

 

 

Dentures, complete, overdentures, tissue borne, supported by natural teeth with or without coping crowns, no attachments

 

 

51711

Maxillary + L

 

830.40

51712

Mandibular + L

 

892.00

51713

Maxillary plus Mandibular (combined) + L

 

IC

 

Dentures, complete, overdentures, tissue borne, supported by implants with or without coping crowns, no attachments

 

 

51721

Maxillary + L

 

IC

51722

Mandibular + L

 

IC

51723

Maxillary plus Mandibular (combined) + L

 

IC

 

Dentures, complete, overdentures, tissue borne, supported by a combination of natural teeth and implants with or without coping crowns, no attachments

 

 

51731

Maxillary + L

 

IC

51732

Mandibular + L

 

IC

51733

Maxillary plus Mandibular (combined) + L

 

IC

 

Dentures, complete, overdentures, (immediate) tissue borne, supported by natural teeth with or without coping crowns, no attachments

 

 

51811

Maxillary + L

 

IC

51812

Mandibular + L

 

IC

51813

Maxillary plus Mandibular (combined) + L

 

IC

 

Dentures, complete, overdentures, (immediate) tissue borne, supported by implants with or without coping crowns, no attachments

 

 

51821

Maxillary + L

 

IC

51822

Mandibular + L

 

IC

51823

Maxillary plus Mandibular (combined) + L

 

IC

 

Dentures, complete, overdentures, tissue borne, supported by a combination of natural teeth and implants with or without coping crowns, no attachments

 

 

51831

Maxillary + L

 

IC

51832

Mandibular + L

 

IC

51833

Maxillary plus Mandibular (combined) + L

 

IC

 

8. Dentures, complete, attached to implants

 

 

 

Dentures, complete, overdentures, tissue borne, with independent attachments secured to natural teeth with or without coping crowns

 

 

51911

Maxillary + L

 

1024.00

51912

Mandibular + L

 

1087.20

51913

Maxillary plus Mandibular (combined) + L

 

IC

 

Dentures, complete, overdentures, tissue borne, with independent attachments secured to implants with or without coping crowns

 

 

51921

Maxillary + L 

 

2016.00 + L + comp

51922

Mandibular + L

 

2016.00 + L + comp

51923

Maxillary plus Mandibular (combined) + L

 

3760.00 + L + comp

 

Dentures, removable, tissue bone, with independent attachments secured to implants

 

 

51921

Maxillary + L

PA

PA

51922

Mandibular + L

PA

PA

Dentures, Partial, Acrylic

 

1. Dentures, partial, acrylic base (transitional) (with or without clasps)

 

 

52101

Maxillary + L

183.28

436.00 + L

52102

Mandibular + L

183.28

436.00 + L

52103

Maxillary plus Mandibular (combined) + L

 

949.60 + L

 

2. Dentures, partial, acrylic base (immediate)

 

 

52111

Maxillary + L

PA

436.00 + L

52112

Mandibular + L

PA

436.00 + L

52113

Maxillary plus Mandibular (combined) + L

 

949.60 + L

 

3. Dentures, partial, acrylic, resilient retainer

 

 

52201 

Maxillary + L

 

553.38 + L

52202

Mandibular + L

 

587.41 + L

52203

Maxillary plus Mandibular (combined) + L

 

 

 

Dentures, partial, acrylic, resilient retainer (immediate) (includes first tissue conditioner, but not processed reline)

 

 

52211

Maxillary + L

 

722.40 + L

52212

Mandibular + L

 

787.20 + L

52213

Maxillary plus Mandibular (combined) + L

 

 

 

4. Dentures, partial, acrylic, with metal wrought/cast clasps and/or rests

 

52301

Maxillary + L

360.05

705.28

52302

Mandibular + L

360.05

705.28

52303

Maxillary plus Mandibular (combined) + L

 

1327.20

 

5. Dentures, partial, acrylic, with metal wrought/cast clasps and/or rests (immediate)

 

52311

Maxillary + L

360.05

705.28 + L

52312

Mandibular + L

360.05

705.28 + L

52313

Maxillary plus Mandibular (combined) + L

 

1327.20 + L

 

6. Dentures, partial, acrylic, with metal wrought palatal/lingual bar and clasps and/or rests

 

52401

Maxillary + L

 

705.28 + L

52402

Mandibular + L

 

705.28 + L

52403

Maxillary plus Mandibular (combined) + L

 

1327.20 + L

 

7. Dentures, partial, overdentures, acrylic, with cast/wrought clasps and/or rests supported by natural teeth or implants with or without coping crowns, no attachments

 

 

Dentures, partial, overdentures, acrylic, with cast/wrought clasps and/or rests supported by natural teeth with or without coping crowns, no attachments

 

 

52711

Maxillary + L

 

IC

52712

Mandibular + L

 

IC

52713

Maxillary + Mandibular (combined) + L

 

IC

 

Dentures, partial, overdentures, acrylic, with cast/wrought clasps and/or rests supported by implants with or without coping crowns, no attachments

 

 

52721 

Maxillary + L

 

IC

52722

Mandibular + L

 

IC

52723

Maxillary + Mandibular (combined) + L

 

IC

 

Dentures, partial, overdentures, acrylic, with cast/wrought clasps and/or rests supported by a combination of natural teeth and implants with or without coping crowns, no attachments

 

 

52731

Maxillary + L

 

IC

52732

Mandibular + L

 

IC

52733

Maxillary plus Mandibular (combined) + L

 

IC

 

8. Dentures, partial, overdentures, (immediate) acrylic, with cast/wrought clasps and/or rests supported by natural teeth or implants with or without coping crowns, no attachments


 

 

Dentures, partial, overdentures, (immediate) acrylic, with cast/wrought clasps and/or rests supported by natural teeth with or without coping crowns, no attachments

 

 

52811

Maxillary + L

 

IC

52812

Mandibular + L

 

IC

52813

Maxillary + Mandibular (combined) + L

 

IC

 

Dentures, partial, overdentures, (immediate) acrylic, with cast/wrought clasps and/or rests supported by implants with or without coping crowns, no attachments

 

 

52821

Maxillary + L

 

IC

52822

Mandibular + L

 

IC

52823

Maxillary + Mandibular (combined) + L

 

IC

 

Dentures, partial, overdentures, (immediate) acrylic, with cast/wrought clasps and/or rests supported by a combination of natural teeth and implants with or without coping crowns, no attachments

 

 

52831

Maxillary + L

 

IC

52832

Mandibular + L

 

IC

52833

Maxillary + Mandibular (combined) + L

 

IC

Dentures, Partial, Cast with Acrylic Base

 

1. Dentures, partial, free end, cast frame/connector, clasps and rests

 

53101

Maxillary + L

PA

1520.00 + L

53102

Mandibular + L

PA

1520.00 + L

53103

Maxillary plus Mandibular (combined) + L

 

2800.00 + L

53104

Altered cast impression technique in conjunction with 53101 and 53102

 

 

 

2. Dentures, partial, tooth borne, cast frame/connector, clasps and rests

 

53201

Maxillary + L

513.96

PA

53202

Mandibular + L

513.96

PA

53205

Unilateral, one piece casting clasps and pontics + L

 

294.00 + L

 

3. Dentures, partial, cast, precision attachments

 

 

53401

Maxillary + L

729.28

PA

53402

Mandibular + L

729.28

PA

53403

Maxillary plus Mandibular (combined) + L

 

IC

 

4. Dentures, partial, cast, semi-precision attachments

 

 

53501

Maxillary + L

PA

1520.00 + L

53502

Mandibular + L

PA

1520.00 + L

53503

Maxillary plus Mandibular (combined) + L

 

2800.00 + L

53504

Altered cast impression technique done in conjunction with the above-mentioned codes

 

87.93

 

5. Dentures, partial, cast, overdentures, supported by natural teeth or implants with or without coping crowns, no attachments

 

 

Dentures, partial, cast, overdentures, supported by natural teeth with or without coping crowns, no attachments

 

 

53711

Maxillary + L

 

IC

53712

Mandibular + L

 

IC

53713

Maxillary plus Mandibular (combined) + L

 

IC

 

Dentures, partial, cast, overdentures, supported by implants with or without coping crowns, no attachments

 

 

53721

Maxillary + L

 

IC

53722

Mandibular + L

 

IC

53723

Maxillary plus Mandibular (combined) + L

 

IC

 

Dentures, partial, cast, overdentures, supported by a combination of natural teeth and implants with or without coping crowns, no attachments

 

 

53731

Maxillary + L

 

IC

53732

Mandibular + L

 

IC

53733

Maxillary plus Mandibular (combined) + L

 

IC

 

6. Dentures, partial, cast, overdenture, with independent attachments secured to natural teeth, with or without coping crowns

 

53911

Maxillary + L

 

1520.00 + L

53912

Mandibular + L

 

1520.00 + L

53913

Maxillary plus Mandibular (combined) + L

 

2800.00 + L

53914

Altered cast impression technique done in conjunction with the above-mentioned codes

 

IC

 

7. Dentures, partial, cast, overdentures with independent attachments secured to implants with or without coping crowns

 

53921

Maxillary + L

 

2016.00 + L + comp

53922

Mandibular + L

 

2016.00 + L + comp

53923

Maxillary plus Mandibular (combined) + L

 

3760.00 + L + comp

53924

Altered cast impression technique done in conjunction with the above-mentioned codes

 

IC

 

8. Dentures, partial, cast overdentures, with independent attachments secured to a combination of natural teeth and implants, with or without coping crowns

 

53931

Maxillary + L

 

2016.00 + L + comp

53932

Mandibular + L

 

2016.00 + L + comp

53933

Maxillary plus Mandibular (combined) + L

 

3760.00 + L + comp

53934

Altered cast impression technique done in conjunction with the above-mentioned codes

 

IC

 

9. Dentures, partial, cast, overdentures, with retention from a retentive bar, secured to coping crowns supported by natural teeth (see 62104 for retentive bar)

 

53941

Maxillary + L

 

935.20 + L

53942

Mandibular + L

 

1020.00 + L

53943

Maxillary plus Mandibular (combined) + L

 

IC

Dentures, Adjustments

(after 3 months post-insertion or by other than the dentist providing prosthesis)

 

1. Denture adjustments, partial or complete denture, minor

 

54201

1 unit of time + L

47.17

95.36

54202

2 units of time + L

 

191.36

54209

Each additional unit of time over 2

 

95.36


 

2. Denture adjustments, partial or complete denture, remount and occlusal equilibration

 

54301

Maxillary + L

PA

433.60

54302

Mandibular + L

PA

442.88

54303

Maxillary plus Mandibular (combined) + L

 

572.80

 

Dentures, Repairs/Additions

 

 

 

1. Denture, repair, complete denture, no impression required

 

55101

Maxillary + L

42.50

52.30

55102

Mandibular + L

42.50

52.30

 

2. Denture, repair, complete denture, impression required

 

 

55201

Maxillary + L

85.80

199.12

55202

Mandibular + L

85.80

199.12

55203

Maxillary plus Mandibular (combined) + L

 

363.10

 

3. Denture, repairs/additions, partial denture, no impression required

 

55301

Maxillary + L

42.50

57.73

55302

Mandibular + L

42.50

57.73

 

4. Denture, repairs/additions, partial denture, impression required

 

55401

Maxillary + L

85.80

199.12

55402

Mandibular + L

85.80

199.12

55403

Maxillary plus Mandibular (combined) + L

 

363.10

 

5. Dentures, implant retained prosthesis, prophylaxis and polishing

 

55501

1 unit of time + L

PA

PA

55509

Each additional unit of time

PA

PA

 

6. Dentures, rebuilding, worn acrylic denture teeth (direct chairside) with tooth-coloured materials

 

55601

1 unit of time

 

100.09

55609

Each additional unit of time

 

100.09

Dentures, Duplication, Relining, Rebasing, and Remaking

 

1. Dentures, duplication

 

 

 

Denture, replication, complete denture, provisional (no intra-oral impression required)

 

 

56111

Maxillary + L

PA

PA

56112

Mandibular + L

PA

PA

56113

Maxillary + Mandibular (combined) + L

PA

PA

 

2. Dentures, relining

 

 

 

Denture, reline, direct, complete denture

 

 

56211

Maxillary

151.63

154.67

56212

Mandibular

151.63

154.67

56213

Maxillary plus Mandibular (combined) + L

 

481.60

 

Denture, reline, direct, partial denture

 

 

56221

Maxillary + L

145.44

262.40

56222

Mandibular + L

145.44

262.40

56223

Maxillary plus Mandibular (combined)

 

481.60

 

Denture, reline, processed, complete denture

 

 

56231

Maxillary + L

188.67

192.44

56232

Mandibular + L

188.67

192.44

56233

Maxillary plus Mandibular (combined) + L

 

832.80

 

Denture, reline, processed, partial denture

 

 

56241

Maxillary + L

111.16

113.39

56242

Mandibular + L

111.16

113.39

56243

Maxillary plus Mandibular (combined) + L

 

549.60

 

Denture, reline, processed, functional impression requiring 3 appointments, partial denture

 

 

56261

Maxillary + L

188.67

192.44

56262

Mandibular + L

188.67

192.44

 

3. Dentures, rebasing

 

 

 

Denture, rebase, complete denture

 

 

56311

Maxillary + L

 

451.20

56312

Mandibular + L

 

600.54

56313

Maxillary plus Mandibular (combined) + L

 

903.20

 

4. Dentures, remake

 

 

 

Denture, remake, using existing framework, partial denture

 

 

56411

Maxillary + L

PA

PA

56412

Mandibular + L

PA

PA

56413

Maxillary plus Mandibular (combined) + L

 

1047.76

Dentures, Tissue Conditioning

 

1. Denture, tissue conditioning, per appointment, complete denture

 

 

56511

Maxillary + L

92.34

94.19

56512

Mandibular + L

92.34

94.19

56513

Maxillary plus Mandibular (combined) + L

 

317.31

 

2. Denture, tissue conditioning, per appointment, partial denture

 

56521

Maxillary + L

106.83

108.96

56522

Mandibular + L

106.83

108.96

56523

Maxillary plus Mandibular (combined)

 

317.31

Dentures, Miscellaneous Services

56601

Resilient liner, in relined or rebased denture (in addition to reline or rebase of denture) + L

92.34

94.19

56602

Resetting of teeth (not including reline or rebase of denture) + L

PA

PA

56603

Cast occlusal surfaces (includes remount and equilibration) + L

 

367.12 + L

56604

Amalgam centric-holding stops (per unit of time)

 

293.84 + L

 

Attaching or re-attaching retention elements to a removable prosthesis direct

 

 

56611

1 unit of time + E

 

160.00 + comp

56612

2 units of time + E

 

280.00 + comp

56619

Each unit of time over 2 + E

 

160.00 + comp

 

Attaching or re-attaching retention elements to a removal prosthesis indirect

 

 

56621

Attaching or re-attaching elements to a removable prosthesis, indirect + E

 

160.00 + L + comp

57601

Ridge Extension + L

 

160.00 + L


Part 8: Prosthodontics—Fixed—60000–69999

Fixed Bridges

Each abutment, each retainer and each pontic constitutes a

separate unit in a bridge, with a separate code number.

 

1. Pontics, bridge

 

 

 

Pontics, cast

 

 

62101

Pontics, cast metal + L

PA

898.69

62102

Pontics, cast metal core with separate porcelain jacket pontic + L

PA

806.40

62103

Pontics, prefabricated attachable facing + L

 

999.85

62104

Pontics, retentive bar, pre-fabricated or custom (dolder or hader) bar, attached to retainer + L + E

 

762.88

62105

Pontics, retentive bar, pre-fabricated or custom (dolder or hader) bar, attached to implant-supported retainer, to retain removable prosthesis, each bar + L + E

 

762.88

62107

Semi-precision rest (interlock) (in addition to cast metal pontic) + L + E

 

123.52

62108

Semi-precision rest or precision attachment, RPD retainer (in addition to cast metal pontic) + L + E

 

242.56

 

Pontics, porcelain/polymer glass

 

 

62501

Pontics, porcelain fused to metal + L

PA

287.31

62502

Pontics, porcelain, aluminous + L 

PA

287.31

62507

Semi-precision rest (interlock) (in addition to pontic porcelain/ceramic/polymer glass fused to metal) + L + E

 

129.28

62508

Semi-precision or precision attachment, rpd, retainer (in addition to pontic porcelain/ceramic/polymer glass fused to metal) + L + E

 

242.56

 

Pontics, acrylic/plastic/composite

 

 

62701

Pontics, acrylic/composite/compomer, processed to metal + L

 

820.96

62702

Pontics, acrylic/plastic/composite, processed indirect transitional) + L 

PA

PA

62703

Pontics, acrylic/plastic/composite, transitional direct

PA

PA

62704

Pontics, acrylic/composite/compomer + L

 

820.96

62707

Semi-precision or precision rest, RPD retainer (in addition to acrylic/composite/compomer processed to metal pontic + L + E

 

123.52

62708

Semi-precision or precision attachment RPD retainer (in addition to acrylic/composite/compomer processed to metal pontic + L + E

 

242.56

 

Pontics, natural tooth

 

 

62801

Pontics, natural crown, direct bonded to adjacent teeth (provisional)

 

304.00

62802

Pontics, natural tooth crown, direct bonded to adjacent teeth long-term provisional

 

337.28

 

2. Recontouring of retainers/pontics, per tooth (of existing bridgework)

 

63001

1 unit of time

PA

PA

63009

Each additional unit of time

PA

PA

 

3. Repairs, removal, fixed bridge/prosthesis—to be re-cemented

 

66211

1 unit of time

55.22

67.58

66212

2 units of time + L

110.43

135.12

66213

3 units of time + L

165.64

202.86

66214

4 units

 

471.04

66219

Each additional unit of time

55.22

67.58

 

4. Repairs, removal, fixed bridge/prosthesis—to be replaced by a new prosthesis

 

66221

1 unit of time

 

97.28

66222

2 units

 

194.56

66223

3 units

 

291.84

66224

4 units

 

389.12

66229

Each additional unit over 4

 

97.28

 

5. Repairs, removal, fixed bridge/prosthesis, implant-supported—to be reinserted

 

66231

1 unit of time

 

117.12

66232

2 units

 

234.24

66233

3 units

 

351.36

66234

4 units

 

468.48

66239

Each additional unit over 4

 

117.12

 

6. Repairs, removal, fixed bridge/prosthesis, implant-supported to be replaced by a new prosthesis

 

66241

1 unit of time

 

97.28

66242

2 units

 

194.56

66243

3 units

 

291.84

66244

4 units

 

389.12

66249

Each additional unit over 4

 

97.28

 

7. Repairs, sectioning of an abutment or a pontic plus polishing remaining portion (existing bridge)

 

66251

1 unit of time

 

97.28

66252

2 units

 

194.56

66253

3 units

 

291.84

66254

4 units

 

389.12

66259

Each additional unit over 4

 

97.28

 

8. Repairs, recementation (+ L if laboratory charges are incurred during repair of bridge)

 

66301

1 unit of time + L

63.49

77.50

66302

2 units

 

196.80

66303

3 units

 

296.00

66304

4 units

 

393.60

66309

Each additional unit over 4

 

98.40

 

Repairs, reinsertion/recementation implant-supported bridge/prosthesis

 

 

66311

1 unit of time + L and/or + E

 

117.12

66312

2 units + L and/or + E

 

234.24

66313

3 units + L and/or + E

 

351.36

66314

4 units + L and/or + E

 

468.48

66319

Each additional unit over 4 + L and/or + E

 

117.12

 

9. Repairs, fixed bridge

 

 

 

Repairs, porcelain/ceramic/plastic/composite, direct

 

 

66711

First tooth

PA

PA

66719

Each additional tooth

PA

PA

 

Repairs, solder indexing to repair broken solder joint

 

 

66721

1 unit of time + L

PA

PA

66729

Each additional unit of time

PA

PA

 

Repair fractured porcelain/metal pontic with telescoping type crown (pontic prepared, impression made and processed crown seated over metal)

 

 

66731

First pontic + L

 

1005.60

66739

Each additional pontic + L

 

1005.60

 

Repairs, fixed bridge/prosthesis, implant-supported, direct

 

 

66741

1 unit of time + E

 

97.28

66742

2 units + E 

 

196.48

66743

3 units + E 

 

295.68

66744

4 units + E

 

394.88

Fixed Bridge Retainers

 

1. Retainers, plastic/acrylic

 

 

67111

Retainer, plastic/acrylic, processed + L 

56.76

71.68

67112

Retainer, plastic processed to metal + L

56.76

71.68

67113

Retainers, acrylic, composite/compomer, provisional indirect (lab-fabricated/relined intraorally) + L

 

541.44

67115

Retainers, acrylic, composite/compomer, implant-supported indirect + L

 

158.72

 

Retainers, plastic/acrylic, direct (transitional during healing, done at chairside)

 

 

67121

First tooth

PA

PA

67125

Retainers, acrylic, composite/compomer, (provisional during healing, done at chairside) implant-supported, direct + E

 

320.00 + comp

67129

Each additional tooth

PA

PA

 

Retainers, plastic/acrylic, indirect, processed

 

 

67131

First tooth + L

PA

PA

67139

Each additional tooth + L

PA

PA

 

2. Retainers, porcelain/ceramic/polymer glass

 

 

67201

Retainer, porcelain/ceramic + L

PA

PA

67202

Retainer, porcelain/ceramic/polymer glass, complicated + L

 

1110.40

67205

Retainer, porcelain/ceramic/polymer glass, implant-supported + L + E

 

1262.08

 

Retainers, porcelain fused to metal

 

 

67211

Retainers, porcelain/ceramic fused to metal + L

PA

624.63

67212

Stress breaker and/or precision attachments, in addition to above + L

PA

178.32

67213

Retainers, porcelain/ceramic/polymer glass, fused to metal base with a porcelain/ceramic/polymer glass facial margin + L

 

1080.00 + L

67215

Retainers, porcelain/ceramic/polymer glass, fused to metal base, implant-supported + L + E

 

1287.04

67217

Semi-precision rest (interlock) (in addition to retainer) + L + E

 

211.84

67218

Semi-precision or precision attachment, RPD retainer (in addition to retainer) + L + E

 

255.36

 

Retainers, porcelain/ceramic fused to metal, attached to implant

 

 

67221

First implant + L

PA

PA

 

Retainers, porcelain/ceramic/polymer glass, two surface inlay, bonded 

 

 

67231

Retainers, porcelain/ceramic/polymer glass, two surface inlay, bonded + L

 

786.56

 

Retainers, porcelain/ceramic/polymer glass, three surface inlay, bonded

 

 

67241

Retainers, porcelain/ceramic/polymer glass, three surface inlay, bonded + L

 

864.00

 

Retainers, porcelain/ceramic/polymer glass, onlay, bonded (where one or more cusps are restored)

 

 

67251

Retainers, porcelain/ceramic/polymer glass, onlay, bonded + L

 

943.36

 

3. Retainers, metal, cast

 

 

 

Retainers, metal full cast

 

 

67301

Retainers, metal full cast + L

PA

624.63

67302

Stress breaker and/or precision attachments, in addition to above + L

PA

213.15

67305

Retainers, cast metal, implant-supported + L + E

 

1234.56

67307

Semi-precision rests (interlock) (in addition to retainer) + L + E

 

211.84

67308

Semi-precision or precision attachment, RPD retainer (in addition to retainer) + L + E

 

255.36

 

Retainers, metal 3/4 cast

 

 

67311

Retainers, metal 3/4 cast + L

PA

624.63

67312

Stress breakers and/or precision attachments, in addition to above + L

PA

178.32

67317

Semi-precision rests (interlock) (in addition to retainer) + L + E

 

128.64

 

Retainers, metal inlay (used with broken stress technique)

 

 

67321

Retainer, metal inlay, 2 surfaces + L

PA

475.11

67322

Retainer, metal inlay, 3 or more surfaces + L

PA

596.05

67327

Semi-precision or precision rest (interlock) in addition to inlay retainer + L + E

 

124.16

 

Retainers, metal, onlay (internal retention type)

 

 

67331

Retainer, metal, onlay + L

PA

596.05

67337

Semi-precision or precision rest (interlock) (in addition to onlay retainer) + L + E

 

124.16

67338

Semi-precision or precision attachment, RPD retainer (in addition to onlay retainer) + L + E

 

247.04

 

Retainers, metal, onlay (external retention type)

 

 

67341

Retainer, metal, onlay, acid etch and/or perforated, bonded to abutment tooth, (pontic extra) + L

PA

PA

 

Retainers, metal, prefabricated or custom cast, attached to transmucosal component used with 67503

 

 

67351

Retainer + L and/or (+ E—not covered)

PA

PA

67359

Each additional retainer + L and/or (+ E—not covered)

PA

 PA

 

4. Retainers, overdentures, custom cast or prefabricated with no occlusal component

 

 

Retainer, metal, custom cast with no occlusal component

 

 

67411

Retainer, metal, custom cast with no occlusal component (see 62104 for retentive bar) + L + E

 

302.08

67415

Retainer, metal, prefabricated or custom cast, implant-supported, with or without mesostructure with no occlusal component (see 62105 for retentive bar) + L + E

 

762.88

Fixed Prosthodontics, Abutments/Retainers, Miscellaneous Services

67501

Abutment preparation under existing partial denture clasp, in addition to retainer codes + L

PA

PA

67502

Telescoping crown unit + L

PA

838.78

Fixed Prosthetics, Other Services

 

1. Fixed prosthetics, miscellaneous services

 

 

69101

Fixed prosthesis, porcelain, to replace a substantial portion of the alveolar process (in addition to retainer and pontics) + L

PA

PA

 

2. Fixed prosthetics, splinting

 

 

69201

Splinting for extensive or complicated restorative dentistry (per tooth) + L

PA

PA

 

3. Fixed prosthetics, retentive pins (for retainers in addition to restoration)

 

69301

1 pin/restoration + L

28.33

28.61

69302

2 pins/restoration + L

41.64

42.47

69303

3 pins/restoration + L

56.20

57.32

69304

4 pins/restoration + L

74.75

76.24

69305

5 pins or more/restoration + L

105.40

107.51

 

4. Fixed prosthodontics, where an entire arch is reconstructed (used in extensive or complicated fixed restorative dentistry)

 

69601

Surcharge, maxillary arch (in addition to retainers & pontics) + L

 

6012.00 + L + comp

(use code 69821)

69602

Surcharge, mandibular Arch (in addition to retainers & pontics) + L

 

6012.00 + L + comp

(use code 69821)

 

5. Fixed prosthetics, provisional coverage (in extensive or complicated restorative dentistry

 

69701

Abutment tooth + L

58.93

71.74

69702

Pontic + L

PA

PA

 

6. Fixed prosthetic framework, attached to endosseous integrated implants

 

 

Fixed framework attached with screws and incorporated teeth (denture teeth and acrylic)

 

 

69811

Maxillary + L

PA

PA

69812

Mandibular + L

PA

PA

 

Fixed framework attached with screws and incorporating teeth (full metal and porcelain bonded to metal crowns)

 

 

69821

Maxillary + L

PA

PA

69822

Mandibular + L

PA

PA


Part 9: Restorative Services—20000–29999

Caries, Trauma and Pain Control (permanent teeth only)

 

Removal of carious lesions or existing restorations and placement of sedative/protective dressings, includes pulp caps when necessary, as a separate procedure

 

20111

First tooth

64.95

79.58

 

Removal of carious lesions or existing restorations and placement of sedative/protective dressings, includes pulp caps when necessary and the use of a band for retention and support

 

20121

First tooth

88.20

89.96

 

Trauma control, smoothing of fractured surfaces per tooth

 

 

20131

First tooth

33.60

38.85

Restorations, Amalgam

 

1. Restorations, amalgam, primary teeth

 

 

 

Restorations, amalgam, non-bonded, primary teeth

 

 

21111

1 surface

46.17

52.59

21112

2 surfaces

61.93

76.18

21113

3 surfaces

71.16

87.13

21114

4 surfaces

89.79

109.69

21115

5 surfaces or maximum surfaces per tooth

113.01

138.31

 

Restorations, amalgam, bonded, primary teeth

 

 

21121

1 surface

47.49

52.59

21122

2 surfaces

61.93

76.18

21123

3 surfaces

71.16

87.13

21124

4 surfaces

89.79

109.69

21125

5 surfaces or maximum surfaces per tooth

113.01

138.31

 

2. Restorations, amalgam, permanent teeth

 

 

 

Restorations, amalgam, non-bonded, permanent bicuspids and anteriors

 

 

21211

1 surface

55.71

68.06

21212

2 surfaces

83.59

101.66

21213

3 surfaces

105.20

128.10

21214

4 surfaces

136.14

172.87

21215

5 surfaces or maximum surfaces per tooth

167.15

203.54

 

Restorations, amalgam, non-bonded, permanent molars

 

 

21221

1 surface

63.99

74.46

21222

2 surfaces

90.89

110.91

21223

3 surfaces

119.10

144.90

21224

4 surfaces

164.00

200.89

21225

5 surfaces or maximum surfaces per tooth

218.23

262.50

 

Restorations, amalgam, bonded, permanent bicuspid and anteriors

 

 

21231

1 surface

65.96

68.06

21232

2 surfaces

83.59

101.66

21233

3 surfaces

105.20

128.30

21234

4 surfaces

136.14

172.87

21235

5 surfaces or maximum surfaces per tooth

167.15

203.54

 

Restorations, amalgam, bonded, permanent molars

 

 

21241

1 surface

73.88

74.46

21242

2 surfaces

90.89

110.91

21243

3 surfaces

119.10

144.90

21244

4 surfaces

164.00

200.89

21245

5 surfaces or maximum surfaces per tooth

218.33

265.83

 

3. Restorations, amalgam cores

 

 

21301

Restorations, amalgam core, in conjunction with crown

PA

PA

21302

Restorations, amalgam core, bonded, in conjunction with crown

PA

PA

 

4. Pins, retentive per restoration (for amalgams and tooth-coloured restorations)

 

21401

1 pin

16.77

17.10

21402

2 pins

29.36

29.95

21403

3 pins

37.16

37.91

21404

4 pins

45.92

46.83

21405

5 pins or more

53.32

54.39

 

5. Restorations made to a tooth supporting an existing partial denture clasp (additional to restoration)

 

21501

Per restoration

PA

PA

Restorations, Prefabricated, Full Coverage

 

1. Restorations, prefabricated, metal, primary dentition

 

 

22201

Primary anterior

128.63

163.58

22202

Permanent anterior, open face

124.31

151.99

22211

Permanent posterior

128.63

163.58

22212

Permanent posterior, open face

124.31

151.99

 

2. Restorations, prefabricated, metal, permanent dentition

 

 

22301

Primary anterior

128.63

163.58

22302

Permanent anterior, open face

124.31

151.99

22311

Permanent posterior

128.63

163.58

22312

Permanent posterior, open face

124.31

151.99

 

3. Restorations, prefabricated, plastic, permanent dentition

 

22501

Permanent anterior

134.40

179.55

22511

Permanent posterior

134.40

179.55

Restorations, Tooth-coloured

 

1. Restorations, tooth-coloured, permanent anteriors, acid etch/bond technique (not to be used for veneer applications or diastema closures)

 

23111

1 surface

77.35

94.20

23112

2 surfaces (continuous)

100.98

123.28

23113

3 surfaces (continuous)

117.61

144.06

23114

4 surfaces (continuous)

187.23

231.83

23115

5 surfaces (continuous, maximum surfaces per tooth)

187.23

231.83

 

2. Restorations, tooth-coloured, veneer applications

 

 

23121

Tooth-coloured veneer application, direct chairside prefabricated, acid etch/bond

187.23

256.80

23122

Tooth-coloured veneer application, non-prefabricated direct buildup, acid etch/bond

187.23

363.20

23123

Tooth-coloured veneer application—diastema closure, interproximal only, bonded

 

256.80

 

3. Restorations, tooth-coloured, permanent posteriors, acid etch/bond technique

 

23311

1 surface

83.11

68.06

23312

2 surfaces

102.90

101.66

23313

3 surfaces

128.52

128.30

23314

4 surfaces

170.18

172.87

23315

5 surfaces or maximum surfaces per tooth

194.59

203.54

 

Tooth-coloured, permanent molars

 

 

23321

1 surface

87.07

74.46

23322

2 surfaces

104.22

110.91

23323

3 surfaces

142.47

144.90

23324

4 surfaces

172.82

200.89

23325

5 surfaces

218.23

265.83

 

4. Restorations, tooth-coloured, primary, anterior, acid etch/bond technique

 

23411

1 surface

71.89

87.96

23412

2 surfaces (continuous)

71.89

87.96

23413

3 surfaces (continuous)

100.98

123.28

23414

4 surfaces (continuous)

153.30

172.82

23415

5 surfaces (continuous or maximum surfaces per tooth)

156.12

172.82

 

5. Restorations, tooth-coloured, primary, posterior, acid etch/bond technique

 

23511

1 surface

59.47

52.70

23512

2 surfaces

73.82

76.18

23513

3 surfaces

90.36

87.13

23514

4 surfaces

100.92

109.69

23515

5 surfaces or maximum surfaces per tooth

113.01

138.31

 

6. Restorations, tooth-coloured/plastic with silver filings, cores

 

23601

Restoration, tooth-coloured, core, in conjunction with crown

135.80

150.32

23602

Restoration, tooth-coloured, acid etch/bonded, core, in conjunction with crown

135.80

150.32

 

(See prosthodontics section for inlays, onlays and pins.)

 

 

Restorations, tooth-coloured, permanent posteriors—bonded

 

1. Restorations, inlays, onlays, pins and posts

 

 

 

Restorations, inlays

 

 

25111

1 surface + L 

 

418.00

25112

2 surfaces + L

 

752.00

25113

3 surfaces + L

 

940.80

25114

3 surfaces modified + L

 

1017.60

 

Inlays, composite/compomer indirect (bonded)

 

 

25121

1 surface + L 

 

467.20

25122

2 surfaces + L

 

830.40

25123

3 surfaces + L

 

1019.20

25124

3 surfaces modified + L

 

1019.20

 

Inlays, porcelain/ceramic/polymer glass

 

 

25131

1 surface + L 

 

424.32

25132

2 surfaces + L

 

587.52

25133

3 surfaces + L

 

668.16

25134

3 surfaces modified + L

 

668.16

 

Inlays, porcelain/ceramic polymer glass (bonded)

 

 

25141

1 surface + L 

 

480.00

25142

2 surfaces + L

 

892.80

25143

3 surfaces + L

 

1146.40

25144

3 surfaces modified + L

 

1146.40

Posts

 

Posts, cast metal (including core) as a separate procedure

 

 

25711

Single section + L

180.96

256.64

25712

2 sections + L

244.71

256.64

25713

3 sections + L

PA

492.95

 

Posts, cast metal (including core) concurrent with impression for crown

 

25721

Single section + L

150.15

256.64

25722

2 sections + L

180.96

256.64

25723

3 sections + L

PA

492.95

 

Posts, prefabricated retentive (separate procedure)

 

 

25731

1 post

114.7

139.98

25732

2 posts same tooth

144.46

139.98

25733

3 posts same tooth

180.08

139.98

 

Posts, prefabricated, retentive and cast core

 

 

25741

1 post and cast core + L

180.96

256.64

25742

2 posts (same tooth) and cast core + L

180.96

256.64

25743

3 posts (same tooth) and cast core + L

PA

492.95

 

Posts, prefabricated, with core for crown restoration
(when pins are applicable, refer to 21401–21405 for additional fee)

 

 

25751

1 post, with amalgam core + pins 

PA

PA

25752

2 posts (same tooth) with amalgam core + pins

PA

PA

25753

3 posts (same tooth) with amalgam core + pins

PA

PA

25754

1 post, with composite core + pins

187.98

230.09

25755

2 posts (same tooth) with composite core + pins

PA

PA

25756

3 posts (same tooth) with composite core + pins

PA

PA

 

Posts, prefabricated, with bonded core for crown restoration
(including pin(s) where applicable) + E or Fixed Bridge Retainer

 

25764

1 post, with bonded composite core and pin(s) + E

 

456.96

25765

2 posts (same tooth) with bonded composite core and pin(s) + E

 

535.04

 

Post removal

 

 

25781

1 unit of time

PA

PA

 

Mesostructures, (a separate component positioned between the head of an implant and the final restoration, retained by either a cemented post or screw)

 

  

1. Mesostructures, osseo-integrated implant-supported

 

 

26101

Indirect, angulated or transmucosal pre-fabricated abutment, per implant + L + E

 

371.84

26102

Indirect, custom laboratory fabricated, per implant + L + E

 

371.84

Crowns

 

1. Crowns, plastic (single units only)

 

 

 

Crowns, plastic, processed

 

 

27111

Crown, plastic, processed + L

415.99

424.31

27112

Crown, plastic, processed complicated (restorative, positional and/or aesthetic) + L 

PA

PA

27113

Crown acrylic/composite/compomer provisional (long term), indirect, lab fabricated/relined intra-orally + L

PA

976.00

27114

Crown, plastic/metal base, processed + L

510.80

625.23

27115

Crowns, acrylic/composite/compomer, indirect, implant-supported + L + E

 

1080.00 + L + comp

 

Crowns, acrylic/composite/compomer, direct

 

 

27121

Crown, plastic, direct, transitional (chairside)

121.13

315.52

27122

Crown, transitional restoration of fractured anterior

 

 

27125

Crowns, acrylic/composite/compomer, direct, provisional implant-supported + E

 

346.88

 

2. Crowns, porcelain/ceramic/polymer glass

 

 

27201

Crown, porcelain/ceramic jacket + L

510.80

625.83

27202

Crown, transitional restoration of fractured anterior

PA

PA

 

Crowns, porcelain/ceramic fused to metal

 

 

27211

Crown, porcelain/ceramic fused to metal base + L

510.80

625.83

27212

Crown, porcelain/ceramic fused to metal base, complicated (restorative, positional and/or aesthetic) + L

PA

PA

27213

Crown, porcelain/ceramic fused to metal base, screwed directly to an implant without the intervening post (+ L and/or + E)

PA

PA

27215

Crown, porcelain/ceramic fused to metal base, implant-supported + L + E

 

1080.00 + L + comp

 

Crowns, porcelain/ceramic, 3/4 partial veneer

 

 

27221

Crown, porcelain/ceramic, 3/4 partial veneer + L

PA

PA

27222

Crown, porcelain/ceramic, 3/4 partial veneer complicated + L

PA

PA

 

3. Crowns, metal, cast

 

 

27301

Crown, metal, full cast, uncomplicated + L

463.72

567.59

27302

Crown, metal, full cast, complicated (restorative, positional) + L

463.72

567.59

 

Crowns, metal 3/4 partial veneer

 

 

27311

Crowns, metal 3/4 partial veneer + L

510.80

625.23

27312

Crowns, metal 3/4 partial veneer, complicated + L

510.80

625.23

27313

Crowns, metal 3/4 partial veneer, with direct tooth-coloured corner + L

510.80

625.23

 

4. Crowns made to an existing partial denture clasp (additional to crown)

 

27401

1 crown

58.19

59.36

Copings, Metal/Plastic, Transfer (Thimble Type)

27501

Coping, metal/plastic, transfer (thimble) as a separate procedure + L

PA

PA

27502

Coping, metal/plastic, transfer (thimble), each additional coping as a separate procedure + L

PA

PA

27503

Copings, metal/plastic, transfer (thimble), concurrent with impression for crown + L

PA

PA

27504

Coping, metal/plastic, transfer (thimble), each additional coping concurrent with impression for additional crown + L

PA

PA

Veneer, Laboratory Processed

27602

Veneers, porcelain/ceramic, acid etch/bonded + L

PA

PA

Repairs

(single units only, does not include removal and recementation)

 

Repairs, inlays, onlays or crowns, acrylic/composite/compomer (single units)

 

27711

Repairs, plastic, direct

113.94

113.94

 

Repairs, inlays, onlays or crowns, porcelain/ceramic (single units)

 

27721

Repairs, porcelain/ceramic, direct

PA

PA

27722

Repairs, porcelain/ceramic, indirect + L

PA

PA

 

Gold, butt margins (including collarless veneers), custom shading or any aesthetics included in the lab fees are uninsured.

 

 

 

Recontouring of existing crowns per tooth

 

 

27801

1 unit of time

 

104.32

27809

Each additional unit of time

 

104.32

Restorative Procedures, Overdentures

 

1. Restorative procedures, overdentures, direct

 

 

28101

Natural tooth preparation, placement of pulp chamber restoration (amalgam or composite) and fluoride application

PA

PA

28102

Prefabricated attachment, as an internal or external overdenture retentive device, direct chairside + E

PA

PA

28103

Natural tooth preparation and fluoride application, vital tooth

PA

PA

28105

Implant-supported prefabricated attachment as an overdenture retentive devise, direct + E

 

193.59

+ L + E

 

2. Restorative procedures, overdentures, indirect

 

 

 

Coping crowns, metal cast

 

 

28211

Coping crown, metal cast—no attachment, indirect + L

PA

PA

28212

Coping crown, metal cast—with attachment, indirect + L

PA

PA

Restorative Services, Other

 

1. Recementation/rebonding, inlays/onlays/crowns/veneers/ posts/natural tooth fragments
(single units only) (+ L if laboratory charges are incurred during repair of the unit) (maximum of 2 single services)

 

29101

1 unit of time

61.03

62.24

29102

2 units of time

122.02

124.46

29103

3 units of time

183.03

186.96

 

2. Reinsertion/recementation implant-supported crown

 

 

29111

1 unit of time + L + E

 

119.04

29112

2 units of time + L + E 

 

238.08

29113

3 units of time + L + E 

 

357.12

29114

4 units of time + L + E 

 

476.16

29119

Each additional unit over 4 + L + E

 

119.04

 

3. Removal, inlays/onlays/crowns/veneers (single units only)

 

29301

1 unit of time

 

99.84

29302

2 units

 

199.68

29303

3 units

 

300.00

29304

4 units

 

399.36

29309

Each additional unit of time over 4

 

99.20

 

4. Removal implant-supported crowns (single units only)

 

 

29311

1 unit of time

 

119.04

29312

2 units

 

238.08

29313

3 units

 

357.12

29314

4 units

 

476.16

29319

Each additional unit of time over 4

 

119.04

 

5. Removal, mesostructure (to be reseated)

 

 

29321

1 unit of time

 

119.04

29322

2 units

 

238.08

29323

3 units

 

357.12

29324

4 units

 

476.16

29329

Each additional unit of time over 4

 

119.04

 

6. Removal of compromised mesostructure (to be replaced)

 

29331

1 unit of time

 

154.88

29332

2 units

 

309.76

29333

3 units

 

464.64

29334

4 units

 

619.52

29339

Each additional unit of time over 4

 

154.88

 

7. Removal and replacement of healing abutment with a new healing abutment (to stimulate improved gingival emergence profile)

 

29341

1 unit of time + E

 

78.72

29342

2 units + E

 

157.44

29343

3 units+ E

 

236.16

29344

4 units + E

 

314.88

29349

Each additional unit of time over 4 + E

 

78.72

 

8. Removal, fractured implant-supported crown retaining screw

 

29351

1 unit of time

 

154.88

29352

2 units

 

309.76

29353

3 units

 

464.64

29354

4 units

 

619.52

29359

Each additional unit of time over 4

 

154.88

 

9. Staining, porcelain (chairside)

 

 

29401

1 unit of time

PA

PA

29402

2 units of time

PA

PA

29403

3 units of time

PA

PA

29404

4 units of time

PA

PA

29409

Each additional unit of time over 4

PA

PA


 ________________________________________________________________ 


Schedule B—Children’s Oral Health Program


The Children’s Oral Health Program provides insured diagnostic, preventive and restorative services for residents until the resident turns 15 years of age.



Part 1: Diagnostic—01000–09999

Examinations

 

 

GP Fee

SP Fee

GP Hospital Premium

SP Hospital Premium

 

1. Examinations and diagnosis, complete oral

 

 

01101

Examination and diagnosis, complete, primary dentition, to include extended examination and diagnosis on primary dentition, recording history, charting, treatment planning and case presentation

50.40

113.38

65.52

147.39

01102

Examination and diagnosis, complete, mixed dentition

64.80

100.00

84.24

130.00

01103

Examination and diagnosis, complete, permanent dentition

89.60

136.80

116.48

177.84

 

2.  Examinations and diagnosis, limited oral

 

 

 

01202

Examination and diagnosis, limited oral, previous patient (recall): examination and diagnosis with mirror and explorer of hard and soft tissues, including checking occlusion and appliances, but not including specific tests

30.40

54.40

39.52

70.72

01204

Examination and diagnosis, specific: examination, diagnosis and evaluation of a specific situation in a localized area

48.00

80.64

62.40

104.83

01205

Examination and diagnosis, emergency: examination to investigate discomfort and/or infection in a localized area

48.80

80.64

63.44

104.83

05201

Consultation, in office (specialist other than orthodontist)

NA

118.30

NA

153.79

Radiographs

(includes radiographic examinations and interpretation)

Coverage guidelines apply (see preamble in the Dentists Guide).

 

1. Radiographs, intra-oral, periapical

 

 

 

 

02111

Single film

15.20

32.40

19.76

42.12

02112

2 films

20.80

39.60

27.04

51.48

 

2. Radiographs, intra-oral, bitewing

 

 

 

 

02141

Single film

15.20

30.96

19.76

40.25

02142

2 films

20.80

39.60

27.04

51.48

 

3. Radiographs, panoramic

 

 

 

 

02601

Single film (once per lifetime, only in connection with a specific request for a consultation with a specialist other than an orthodontist). This service is not insured if provided for reasons related to spacing, crowding, eruption, timing and other orthodontic-related concerns.

62.40

68.00

81.12

88.40

 

4. Radiographs, cephalometric

 

 

 

 

02701

Single film (once per lifetime, only in connection with a specific request for a consultation with a specialist other than an orthodontist)
This service is not insured if provided for reasons related to spacing, crowding, eruption, timing and other orthodontic related concerns.

62.40

68.00

81.12

88.40

 

5. Radiographs, interpretation (received from another source, or exposed on hospital equipment)

 

 

02801

MSI: paid at 1/2 regular fee

40.00

40.00

40.00

40.00

Tests and Laboratory Examinations

Coverage guidelines apply (see preamble in the Dentists Guide).

 

1. Tests, microbiological

 

 

 

 

04101

Microbiological test for the determination of pathological agents + L

56.00

66.21

72.80

86.07

 

2. Tests, caries susceptibility

 

 

 

 

04201

Bacteriological test for the determination of dental caries susceptibility + L

56.00

65.52

72.80

85.18

 

3. Tests, histological

 

 

 

 

 

Test, histological, soft tissue

 

 

 

 

04311

Biopsy, soft oral tissue, by puncture + L

134.40

144.80

174.72

188.24

04312

Biopsy, soft oral tissue, by incision + L

134.40

144.80

174.72

188.24

04313

Biopsy, soft oral tissue, by aspiration + L

134.40

144.80

174.72

188.24

 

Tests, histological, hard tissue

 

 

 

 

04321

Biopsy, hard oral tissue, by puncture + L

159.20

IC

206.96

IC

04322

Biopsy, hard oral tissue, by incision + L

159.20

IC

206.96

IC

04323

Biopsy, hard oral tissue, by aspiration + L

159.20

IC

206.96

IC

 

4. Tests, cytological

 

 

 

 

04401

Cytological smear from the oral cavity + L

56.00

68.40

72.80

88.92

 

5. Tests, pulp vitality

 

 

 

 

04501

1 unit

70.40

79.65

91.52

103.54

Casts, Diagnostic

Coverage guidelines apply (see preamble in the Dentists Guide).

 

1.  Cast, diagnostic, unmounted

 

 

 

 

04911

Cast, diagnostic, unmounted + L

36.00

60.80

46.80

79.04

04912

Cast, diagnostic, unmounted, duplicate + L

PA

23.20

PA

31.20

PA

30.16

PA

40.56

 

2. Cast, diagnostic, mounted

 

 

 

 

04921

Cast, diagnostic, mounted + L

PA

64.80

PA

96.48

PA

84.24

PA

125.42

04922

Cast, diagnostic, mounted using face bow transfer + L

PA

108.80

PA

200.99

PA

141.44

PA

261.99

04923

Cast, diagnostic, mounted, using face bow + occlusal records + L

PA

160.00

PA

300.20

PA

208.00

PA

390.26


Part 2: Preventive Services—10000–19999

Scaling

Coverage guidelines apply (see preamble in the Dentists Guide).

 

Scaling

 

 

 

 

11111

1 unit of time

38.64

74.40

50.23

96.72

11112

2 units of time

77.28

148.80

100.46

193.44

Topical Fluoride Applications

Coverage guidelines apply (see preamble in the Dentists Guide).

 

Fluoride Treatments

 

 

 

 

12112

Fluoride treatment, gel or foam

16.80

19.17

21.84

24.92

12113

Fluoride treatment, varnish

20.00

23.43

26.00

30.45

Preventive Services, Other

 

1. Nutritional dietary counselling
(maximum payable per lifetime is 1 series of 4 appointments)

 

 

13101

1 unit of time

26.25

54.40

34.13

70.72

 

2. Caries prevention service
(Oral hygiene instruction/plaque control, including brushing and/or flossing and/or embrasure cleaning)

 

 

13211

1 unit of time

31.80

56.88

41.34

73.94

 

3. Sealants, pit and fissure (acid etch preparation included)
Coverage guidelines apply (see preamble in the Dentists Guide).

 

 

13401

Each tooth

21.00

63.36

27.30

82.37

13409

Each additional tooth within the same quadrant

14.70

31.68

19.11

41.18

 

4. Topical application to hard tissue lesion(s) of an antimicrobial or remineralization agent

 

 

13601

1 unit of time + E

32.00

73.00

41.60

94.90

13602

2 units of time + E

64.00

148.00

83.20

192.30

 

5. Disking of teeth, interproximal
(maximum 3 units per lifetime, primary teeth only)

 

 

16201

1 unit of time

72.80

72.80

94.64

94.64

16202

2 units of time

145.60

145.60

189.28

189.28

16203

3 units of time

218.40

317.42

283.92

412.64

Space Maintainers

(includes design, separation, fabrication, insertion and,

if applicable, initial cementation and removal)

 

1. Space maintainers, band type

 

 

 

 

15101

Space maintainer, band type, fixed, unilateral + L

133.60

239.20

173.68

310.96

15103

Space maintainer, band type, fixed, bilateral (soldered lingual arch) + L

156.45

357.60

203.38

464.88

15105

Space maintainer, band type, fixed, bilateral tubes and locking wires + L

190.05

402.40

247.07

523.12

 

2. Space maintainers, stainless steel crown type

 

 

15201

Space maintainer, stainless steel crown type, fixed + L

168.00

270.72

218.40

351.94

 

3. Space maintainers, maintenance of
(This service is not insured if provided to address necessary repairs and adjustments after 30 days following the original placement.)

 

 

15601

Maintenance, space maintainer appliance, including adjustment and/or recementation after 30 days post-insertion

60.00

107.28

78.00

139.46


Part 3: Restorative Services—20000–29999

Caries, Trauma and Pain Control
(permanent teeth only)

 

Caries/trauma/pain control (includes pulp caps when necessary as a separate procedure).

 

 

20111

First tooth

98.40

107.52

127.92

139.78

 

Caries/trauma/pain control (includes pulp caps when necessary and use of band for retention and support as a separate procedure)

 

 

20121

First tooth

111.20

111.20

144.56

144.56

20131

Trauma control, first tooth

40.80

40.80

53.04

53.04

Restorations, Amalgam

 

1. Restorations, amalgam, primary teeth

 

 

 

 

 

Restorations, amalgam, non-bonded, primary teeth

 

 

 

 

21111

1 surface

86.40

110.80

112.32

144.04

21112

2 surfaces

110.40

167.49

143.52

217.74

21113

3 surfaces

133.60

184.24

173.68

239.52

21114

4 surfaces

148.00

230.63

192.40

299.81

21115

5 surfaces or maximum surfaces per tooth

195.20

260.64

253.76

338.83

 

Restorations, amalgam, bonded, primary teeth

 

 

 

 

21121

1 surface

86.40

121.11

112.32

157.44

21122

2 surfaces

110.40

173.52

143.52

225.58

21123

3 surfaces

133.60

213.88

173.68

278.04

21124

4 surfaces

148.00

234.72

192.40

305.14

21125

5 surfaces or maximum surfaces per tooth

195.20

260.64

253.76

338.83

 

2. Restorations, amalgam, permanent teeth

 

 

 

Restorations, amalgam, non-bonded, permanent bicuspids and anteriors

 

 

 

 

21211

1 surface

117.60

117.60

152.88

152.88

21212

2 surfaces

148.80

148.80

193.44

193.44

21213

3 surfaces

180.80

180.80

235.04

235.04

21214

4 surfaces

200.80

222.08

261.04

288.70

21215

5 surfaces or maximum surfaces per tooth

264.00

264.00

343.20

343.20

 

Restorations, amalgam, non-bonded, permanent molars

 

 

 

 

21221

1 surface

122.40

133.76

159.12

173.89

21222

2 surfaces

155.20

167.04

201.76

217.15

21223

3 surfaces

188.80

200.96

245.44

261.25

21224

4 surfaces

209.60

256.00

272.48

332.80

21225

5 surfaces or maximum surfaces per tooth

275.20

275.20

357.76

357.76

 

Restorations, amalgam, bonded, permanent bicuspids and anteriors

 

 

 

 

21231

1 surface

117.60

117.60

152.88

152.88

21232

2 surfaces

148.80

148.80

193.44

193.44

21233

3 surfaces

180.80

180.80

235.04

235.04

21234

4 surfaces

200.80

232.32

261.04

302.02

21235

5 surfaces or maximum surfaces per tooth

264.00

264.00

343.20

343.20

 

Restorations, amalgam, bonded, permanent molars

 

 

 

 

21241

1 surface

122.40

133.76

159.12

173.89

21242

2 surfaces

155.20

167.04

201.76

217.15

21243

3 surfaces

188.80

200.96

245.44

261.25

21244

4 surfaces

209.60

266.88

272.48

346.94

21245

5 surfaces or maximum surfaces per tooth

275.20

282.24

357.76

366.91

 

3. Pins, retentive per restoration (for amalgams and tooth-coloured restorations)

 

 

21401

1 surface

24.00

32.80

31.20

42.64

21402

2 surfaces

37.60

56.00

48.88

72.80

21403

3 surfaces

51.20

70.40

66.56

91.52

21404

4 surfaces

64.80

91.20

84.24

118.56

21405

5 surfaces or maximum surfaces per tooth

79.20

104.80

102.96

136.24

Restorations, Prefabricated, Full Coverage

Single surface restoration is payable concurrently with open-faced stainless steel crowns.

 

1. Restorations, prefabricated, metal, primary dentition

 

 

22201

Primary anterior

153.60

218.88

199.68

284.54

22211

Primary posterior

153.60

218.88

199.68

284.54

22212

Primary posterior, open face

184.00

195.20

239.20

253.76

 

2. Restorations, prefabricated, metal, permanent dentition

 

 

22301

Permanent anterior

153.60

210.40

199.68

273.52

22302

Permanent anterior, open face 

NA

215.20

NA

279.76

22311

Permanent posterior

153.60

174.08

199.68

226.30

22312

Permanent posterior, open face

NA

197.60

NA

256.88

 

3. Restorations, prefabricated, plastic, permanent dentition

 

 

22501

Permanent anterior

153.60

179.55

199.68

233.42

22511

Permanent posterior

153.60

179.55

199.68

233.42

Restorations, Tooth-coloured

Fee codes 23113, 23114, 23115, 23413, 23414 and 23415

include reattachment of fractured tooth fragments.

 

1. Restorations, tooth-coloured, permanent anteriors, acid etch/bond technique

 

 

23111

1 surface

109.60

111.36

142.48

144.77

23112

2 surfaces (continuous)

139.20

154.88

180.96

201.34

23113

3 surfaces (continuous)

168.80

185.60

219.44

241.28

23114

4 surfaces (continuous)

198.40

240.64

257.92

312.83

23115

5 surfaces (continuous, maximum surfaces per tooth)

260.80

309.60

339.04

402.48

 

2. Restorations, tooth-coloured, permanent posteriors, acid etch/bond technique

 

 

23311

1 surface

130.40

135.68

169.52

176.38

23312

2 surfaces

165.60

169.60

215.28

220.48

23313

3 surfaces

200.80

216.80

261.04

281.84

23314

4 surfaces

236.00

255.36

306.80

331.97

23315

5 surfaces or maximum surfaces per tooth

310.40

310.40

403.52

403.52

 

3. Restorations, tooth-coloured, permanent molars, acid etch/bond technique

 

 

23321

1 surface

136.00

148.48

176.80

193.02

23322

2 surfaces

172.80

185.60

224.64

241.28

23323

3 surfaces

209.60

223.36

272.48

290.37

23324

4 surfaces

246.40

279.04

320.32

362.75

23325

5 surfaces or maximum surfaces per tooth

324.00

332.00

421.20

431.60

 

4. Tooth-coloured, permanent molars

 

 

 

 

23411

1 surface

96.80

138.96

125.84

180.65

23412

2 surfaces (continuous)

122.40

161.05

159.12

209.37

23413

3 surfaces (continuous)

148.80

217.44

193.44

282.67

23414

4 surfaces (continuous)

174.40

254.88

226.72

331.34

23415

5 surfaces (continuous, maximum surfaces per tooth)

229.60

295.05

298.48

383.56

 

5. Restorations, tooth-coloured, primary, posterior, acid etch/bond technique

 

 

23511

1 surface

96.80

138.96

125.84

180.65

23512

2 surfaces

122.40

181.67

159.12

236.17

23513

3 surfaces

148.80

217.44

193.44

282.67

23514

4 surfaces

174.40

254.88

226.72

331.34

23515

5 surfaces or maximum surfaces per tooth

229.60

306.00

298.48

397.80

 

(See prosthodontics section for inlays, onlays and pins.)

 

 

 

6. Posts

 

 

 

 

25711

Single section + L

320.80

535.04

417.04

695.55

25712

2 sections + L

427.20

659.20

555.36

856.96

25713

3 sections + L

488.80

810.88

635.44

1054.14

 

Posts, cast metal (including core) concurrent with impression for crown

 

 

 

 

25721

Single section + L

166.40

256.64

216.32

333.63

25722

2 sections + L

272.80

336.80

354.64

437.84

25723

3 sections + L

393.96

544.80

512.15

708.24

 

Posts, prefabricated retentive (separate procedure)

 

 

 

 

25731

1 post

153.60

184.32

199.68

239.62

25732

2 posts same tooth

260.80

260.80

339.04

339.04

25733

3 posts same tooth

321.60

333.60

418.08

433.68

 

Posts, prefabricated, retentive and cast core

 

 

 

 

25741

1 post and cast core + L

NA

256.64

NA

333.63

25742

2 posts (same tooth) and cast core + L3 posts (same tooth) and cast core + L

NA

470.40

NA

611.52

25743

3 posts (same tooth) and cast core + L

NA

511.20

NA

664.56

 

Post, prefabricated, with core for crown restoration

 

 

 

 

25754

1 post, with composite core + pins

261.60

431.36

340.08

560.77

Crowns

Coverage guidelines apply (see preamble in the Dentists Guide).

Gold, butt margins (including collarless veneers), custom shading
or any aesthetics included in the lab fees are not insured.

 

1. Crowns, plastic (single units only)

 

 

 

 

 

Crowns, plastic, processed

 

 

 

 

27111

Crown, plastic, processed + L

520.80

963.20

677.04

1252.16

27113

Crown, plastic, transitional, indirect + L

176.80

976.00

229.84

1268.80

 

Crowns, plastic, direct (not payable in addition to permanent crowns)

 

 

 

 

27121

Crown, plastic, direct, transitional (chairside)

169.60

355.84

220.48

462.59

 

2. Crowns, porcelain/ceramic/polymer glass

 

 

27201

Crown, porcelain/ceramic jacket + L

673.60

1038.72

875.68

1350.34

 

3. Crowns, porcelain/ceramic fused to metal

 

 

27211

Crown, porcelain/ceramic fused to metal base + L

673.60

1105.92

875.68

1437.70

 

4. Recementation/rebonding, inlays/onlays/crowns/veneers/ posts/natural tooth fragments

(maximum of 3 units per tooth)

For stainless steel crowns, recementation is payable after 120 days following original placement by same or different dentist.

 

 

 

 

 

29101

1 unit of time

63.20

112.64

82.16

146.43

29102

2 units of time

126.40

225.28

164.32

292.86

29103

3 units of time

189.60

337.92

246.48

439.30

Endodontics

 

1. Pulpotomy

 

 

 

 

 

Pulpotomy vital, permanent teeth (as a separate emergency procedure)

 

 

 

 

32221

Anterior and bicuspid teeth

112.80

152.00

146.64

197.60

32222

Molar teeth

135.20

213.84

175.76

277.99

 

Pulpotomy, vital, primary teeth

 

 

 

 

32231

Primary tooth as a separate procedure

89.60

145.59

116.48

189.27

32232

Primary tooth, concurrent with restorations (but excluding final restorations)

80.80

90.40

105.04

117.52

 

2. Pulpectomy (as a separate emergency procedure)

 

 

 

Pulpectomy, permanent teeth/retained primary teeth

 

 

 

 

32311

1 canal

149.60

218.88

194.48

284.54

32312

2 canals

196.80

225.36

255.84

292.97

32313

3 canals

243.20

321.84

316.16

418.39

32314

4 or more canals

320.00

421.92

416.00

548.50

 

Pulpectomy, primary teeth

 

 

 

 

32321

Anterior tooth

93.60

148.17

121.68

192.62

32322

Posterior tooth

140.00

162.91

182.00

211.79

Root Canal Therapy

 

1. Root canals, permanent teeth, retained primary teeth (includes clinical procedures with appropriate radiographs, excluding final restoration)

 

 

33111

1 canal

356.00

591.12

462.80

768.46

33121

2 canals

616.80

790.56

801.84

1027.73

33131

3 canals

788.00

938.16

1024.40

1219.61

33141

4 or more canals

958.40

1092.96

1245.92

1420.85

 

2. Root canals, primary teeth

 

 

 

 

33401

1 canal

190.40

235.44

247.52

306.07

33402

2 canals

248.80

473.60

323.44

615.68

33403

3 or more canals

NA

473.60

NA

615.68

 

3.  Apexification/apical closure/induction of hard tissue repair (including biomechanical preparation and placement of dentogenic media)

 

 

33601

1 canal

169.60

310.51

220.48

403.66

33602

2 canals

220.00

445.79

286.00

579.53

33603

3 canals

276.00

593.96

358.80

772.14

33604

4 or more canals

492.80

892.87

640.64

1160.73

 

4. Re-insertion of dentogenic media per visit

 

 

33611

1 canal

71.20

109.51

92.56

142.37

33612

2 canals

71.20

130.32

92.56

169.42

33613

3 canals

71.20

130.32

92.56

169.42

33614

4 or more canals

71.20

195.84

92.56

254.59

Periapical Services

 

1. Apicoectomy/apical curettage

 

 

 

 

 

Maxillary anterior

 

 

 

 

34111

1 root

250.40

545.76

325.52

709.49

34112

2 roots

358.40

653.04

465.92

848.95

 

Maxillary bicuspid

 

 

 

 

34121

1 root

285.60

634.32

371.28

824.62

34122

2 roots

379.20

758.88

492.96

986.54

34123

3 or more roots

461.60

842.40

600.08

1095.12

 

Maxillary molar

 

 

 

 

34131

1 root

320.00

673.92

416.00

876.10

34132

2 roots

425.60

781.92

553.28

1016.50

34133

3 roots

536.80

892.80

697.84

1160.64

34134

4 or more roots

IC

892.80

IC

1160.64

 

Mandibular anterior

 

 

 

 

34141

1 root

248.80

663.84

323.44

862.99

34142

2 or more roots

356.80

770.40

463.84

1001.52

 

Mandibular bicuspid

 

 

 

 

34151

1 root

285.60

735.12

371.28

955.66

34152

2 roots

379.20

828.00

492.96

1076.40

34153

3 or more roots

474.40

944.64

616.72

1228.03

 

Mandibular molar

 

 

 

 

34161

1 root

352.80

735.12

458.64

955.66

34162

2 roots

467.20

828.00

607.36

1076.40

34163

3 roots

588.80

918.72

765.44

1194.34

34164

4 or more roots

IC

1164.24

IC

1513.51

 

2. Retrofilling

 

 

 

 

 

Maxillary anterior

 

 

 

 

34211

1 canal

88.80

110.40

115.44

143.52

34212

2 or more canals

106.40

152.64

138.32

198.43

 

Maxillary bicuspid

 

 

 

 

34221

1 canal

105.60

152.64

137.28

198.43

34222

2 canals

131.20

160.56

170.56

208.73

34223

3 canals

145.60

244.80

189.28

318.24

34224

4 or more canals

156.80

244.80

203.84

318.24

 

Maxillary molar

 

 

 

 

34231

1 canal

128.00

152.64

166.40

198.43

34232

2 canals

159.20

252.72

206.96

328.54

34233

3 canals

175.20

259.20

227.76

336.96

34234

4 or more canals

185.60

346.32

241.28

450.22

 

Mandibular anterior

 

 

 

 

34241

1 canal

87.20

157.68

113.36

204.98

34242

2 or more canals

105.60

163.44

137.28

212.47

 

Mandibular bicuspid

 

 

 

 

34251

1 canal

104.00

160.56

135.20

208.73

34252

2 canals

128.00

172.80

166.40

224.64

34253

3 canals

143.20

259.20

186.16

336.96

34254

4 canals

154.40

259.20

200.72

336.96

 

Mandibular molar

 

 

 

 

34261

1 canal

128.00

168.48

166.40

219.02

34262

2 canals

159.20

252.72

206.96

328.54

34263

3 canals

175.20

259.20

227.76

336.96

34264

4 or more canals

185.60

346.32

241.28

450.22

 

3. Open and drain (separate emergency procedures)

 

 

39201

Anteriors and bicuspids

84.00

141.72

109.20

184.24

39202

Molars

84.00

141.72

109.20

184.24

 

4. Opening through artificial crown (in addition to procedures)

 

 

39211

Anteriors and bicuspids

NA

100.00

NA

130.00

39212

Molars

148.00

172.08

192.40

223.70

 

5. Bleaching, non-vital

(maximum of 3 units insured per resident)

 

 

 

 

 

Bleaching endodontically treated tooth/teeth

 

 

 

 

39311

1 unit of time

81.60

81.60

106.08

106.08

39312

2 units of time

163.20

164.80

212.16

214.24

39313

3 units of time

244.80

244.80

318.24

318.24


Part 4: Periodontics—40000–49999

Desensitization

This may involve application and burnishing of medicinal aids on the root or the use of a variety of therapeutic procedures. More than 1 appointment may be necessary.

41301

1 unit of time

39.20

85.60

50.96

111.28

41302

2 units of time

78.40

171.20

101.92

222.56

41309

Each additional unit of time over 2

39.20

85.60

50.96

111.28

Periodontal Procedures, Adjunctive

 

1. Periodontal splinting or ligation, provisional, intra-coronal “A” splint (acrylic, composite or amalgam, plus knurled wire)

 

 

43111

Per joint

72.00

87.20

93.60

113.36

 

2. Periodontal splinting or ligation, provisional, extra-coronal

 

 

 

Acid etch joint restorations (per joint)

 

 

 

 

43211

Per joint

72.00

87.20

93.60

113.36

 

Acid etch, interproximal enamel splint

 

 

 

 

43221

Per joint

72.00

140.44

93.60

182.57

 

Wire ligation

 

 

 

 

43231

Per joint

183.20

183.20

238.16

238.16

 

Wire ligation, acrylic covered

 

 

 

 

43241

Per joint

244.00

244.00

317.20

317.20

 

Dental floss ligation

 

 

 

 

43251

Per joint

NA

295.20

NA

383.76

 

Orthodontic band splint

 

 

 

 

43261

Per band

NA

IC

NA

IC

 

Cast/soldered splint acid etch/resin bonded

 

 

 

 

43271

Per abutment + L

157.60

253.44

204.88

329.47


Part 5: Prosthetics—Removable—50000–59999

(Cast partials are not insured services)

 

Dentures, partial, acrylic, with wrought/cast clasps and/or rests (Covered only if required because of congenital condition or accident.)

 

 

52301

Maxillary + L

501.60

787.84

652.08

1024.19

52302

Mandibular + L

501.60

787.84

652.08

1024.19


Part 6: Oral and Maxillofacial Surgery—70000–79999

 

Certain procedures included in this Part are also contained in Schedule C—Oral and Maxillofacial Surgery covering all eligible residents of the Province. Refer to Schedule C for fees when oral and maxillofacial surgical procedures are performed in hospital.

Coverage guidelines apply (see preamble in the Dentists Guide).

 

Removals (Extractions), Erupted Teeth

 

1. Removals, erupted teeth, uncomplicated

 

 

71101

Single tooth, uncomplicated

116.80

139.49

151.84

181.34

71109

Each additional tooth, same quadrant, same appointment

88.00

88.00

114.40

114.40

 

2. Removals, erupted teeth, complicated

 

 

 

 

71201

Odontectomy, (extraction), erupted tooth, surgical approach, requiring surgical flap and/or sectioning of tooth

219.20

268.56

284.96

349.13

71209

Each additional tooth, same quadrant

164.80

224.00

214.24

291.20

Removals (Extractions), Surgical

 

1. Removals, impactions, soft tissue coverage

 

 

 

Removals, impaction, requiring incision of overlying soft tissue and removal of the tooth

 

 

 

 

72111

Single tooth

212.80

279.36

276.64

303.36

72119

Each additional tooth, same quadrant

159.20

224.00

206.96

291.20

 

2. Removals, impactions, involving tissue and/or bone coverage (including removal of bone and tooth or sectioning and removal of tooth)

 

 

72211

Single tooth

252.00

401.60

327.60

522.08

72219

Each additional tooth, same quadrant

188.80

330.40

245.44

429.52

 

Removals, impaction, requiring incision of overlying soft tissue, elevation of a flap, removal of bone and sectioning of tooth for removal

 

 

72221

Single tooth

344.00

448.28

447.20

582.76

72229

Each additional tooth, same quadrant

257.60

375.12

334.88

487.66

 

3. Removals (extractions), residual roots

 

 

 

 

 

Removals, residual roots, erupted

 

 

 

 

72311

Single tooth

89.60

123.12

116.48

160.06

72319

Each additional tooth, same quadrant

67.20

92.00

87.36

119.60

 

Removals, residual roots, soft tissue coverage

 

 

 

 

72321

Single tooth

162.40

215.87

211.12

280.64

72329

Each additional tooth, same quadrant

121.60

177.60

158.08

230.88

 

Removals, residual roots, bone tissue coverage

 

 

 

 

72331

Single tooth

321.60

321.60

418.08

418.08

72339

Each additional tooth, same quadrant

241.60

244.00

314.08

317.20

Surgical Incisions

 

Surgical incision and drainage and/or exploration, intra-oral soft tissue

 

 

75111

Intra-oral, surgical exploration, soft tissue

130.40

211.68

169.52

275.18

75112

Intra-oral, abscess, soft tissue

130.40

204.80

169.52

266.24

75113

Intra-oral, abscess, in major anatomical area with drain

NA

IC

NA

IC

Treatment of Fractures

 

Replantation, avulsed tooth/teeth (including splinting)

 

 

76941

Replantation, first tooth

392.00

420.80

509.60

547.04

76949

Each additional tooth

200.00

211.20

260.00

274.56

 

Repositioning of traumatically displaced teeth

 

 

76951

1 unit of time

94.40

102.40

122.72

133.12

76952

2 units of time

188.80

207.20

245.44

269.36

76959

Each additional unit of time over 2

94.40

102.40

122.72

133.12

Hemorrhage, Control of

Covered only if the procedure is rendered by a dentist

other than the provider of the original service.

79403

Hemorrhage control, using compression and hemostatic agent

IC

IC

IC

IC

79404

Hemorrhage control, using hemostatic substance and sutures (including removal of bony tissue, if necessary)

IC

IC

IC

IC

Post-Surgical Care

(excludes alveolitis)

79605

Post-surgical care, alveolitis, treatment of (without anesthesia)

NA

76.13

NA

98.97

79606

Post-surgical care, alveolitis, treatment of (with anesthesia)

NA

76.13

NA

98.97


Part 7: Adjunctive General Services—90000–99999

Anesthesia, Conscious Sedation

Coverage guidelines apply (see preamble in the Dentists Guide).


 

1. Nitrous oxide time is measured from the placement of the inhalation device and terminates with the removal of the inhalation device.

 

 

92411

1 unit of time

42.00

63.00

54.60

81.90

92412

2 units of time

84.00

128.00

109.20

166.40

92413

3 units of time

126.00

167.40

163.80

217.62

92414

4 units of time

168.00

200.70

218.40

260.91


 

2. Nitrous oxide with oral sedation, time measured with the administration of nitrous oxide and terminates with the release of the patient from the treatment/recovery room.

 

 

92431

1 unit of time

IC

109.14

IC

141.88

92432

2 units of time

IC

215.62

IC

280.31

92433

3 units of time

IC

324.76

IC

422.19

92434

4 units of time

IC

433.91

IC

564.08


 ________________________________________________________________ 


Schedule C—Oral and Maxillofacial Surgery


Oral and maxillofacial surgical services for residents are provided if the condition of the resident is such that the services are medically required to be rendered in hospital.



Part 1: Diagnostic—01000–09999

 

 

SP Fee

1601 

Examination and diagnosis, surgical, general, includes:

(a) history, medical and dental; and

(b) clinical examinations as above, may include in-depth analysis of medical status, medication, anesthetic and surgical risk, initial consultation with referring dentist or physician, parent or guardian, evaluation of source of chief complaint, evaluation of pulpal vitality, mobility of teeth, occlusal factors or where the patient is to be admitted to hospital for dental procedures

64.21

1205

Examination and diagnosis, emergency: examination to investigate discomfort and/or infection in a localized area
(Covered only for hospital in-patients, when requested by a physician or dentist.)

49.29

94102

Hospital admission
(Admission to hospital when no surgical treatment is rendered.)

67.73

94302

Hospital visit
(For non-surgical admitted patient only. A maximum of 14 daily visits are payable in connection with a hospital admission; but if the patient, at any time within the 14 days, becomes a surgical patient, this service is no longer covered.)

38.08


Part 2: Oral and Maxillofacial Surgery—70000–79999

 

The following surgical services include necessary local anaesthetic, removal of excess gingival tissue, suturing and 1 post-operative treatment, when required.

 

 

A surgical site is considered to include a full quadrant, sextant or group of several teeth that can be practically and conveniently combined for a single surgical sitting, or in some cases a single tooth.

 

Removals

 

1. Removals, erupted teeth, uncomplicated

 

71101

Single tooth, uncomplicated

65.90

71109

Each additional tooth, same quadrant

34.65

 

2. Removals, erupted teeth, complicated

 

71201

Odontectomy, (extraction), erupted tooth, surgical approach, requiring surgical flap and/or sectioning of tooth

93.83

71209

Each additional tooth, same quadrant

46.95

Removals (Extractions), Surgical

 

3. Removals, impactions, soft tissue coverage

 

 

Removals, impaction, requiring incision of overlying soft tissue and removal of the tooth

 

72111

Single tooth

169.72

72119

Each additional tooth, same quadrant

84.86

 

4. Removals, impactions, involving tissue and/or bone coverage

 

 

Removals, impaction, requiring incision of overlying soft tissue elevation of a flap and either removal of bone and tooth or section and removal of tooth (partial bone impaction)

 

72211

Single tooth

169.72

72219

Each additional tooth, same quadrant

84.86

 

Removals, impaction, requiring incision of overlying soft tissue, elevation of a flap, removal of bone AND sectioning of tooth for removal

 

72221

Single tooth

169.72

72229

Each additional tooth, same quadrant

84.86

 

Removals, impaction, requiring incision of overlying soft tissue, elevation of a flap, removal of bone, sectioning of the tooth for removal and/or presents unusual difficulties and circumstances.

 

72231

Single tooth

169.72

72239

Each additional tooth, same quadrant

84.86

 

 5. Removals (extractions), residual roots

 

 

Removals, residual roots, erupted

 

72311

First tooth

100.34

72319

Each additional tooth, same quadrant

50.17

 

Removals, residual roots, soft tissue coverage

 

72321

First tooth

100.34

72329

Each additional tooth, same quadrant

50.17

 

Removals, residual roots, bone tissue coverage

 

72331

First tooth

100.34

72339

Each additional tooth, same quadrant

50.17

 

6.  Surgical movement of teeth

 

 

Transplantation of erupted tooth

 

72611

First tooth

328.10

72619

Each additional tooth, same quadrant

164.04

Apicoectomy

34111

Root Resection, Anterior tooth

166.68

34112

Root Resection, Posterior tooth

249.99

Remodeling and Recontouring Oral Tissues

 

1. Alveoloplasty (bone remodelling of ridge with soft tissue revisions)

 

 

Alveoloplasty, in conjunction with extractions

 

73121

Alveoloplasty, not in conjunction with extractions, per sextant

106.79

 

Remodelling of bone

 

73141

Mylohyoid ridge remodelling

106.79

73142

Genial tubercles remodelling

106.79

 

Excision of bone

 

73151

Nasal spine, excision

160.19

73152

Torus palatinus, excision

308.05

73153

Torus mandibularis, unilateral, excision

228.49

73154

Torus mandibularis, bilateral, excision

368.80

 

Removal of bone, exostosis, multiple

 

73161

Per quadrant

160.19

 

Reduction of bone, tuberosity

 

73171

Unilateral, reduction

160.19

73172

Bilateral, reduction

240.27

 

Augmentation of bone

 

73181

Unilateral, pterygomaxillary tuberosity, augmentation + E

557.55

73182

Bilateral, pterygomaxillary tuberosity, augmentation + E

1105.65

73183

Unilateral, mandibular ridge, augmentation + E

557.55

73184

Bilateral, mandibular ridge, augmentation + E

1114.05

 

2. Gingivoplasty and/or stomatoplasty, oral surgery

 

 

Independent procedure surgery

 

73211

Per sextant

98.07

 

Miscellaneous procedures

 

73222

Excision of vestibular hyperplasia (per sextant)

147.05

73223

Surgical shaving of papillary hyperplasia of the palate

221.34

73224

Excision of pericoronal gingiva (for retained teeth) per tooth/implant

147.05

 

Removals, tissue, hyperplastic (includes incising the mucous membrane, dissecting and removing hyperplastic tissue, replacing and adapting the mucous membrane)

 

73231

Per sextant

98.07

 

Removal, mucosa, excess (complete removal without dissection)

 

73241

Per sextant

98.07

 

3. Remodeling, floor of the mouth

 

73301

Full arch lowering of the floor of the mouth

601.57

73302

Partial arch lowering of the floor of the mouth

601.57

73303

Reinsertion of the mylohyoid muscle

601.57

 

4. Vestibuloplasty

 

 

Vestibuloplasty, sub-mucous

 

73411

Per sextant

159.10

 

Sulcus deepening and ridge reconstruction

 

73421

Per sextant

159.10

 

Vestibuloplasty, with secondary epithelization

 

73431

Per sextant

159.10

 

Vestibuloplasty, with labial inverted flap

 

73441

Per sextant

200.53

 

Vestibuloplasty, with skin graft

 

73451

Per sextant

200.53

 

Vestibuloplasty, with mucosal graft

 

73461

Per sextant

200.53

 

5. Reconstruction, alveolar ridge

 

 

Reconstruction, alveolar ridge, with autogenous bone

 

73511

Per sextant + E

328.16

 

Reconstruction, alveolar ridge, with alloplastic material

 

73521

Per sextant + E

164.07

 

6. Extensions, mucous folds

 

 

Extensions, mucous folds with secondary epithelization

 

73611

Per sextant

200.53

 

Extensions, mucous folds, with skin grafts

 

73621

Per sextant

200.53

 

Extensions, mucous folds, with mucous graft

 

73631

Per sextant

200.53

Surgical Excision

(not in conjunction with tooth removal, including biopsy)

 

1. Surgical excision, tumours, benign

 

74111

1 cm and under

136.95

74112

1–2 cm

136.95

74113

2–3 cm

136.95

74114

3–4 cm

342.10

74115

4–6 cm

342.10

74116

6–9 cm

342.10

74117

9–15 cm

537.11

74118

15 cm and over

537.11

 

Tumours, benign, bone tissue

 

74121

1 cm and under

165.71

74122

1–2 cm

165.71

74123

2–3 cm

165.71

74124

3–4 cm

309.73

74125

4–6 cm

414.73

74126

6–9 cm

414.73

74127

9–15 cm

651.17

74128

15 cm and over

651.17

 

2. Surgical excision, tumours, malignant

 

74211

1 cm and under

136.95

74212

1–2 cm

136.95

74213

2–3 cm

136.95

74214

3–4 cm

342.10

74215

4–6 cm

342.10

74216

6–9 cm

342.10

74217

9–15 cm

537.11

74218

15 cm and over

537.11

 

Tumours, malignant, bone tissue

 

74221

1 cm and under

165.71

74222

1–2 cm

165.71

74223

2–3 cm

165.71

74224

3–4 cm

414.73

74225

4–6 cm

414.73

74226

6–9 cm

414.73

74227

9–15 cm

651.17

74228

15 cm and over

651.17

 

3. Cheiloplasty (lip shave)

 

74311

Cheiloplasty, partial

56.43

74312

Cheiloplasty, total

169.33

 

4. Surgical excision, cysts/granulomas

 

 

Enucleation of cyst/granuloma, odontogenic and non-odontogenic, requiring prior removal of bony tissue and subsequent suture(s)

 

74611

1 cm and under

157.72

74612

1–2 cm

157.72

74613

2–3 cm

157.72

74614

3–4 cm

157.72

74615

4–6 cm

197.07

74616

6–9 cm

197.07

74617

9–15 cm

197.07

74618

15 cm and over

309.37

 

Marsupialization

 

74621

Cyst, marsupialization

169.33

 

Excision of cyst

 

74631

1 cm and under

157.72

74632

1–2 cm

157.72

74633

2–3 cm

157.72

74634

3–4 cm

157.72

74635

4–6 cm

197.07

74636

6–9 cm

197.07

74637

9–15 cm

197.07

74638

15 cm and over

309.37

Surgical Incisions

 

1. Surgical incision and drainage and/or exploration, intra-oral

 

 

Surgical incision and drainage and/or exploration, intra-oral soft tissue

 

75111

Intra-oral, surgical exploration, soft tissue

66.08

75112

Intra-oral, abscess, soft tissue

66.08

75113

Intra-oral, abscess, in major anatomical area with drain

66.08

 

Surgical incision and drainage and/or exploration, intra-oral hard tissue

 

75121

Intra-oral, abscess, hard tissue, trephination and drainage.

85.63

75122

Intra-oral, surgical exploration, hard tissue

85.63

75123

Intra-oral, abscess, hard tissue, trephination and drainage in major anatomical area

85.63

 

2. Surgical incision and drainage and/or exploration, extra-oral

 

 

Surgical incision and drainage and/or exploration, extra-oral, soft tissue

 

75211

Extra-oral, abscess, superficial

132.03

75212

Extra-oral, abscess, deep

132.03

 

Surgical incision and drainage and/or exploration, extra-oral, hard tissue

 

75221

Extra-oral, surgical exploration, hard tissue

159.73

 

 3.  Surgical incision for removal of foreign bodies

 

75301

Removal, from skin or subcutaneous areolar tissue

147.05

75302

Removal, of reaction producing foreign bodies

147.05

75303

Removal, of needle from musculoskeletal system

160.19

 

Sequestrectomy (for osteomyelitis)

 

75401

Intra-oral sequestrectomy

247.95

75402

Saucerization

247.95

75403

Osteomyelitis, non-surgical treatment of

90.55

 

Extra-oral sequestrectomy

 

75411

3 cm and less

330.57

75412

3–4 cm

330.57

75413

4–6 cm

495.89

75414

6–9 cm

495.89

75415

9 cm and over

495.89

 

Mandibulectomy

 

75511

3 cm and less

646.29

75512

3–4 cm

646.29

75513

4–6 cm

646.29

75514

6–9 cm

646.29

75515

9–12 cm

646.29

75516

12–15 cm

646.29

75517

15 cm and over

1014.64

75518

Total mandibulectomy

1680.90

 

Maxillectomy

 

75611

3 cm and less

646.29

75612

3–4 cm

646.29

75613

4–6 cm

646.29

75614

6–9 cm

646.29

75615

9–12 cm

646.29

75616

12–15 cm

646.29

75617

15 cm and over

1014.64

75618

Total maxillectomy

1680.90

Fractures, Treatment of

 

1. Fractures, reductions, mandibular

 

76201

Reduction, mandibular, closed

330.57

76202

Reduction, mandibular, open, simple

578.43

76203

Reduction, mandibular, open, double

867.64

76204

Reduction, mandibular, open, multiple

1156.82

 

2. Fractures, reductions, maxillary, horizontal Le Fort’s I

 

76301

Reduction, maxillary closed

330.57

76302

Reduction, maxillary open, simple

578.43

76303

Reduction, maxillary, open, double

867.64

76304

Reduction, maxillary, open, multiple

1156.82

76305

Reduction, compound fracture or maxilla (requiring reduction and soft tissue repair)

661.19

 

3. Fractures, reductions, maxilla, pyramidal Le Fort II

 

76401

Reduction, maxillary, closed

330.57

76402

Reduction, maxillary, open, unilateral

661.19

76403

Reduction, maxillary, open, bilateral

661.19

 

4. Fractures, reductions, naso-orbital

 

76501

Reduction, unilateral

991.74

76502

Reduction, bilateral

991.74

76503

Reduction, naso-orbital, open, external approach

991.74

76504

Reduction, naso-orbital, open, sinusal approach

991.74

76505

Reduction, naso-orbital, open, orbital approach with insertion of subperiosteal implant

991.74

76506

Exploration, of orbital blowout fracture

991.74

76507

Exploration, of orbital blowout fracture and reconstruction with insertion of a subperiosteal implant

991.74

 

5. Fractures, reductions, malar bone

 

76601

Reduction, malar bone, closed

165.36

76602

Reduction, malar bone, open, by simple elevation

165.36

76603

Reduction, malar bone, open, by osteosynthesis

330.57

76604

Reduction, malar bone, open, by sinus approach

495.89

76605

Reduction, malar bone, simple fracture, (open reduction with antrostomy and packing)

495.89

 

6. Fractures, reductions, zygomatic arch

 

76701

Reduction, zygomatic arch, intra-oral approach

165.36

76702

Reduction, zygomatic arch, temporal approach

165.36

76703

Reduction, zygomatico-maxillary fracture dislocation, complex, closed reduction

330.57

76704

Reduction, zygomatico-maxillary fracture dislocation, open reduction

495.89

 

7. Fractures, reductions, craniofacial dysfunction, Le Fort’s III transverse (specify type of procedure according to previous code used for fracture)

 

76801

Reduction, craniofacial dysfunction, closed

991.74

76802

Reduction, craniofacial dysfunction, open

991.74

 

8. Fractures, reductions alveolar

 

 

Fracture, alveolar, debridement, teeth removed

 

76911

3 cm or less

184.22

76912

3–6 cm

184.22

76913

6 cm and over

330.57

 

Reduction, alveolar, closed, with teeth (fixation extra)

 

76921

3 cm or less

184.22

76922

3–6 cm

184.22

76923

6–9 cm

330.57

76924

9 cm and over

330.57

 

Reduction, alveolar, open, with teeth (fixation extra)

 

76931

3 cm or less

330.57

76932

3–6 cm

330.57

76933

6–9 cm

578.43

76934

9 cm and over

578.43

 

Replantation, avulsed tooth/teeth (including splinting)

 

76941

Replantation, first tooth

93.83

76949

Each additional tooth

46.95

 

Repositioning of traumatically displaced teeth

 

76951

1 unit of time

49.59

76952

2 units of time

99.18

76959

Each additional unit of time over 2

49.59

 

Repairs, lacerations, uncomplicated, intra-oral or extra-oral

 

76961

2 cm or less

66.08

76962

2–4 m

66.08

76963

4–6 cm

66.08

76964

6–9 cm

66.08

76965

9–12 cm

66.08

76966

12–16 cm

161.05

76967

16–20 cm

161.05

76968

20–25 cm

161.05

76969

25 cm and over

161.05

 

Repairs, lacerations, through and through

 

76971

2 cm or less

165.36

76972

2–4 m

165.36

76973

4–6 cm

165.36

76974

6–9 cm

270.94

76975

9–12 cm

270.94

76976

12–16 cm

270.94

76977

16–20 cm

270.94

76978

20–25 cm

270.94

76979

25 cm and over

270.94

 

Repairs, lacerations, complicated (local tissue shifts)

 

76981

2 cm or less

165.36

76982

2–4 m

165.36

76983

4–6 cm

165.36

76984

6–9 cm

270.94

76985

9–12 cm

270.94

76986

12–16 cm

270.94

76987

16–20 cm

270.94

76988

20–25 cm

270.94

76989

25 cm and over

270.94

Maxillofacial Deformities, Treatment of

 

1. Osteotomy/ostectomy, ramus of the mandible

 

77101

Osteotomy, subcondylar, closed

578.58

77102

Osteotomy, subcondylar, open

1400.63

77103

Osteotomy, ramus of the mandible, oblique, extra-oral

1400.63

77104

Osteotomy, ramus of the mandible, oblique, intra-oral

1400.63

77105

Osteotomy/ostectomy, body of the mandible

1400.63

77106

Osteotomy, coronoidectomy

1400.63

77107

Osteotomy, condylar neck

1400.63

77108

Osteotomy, sagittal split

1400.63

 

2. Osteotomy, miscellaneous

 

77201

Osteotomy, oblique with bone graft

1680.71

77202

Osteotomy, inverted “L”

1400.63

77203

Osteotomy, “C”

1400.63

 

3. Osteotomy, maxilla

 

77301

Osteotomy, maxilla, total

1400.63

77302

Osteotomy, maxilla, total with bone graft

1680.90

77303

Osteotomy, maxilla, Le Forte II with bone graft

1400.63

77304

Osteotomy, maxilla, Le Fort III

1680.90

77305

Additional to the above osteotomy requiring 3 segments

76.69

77306

Additional to the above osteotomy requiring 4 segments

115.04

77307

Additional to the above osteotomy requiring a cranial flap

153.37

77308

Closure of cleft fistula (alveolar)

503.87

77309

Closure of cleft fistula (palatal)

672.20

77311

Pharyngoplasty

365.59

77312

Submucous resection

268.89

 

4. Osteotomy, maxillary/mandibular, segmental

 

 

Osteotomy, segmental, maxilla

 

77411

Osteotomy, segmental, anterior

1017.33

77412

Osteotomy, segmental, posterior

1017.33

77413

Osteotomy, midpalatal split, anterior

1017.33

77414

Osteotomy, midpalatal split, complete

1017.33

 

Osteotomy, segmental, mandible

 

77421

Osteotomy, segmental, anterior with transfer of mental eminence

1017.33

77422

Osteotomy, segmental, anterior, without the transfer of mental eminence

1017.33

77423

Osteotomy, segmental, posterior

1017.33

77424

Osteotomy, lower border, mandible

1017.33

77425

Osteotomy, total dento-alveolar, mandible

1017.33

 

5. Genioplasty

 

77501

Genioplasty, sliding, reduction or augmentation

1017.33

77502

Genioplasty, reduction (vertical)

1017.33

77503

Genioplasty, augmentation with graft (see grafting codes)

1017.33

77504

Myotomy, suprahyoid

1017.33

 

6. Miscellaneous treatment of maxillofacial deformities

 

77601

Corticotomy

160.19

77602

Interdental septotomy

160.19

77603

Surgical expansion of the palate

1017.33

 

7. Palatorrhaphy

 

77701

Palatorrhaphy, anterior (closure of palatine fissure)

850.50

77702

Palatorrhaphy, posterior

850.50

77703

Palatorrhaphy, total

1017.33

77704

Palatorrhaphy, with bone graft

1017.33

77705

Palatorrhaphy, bone graft to anterior alveolar ridge

1017.33

 

8. Glossectomy

 

77901

Glossectomy, partial, anterior wedge

342.10

77902

Glossectomy, partial, for orthodontic purposes

342.10

77903

Glossectomy, full posterior-anterior wedge

342.10

 

9. Cleft surgery

 

77911

Primary unilateral cleft lip repair

984.43

77912

Secondary unilateral cleft lip repair

984.43

77913

Primary bilateral cleft lip repair

1476.62

77914

Secondary bilateral cleft lip repair

1476.62

77917

Closure of alveolar cleft (see grafting codes)

984.43

 

10.  Oral nasal fistula

 

77921

Primary closure at time of initial surgery

656.36

77922

Secondary closure with palatal flap

656.36

77923

Secondary closure with pharyngeal flap

656.36

77924

Secondary closure with tongue flap

656.36

77925

Secondary closure with buccal flap

656.36

Temporomandibular Joint Dysfunctions, Treatment of

 

1.  Temporomandibular joint, dislocation, management of

 

78101

Dislocation, open reduction

413.32

78102

TMJ, dislocation, closed reduction, uncomplicated

49.59

78103

TMJ, dislocation, closed reduction, under general anesthetic

49.59

78104

TMJ, luxation, reduction without anesthesia

49.59

78105

TMJ, luxation, reduction under anesthesia

49.59

78106

TMJ, manipulation, under anesthesia

49.59

 

 2. Temporomandibular joint, capsule, management of

 

78201

Condyloplasty

495.89

78202

Condylotomy

495.89

78203

Cyndylectomy

495.89

78204

Eminoplasty

437.50

78205

Re-contour of glenoid fossa

437.50

78206

Menisectomy

656.36

78207

Plication of meniscus

875.25

78208

Repair of meniscus

875.25

78209

Replacement of meniscus

875.25

 

3. Temporomandibular joint, arthrotomy for major reconstruction

 

78301

Fossa replacement (see grafting codes)

962.67

78302

Condylar replacement (see grafting codes)

962.67

78303

Gap arthroplasty for ankylosis (see grafting codes)

962.67

 

4. Temporomandibular joint, arthrocentesis (puncture and aspiration)

 

78501

1 unit of time

82.68

78502

2 units of time

165.35

78509

Each additional unit of time over 2

82.39

 

5. Temporomandibular joint, management by injections

 

78601

Injection, with anti-inflammatory drugs

82.68

78602

Injection, with sclerosing agent

82.68

Oral Surgery Procedures, Other

 

1. Salivary glands, treatment of

 

79101

Salivary duct, dilation of

28.21

79102

Salivary duct, insertion of polyethylene tube

28.82

79103

Salivary duct, sialodochoplasty

338.66

79104

Salivary duct, reconstruction of

338.66

 

Salivary duct, sialolithotomy

 

79111

Sialolithotomy, anterior 1/3 of canal

99.18

79112

Sialolithotomy, posterior 2/3 of canal

297.49

79113

Sialolithotomy, external approach

396.56

 

Salivary gland, excisions

 

79121

Excision of submaxillary gland

396.56

79122

Excision of sublingual gland

396.56

79123

Excision of mucocele

152.50

79124

Excision of ranula

198.44

79125

Marsupialization of ranula

198.44

 

Salivary gland, removal

 

79131

Salivary gland, removal, parotid (subtotal)

595.11

79132

Salivary gland, removal, parotid (radical, including facial nerve)

793.45

 

2. Neurological disturbances, treatment of

 

 

Neurological disturbances, trigeminal nerve

 

79211

Trigeminal nerve, injection for destruction

82.68

79212

Trigeminal nerve, avulsion at periphery

328.41

79213

Trigeminal nerve, total avulsion of a branch

382.41

79214

Trigeminal nerve, alcoholization of a branch

82.68

79215

Trigeminal nerve, infiltration of a branch for diagnosis

82.68

79217

Trigeminal nerve, neurolysis or tumour excision of trigeminal nerve excision branch in soft tissue

328.41

79218

Trigeminal nerve, neurolysis or tumour excision of trigeminal nerve excision branch in bone (mandible, maxilla or orbit) (not to include osteotomy)

328.41

 

Neurological disturbances, inferior dental nerve

 

79231

Inferior dental nerve, complete avulsion

328.41

79232

Inferior dental nerve, decompression in the canal

328.41

 

Neurological disturbances, surgery

 

79246

Excision of tumour or neuroma

328.41

 

3. Antral surgery

 

 

Antral surgery, recovery, foreign bodies

 

79311

Antral surgery, immediate recovery of a dental root or foreign body from the antrum

198.44

79312

Antral surgery, immediate closure of antrum by another dental surgeon

164.39

79313

Antral surgery, delayed recovery of a dental root with oral antrostomy

495.89

79314

Antral surgery with nasal antrostomy

495.89

 

Antral surgery, oro-antral fistula closure (same session) same

 

79331

Oro-antral fistula closure with buccal flap

495.89

79332

Oro-antral fistula closure with gold plate

495.89

79333

Oro-antral fistula closure with palatal flap

495.89

 

Antral surgery, oro-antral fistula closure (subsequent session) subsequent

 

79341

Oro-antral fistula closure with buccal flap

495.89

79342

Oro-antral fistula closure with gold plate

495.89

79343

Oro-antral fistula closure with palatal flap

495.89

Hemorrhage, Control of

Covered only if the procedure is rendered by a dentist

other than the provider of the original service.

79403

Hemorrhage control, using compression and hemostatic agent

53.53

79404

Hemorrhage control, using hemostatic substance and sutures (including removal of bony tissue, if necessary)

53.53

Post-Surgical Care

(excludes alveolitis)

79602

Post-surgical care, minor, by other than treating dentist

53.38

Emergency Office Procedures

79701

Emergency procedure, tracheotomy

IC

79702

Emergency procedure, crico-thyroidotomy

IC

 

 ________________________________________________________________ 


Schedule D—Maxillofacial Prosthodontics Program

 

The Maxillofacial Prosthodontics Program provides insured dental services for residents whose maxillofacial prosthodontic needs are the result of congenital facial disorders, cancer, surgery, trauma, and/or neurological deficit.

 

All of the services set out in this Schedule are payable at $56.60 per 15-minute time unit.

 


Part 1: Examination and Diagnosis

1702

Examination and diagnosis, prosthodontic, specific


Part 2: Prosthetics, Removable—50000–59999

Dentures, Complete

 

1. Dentures, complete, equilibrated (involves remounted equilibration on a semi- adjustable articulator)

51201

Maxillary + L

51202

Mandibular + L

51204

Liners, resilient in addition to above

 

2. Dentures, surgical, standard (immediate) (includes tissue conditioner, but does not include hard reline but does include 3 months post insertion care

51301

Maxillary + L

51302

Mandibular + L

 

3. Dentures, complete, transitional (temporary)

51601

Maxillary + L

51602

Mandibular + L

 

4. Dentures, complete, overdenture

51711

Maxillary + L

51712

Mandibular + L

 

5. Dentures, complete, overdentures (immediate)

51811

Maxillary + L

51812

Mandibular + L

 

6. Dentures, complete, attached to implants

51921

Maxillary + L

51922

Mandibular + L

Dentures, Partial, Acrylic

 

1. Dentures, partial, acrylic base (transitional) (with or without clasps)

52101

Maxillary + L

52102

Mandibular + L

 

2. Dentures, partial, acrylic base (immediate)

52111

Maxillary + L

52112

Mandibular + L

 

3. Dentures, partial, acrylic, with metal wrought/cast clasps and/or rests

52301

Maxillary + L

52302

Mandibular + L

 

4. Dentures, partial, acrylic, with metal wrought/cast clasps and/or rests (immediate)

52311

Maxillary + L

52312

Mandibular + L

 

5. Dentures, partial, overdenture, acrylic, with cast/wrought clasps and/or rests

52501

Maxillary + L

52502

Mandibular + L

 

6. Dentures, partial, overdenture, acrylic, with cast/wrought clasps and/or rests (immediate)

52511

Maxillary + L

52512

Mandibular + L

Dentures, Partial, Cast with Acrylic Base

 

1. Dentures, partial, free end, cast frame/connector, clasps and rests

53101

Maxillary + L

53102

Mandibular + L

53104

Altered cast impression technique in conjunction with 53101, 53102 + L

 

2. Dentures, partial, tooth borne, cast frame/connector, clasps and rests

53201

Maxillary + L

53202

Mandibular + L

 

3. Dentures, partial, cast, precision attachments

53401

Maxillary + L

53402

Mandibular + L

 

4. Dentures, partial, cast, semi-precision attachments

53501

Maxillary + L

53502

Mandibular + L

 

5. Dentures, partial, cast, overdenture, removable

53701

Maxillary + L

53702

Mandibular + L

53704

Altered cast impression technique done in conjunction with 53701 and 53702

Dentures, Adjustments

(after 3 months post-insertion or by other than the dentist who provided the prosthesis)

 

1. Denture adjustments, partial or complete denture, minor

54201

1 unit of time + L

 

2. Denture adjustments, partial or complete denture, remount and occlusal equilibration

54301

Maxillary + L

54302

Mandibular + L

Dentures, Repairs/Additions

 

1. Denture, repair, complete denture, no impression required

55101

Maxillary + L

55102

Mandibular + L

 

2. Denture, repair, complete denture, impression required

55201

Maxillary + L

55202

Mandibular + L

 

3. Denture, repairs/additions, partial denture, no impression required

55301

Maxillary + L

55302

Mandibular + L

 

4. Denture, repairs/additions, partial denture, impression required

55401

Maxillary + L

55402

Mandibular + L

 

5. Dentures, implant retained prosthesis, prophylaxis and polishing

55501

1 unit of time + L

55509

Each additional unit of time

Dentures, Duplication, Relining and Rebasing

 

1. Dentures, duplication

 

Denture, duplication, complete denture

56111

Maxillary + L

56112

Mandibular + L

 

2. Dentures, relining

 

Denture, reline, direct, complete denture

56211

Maxillary

56212

Mandibular

 

Denture, reline, direct, partial denture

56221

Maxillary

56222

Mandibular

 

Denture, reline, processed, complete denture

56231

Maxillary + L

56232

Mandibular + L

 

Denture, reline, processed, partial denture

56241

Maxillary + L

56242

Mandibular + L

 

Denture, reline, processed, functional impression requiring 3 appointments, partial denture

56261

Maxillary + L

56262

Mandibular + L

 

3. Dentures, remake

 

Denture, remake, using existing framework, partial denture

56411

Maxillary + L

56412

Mandibular + L

Dentures, Tissue Conditioning

 

1. Denture, tissue conditioning, per appointment, complete denture

56511

Maxillary + L

56512

Mandibular + L

 

2. Denture, tissue conditioning, per appointment, partial denture

56521

Maxillary + L

56522

Mandibular + L

Dentures, Miscellaneous Services

56601

Resilient liner, in relined or rebased denture (in addition to reline or rebase of denture) + L

56602

Resetting of teeth (not including reline or rebase of denture) + L

Prostheses

 

1. Prosthesis, facial

57101

Orbital + L

57102

Nose + L

57103

Ear + L

57104

Patch + L

57105

Facial, complex + L

57106

Facial Moulage impression

57108

Ocular conformer prosthesis

57109

Ocular prosthesis

 

2. Prosthesis, maxillofacial, obturators

57202

Obturator (definitive) (prosthesis extra) + L

57203

Obturator (post-surgical) (prosthesis extra) + L

57204

Obturator (temporary) (prosthesis extra) + L

57208

Obturator prosthesis, modification (relines or repairs) + L

57209

Speech aid prosthesis

 

3. Prosthesis, maxillofacial, other

57301

Velar (speech) bulb (prosthesis and obturator extra) + L

57302

Velar lift button, mechanical (prosthesis and obturator extra) + L (palatal lift prosthesis)

57304

Retention, magnetic (prosthesis extra) + L

57305

Guide plane, condylar (prosthesis extra) + L

57308

Skull plate, customized + L

57311

Feeding appliance (for infants with cleft palate) + L

57321

Lingual prosthesis

57341

Mandibular resection prosthesis with guide flange + L

57342

Mandibular resection prosthesis without guide flange + L

 

4. Prosthesis, temporomandibular joint

57401

Exerciser, trismus, therapy + L

 

5. Prosthesis, splints

57503

Gunning (upper and lower) + L

57504

Bar splint, labial and lingual + L

57505

Scaffolding, rhinoplastic (nasal stent) + L

57507

Template, surgical + L

57508

Commissure splint + L

 

6. Prosthesis, stents

57601

Ridge extension + L

57602

Maxillary and mandibular + L

57603

Skin grafts

57604

Mucous membrane grafts (mucosal guard)

 

7. Prosthesis, radiation appliances

57651

Radiation vehicle carrier + L

57652

Radiation protection shield (extra-oral) + L

57653

Radiation protection shield (intra-oral) + L

57660

Prosthesis, stents, decompression

 

 ________________________________________________________________ 


Schedule E—Individuals with Special Needs Oral Health Program

 

The Individuals with Special Needs Oral Health Program provides routine insured dental services for residents who are considered by a physician to have an intellectual developmental disorder to a degree where chair management is untenable.

 

The fee for an insured dental service listed in this Schedule is established as the fee set out in the Nova Scotia Dental Association Fee Guide at the general practitioner rate, unless the service is provided in a hospital, in which case the fee is established as the fee set out in the Nova Scotia Dental Association Fee Guide at the general practitioner rate, plus 30%.

 


Part 1: Diagnostic—01000–09999

Examinations

 

 

GP/SP
Fee

Hospital

Premium

 

1. Examinations and diagnosis, complete oral

 

 

01101

Examination and diagnosis, complete, primary dentition, to include extended examination and diagnosis on primary dentition, recording history, charting, treatment planning and case presentation

50.40

65.52

01102

Examination and diagnosis, complete, mixed dentition

66.00

85.80

01103

Examination and diagnosis, complete, permanent dentition

91.00

118.30

 

2. Examinations and diagnosis, limited oral

 

 

01202

Examination and diagnosis, limited oral, previous patient (recall): examination and diagnosis with mirror and explorer of hard and soft tissues, including checking occlusion and appliances, but not including specific tests

32.00

41.60

01204

Examination and diagnosis, specific: examination, diagnosis and evaluation of a specific situation in a localized area

49.00

63.70

01205

Examination and diagnosis, emergency: examination to investigate discomfort and/or infection in a localized area

49.00

63.70

05201

Consultation, in office (specialist other than orthodontist)

95.00

NA

Radiographs (including radiographic examinations and interpretation)

Coverage guidelines apply (see preamble in the Dentists Guide).

 

1. Radiographs, intra-oral, periapical

 

 

02111

Single film

17.00

22.10

02112

2 films

22.00

28.60

 

2. Radiographs, intra-oral, bitewing

 

 

02141

Single film

17.00

22.10

02142

2 films

22.00

28.60

 

3. Radiographs, panoramic

 

 

02601

Single film (once per lifetime, and only in connection with a specific request for a consultation with a specialist other than an orthodontist)
This service is not insured if provided for reasons related to spacing, crowding, eruption, timing and other orthodontic related concerns.

67.00

87.10

 

4. Radiographs, cephalometric

 

 

02701

Single film (once per lifetime, and only in connection with a specific request for a consultation with a specialist other than an orthodontist)

This service is not insured if provided for reasons related to spacing, crowding, eruption, timing and other orthodontic related concerns.

67.00

87.10

 

5. Radiographs, interpretation (received from another source, or for MSI-exposed on hospital equipment)

 

 

02801

MSI: paid at 1/2 regular fee

PA 40.00

40.00

Tests and Laboratory Examinations

Coverage guidelines apply (see preamble in the Dentists Guide).

 

1. Tests, microbiological

 

 

04101

Microbiological test for the determination of pathological agents + L

56.00

72.80

 

2. Tests, caries susceptibility

 

 

04201

Bacteriological test for the determination of dental caries susceptibility + L

56.00

72.80

 

3. Tests, histological

 

 

 

Test, histological, soft tissue

 

 

04311

Biopsy, soft oral tissue, by puncture + L

134.40

174.72

04312

Biopsy, soft oral tissue, by incision + L

134.40

174.72

04313

Biopsy, soft oral tissue, by aspiration + L

134.40

174.72

 

Tests, histological, hard tissue

 

 

04321

Biopsy, hard oral tissue, by puncture + L

159.20

206.96

04322

Biopsy, hard oral tissue, by incision + L

159.20

206.96

04323

Biopsy, hard oral tissue, by aspiration + L

159.20

206.96

 

4. Tests, cytological

 

 

04401

Cytological smear from the oral cavity + L

56.00

72.80

 

5. Tests, pulp vitality

 

 

04501

1 unit

70.40

91.52

Casts, Diagnostic

Coverage guidelines apply (see preamble in the Dentists Guide).

 

1. Cast, diagnostic, unmounted

 

 

04911

Cast, diagnostic, unmounted + L

36.00

46.80

04912

Cast, diagnostic, mounted using face bow transfer + L

23.20

30.16

 

2. Cast, diagnostic, mounted

 

 

04921

Cast, diagnostic, mounted + L

64.80

84.24

04922

Cast, diagnostic, mounted using face bow transfer + L

108.80

141.44

04923

Cast, diagnostic, mounted, using face bow + occlusal records + L

160.00

208.00


Part 2: Preventive Services—10000–19999

Preventive Scaling

11111

1 unit of time

41.00

53.30

11112

2 units of time

82.00

106.60

11113

3 units of time

123.00

159.90

11114

4 units of time

164.00

213.20

Topical Fluoride Applications

Coverage guidelines apply (see preamble in the Dentists Guide).

 

Fluoride Treatments

 

 

12112

Fluoride treatment, gel or foam

16.80

21.84

12113

Fluoride treatment, varnish

20.00

26.00

Preventive Services, Other

 

1. Nutritional dietary counselling (maximum payable per lifetime is 1 series of 4 appointments)

 

13101

1 unit of time

31.00

40.30

 

2. Caries prevention service
(Oral hygiene instruction/plaque control, including brushing

and/or flossing and/or embrasure cleaning)

13211

1 unit of time

31.00

40.30

 

3. Sealants, pit and fissure (acid etch preparation included)
Coverage guidelines apply (see preamble in the Dentists Guide).

 

13401

Each tooth

23.00

29.90

13409

Each additional tooth within the same quadrant

17.00

22.10

 

4. Topical application to hard tissue lesion(s) of an antimicrobial or remineralization agent

 

13601

1 unit of time + E

73.00

94.90

13602

2 units of time + E

148.00

192.30

 

5. Disking of teeth, interproximal
(maximum 3 units per lifetime, primary teeth only)

 

16201

1 unit of time

72.80

94.64

16202

2 units of time

145.60

189.28

16203

3 units of time

218.40

283.92

Space Maintainers

(includes design, separation, fabrication, insertion and

 if applicable, initial cementation and removal)

 

1. Space maintainers, band type

 

 

15101

Space maintainer, band type, fixed, unilateral + L

141.00

183.30

15103

Space maintainer, band type, fixed, bilateral (soldered lingual arch) + L

155.00

201.50

15105

Space maintainer, band type, fixed, bilateral tubes and locking wires + L

188.00

244.40

 

2. Space maintainers, stainless steel crown type

 

 

15201

Space maintainer, stainless steel crown type, fixed + L

166.00

215.80

 

3. Space maintainers, maintenance of
This service is not insured if provided to address necessary repairs and adjustments after 30 days following the original placement.

 

 

15601

Maintenance, space maintainer appliance, including adjustment and/or recementation after 30 days post-insertion

60.00

78.00


Part 3: Restorative Services—20000–29999

Caries, Trauma and Pain Control (permanent teeth only)

 

Caries/trauma/pain control (includes pulp caps when necessary as a separate procedure).

 

20111

First tooth

98.40

127.92

 

Caries/trauma/pain control (includes pulp caps when necessary and use of band for retention and support as a separate procedure)

 

20121

First tooth

111.20

144.56

20131

Trauma control, first tooth

40.80

53.04

Restorations, Amalgam

 

1. Restorations, amalgam, primary teeth

 

 

 

Restorations, amalgam, non-bonded, primary teeth

 

 

21111

1 surface

91.00

118.30

21112

2 surfaces

115.00

149.50

21113

3 surfaces

133.60

173.68

21114

4 surfaces

148.00

192.40

21115

5 surfaces or maximum surfaces per tooth

195.20

253.76

 

Restorations, amalgam, bonded, primary teeth

 

 

21121

1 surface

92.00

119.60

21122

2 surfaces

117.00

152.10

21123

3 surfaces

133.60

173.68

21124

4 surfaces

148.00

192.40

21125

5 surfaces or maximum surfaces per tooth

195.20

253.76

 

2. Restorations, amalgam, permanent teeth

 

 

 

Restorations, amalgam, non-bonded, permanent bicuspids and anteriors

 

 

21211

1 surface

117.60

152.88

21212

2 surfaces

148.80

193.44

21213

3 surfaces

180.80

235.04

21214

4 surfaces

201.00

261.30

21215

5 surfaces or maximum surfaces per tooth

264.00

343.20

 

Restorations, amalgam, non-bonded, permanent molars

 

 

21221

1 surface

122.40

159.12

21222

2 surfaces

155.20

201.76

21223

3 surfaces

188.80

245.44

21224

4 surfaces

217.00

282.10

21225

5 surfaces or maximum surfaces per tooth

276.00

358.80

 

Restorations, amalgam, bonded, permanent bicuspids and anteriors

 

 

21231

1 surface

122.00

158.60

21232

2 surfaces

154.00

200.20

21233

3 surfaces

186.00

241.80

21234

4 surfaces

213.00

276.90

21235

5 surfaces or maximum surfaces per tooth

264.00

343.20

 

Restorations, amalgam, bonded, permanent molars

 

 

21241

1 surface

131.00

170.30

21242

2 surfaces

166.00

215.80

21243

3 surfaces

188.80

245.44

21244

4 surfaces

234.00

304.20

21245

5 surfaces or maximum surfaces per tooth

297.00

386.10

 

3. Pins, retentive per restoration (for amalgams and tooth-coloured restorations)

 

 

21401

1 pin

24.00

31.20

21402

2 pins

37.60

48.88

21403

3 pins

51.20

66.56

21404

4 pins

64.80

84.24

21405

5 or more pins

79.20

102.96

Restorations, Prefabricated, Full Coverage

Note that a single surface restoration is payable concurrently

with open-faced stainless steel crowns.

 

1. Restorations, prefabricated, metal, primary dentition

 

 

22201

Primary anterior

162.00

210.60

22211

Primary posterior

162.00

210.60

22212

Primary posterior, open face

194.00

252.20

 

2. Restorations, prefabricated, metal, permanent dentition

 

 

22301

Permanent anterior

162.00

210.60

22302

Permanent anterior, open face

215.20

279.76

22311

Permanent posterior

162.00

210.60

22312

Permanent posterior, open face

197.60

256.88

 

3. Restorations, prefabricated, plastic, permanent dentition

 

 

22501

Permanent anterior

162.00

210.60

22511

Permanent posterior

162.00

210.60

Restorations, Tooth-Coloured

Fee codes 23113, 23114, 23115, 23413, 23414 and 23415

include reattachment of fractured tooth fragments.

 

1. Restorations, tooth-coloured, permanent anteriors, acid etch/bond technique

 

23111

1 surface

116.00

150.80

23112

2 surfaces (continuous)

148.00

192.40

23113

3 surfaces (continuous)

179.00

232.70

23114

4 surfaces (continuous)

211.00

274.30

23115

5 surfaces (continuous, maximum surfaces per tooth)

277.00

360.10

 

2. Restorations, tooth-coloured, permanent bicuspids, acid etch/bond technique

 

 

Tooth-coloured, permanent bicuspids

 

 

23311

1 surface

138.00

179.40

23312

2 surfaces

176.00

228.80

23313

3 surfaces

213.00

276.90

23314

4 surfaces

236.00

325.00

23315

5 surfaces or maximum surfaces per tooth

329.00

427.70

 

Tooth-coloured, permanent molars

 

 

23321

1 surface

144.00

187.20

23322

2 surfaces

183.00

237.90

23323

3 surfaces

222.00

288.60

23324

4 surfaces

261.00

339.30

23325

5 surfaces

343.00

445.90

 

3. Restorations, tooth-coloured, primary, anterior, acid etch/bond technique

 

 

23411

1 surface

102.00

132.60

23412

2 surfaces (continuous)

122.40

169.00

23413

3 surfaces (continuous)

158.00

205.40

23414

4 surfaces (continuous)

185.00

240.50

23415

5 surfaces (continuous, maximum surfaces per tooth)

243.00

315.90

 

4. Restorations, tooth-coloured, primary, posterior, acid etch/bond technique

 

23511

1 surface

102.00

132.60

23512

2 surfaces

122.40

169.00

23513

3 surfaces

158.00

205.40

23514

4 surfaces

185.00

240.50

23515

5 surfaces or maximum surfaces per tooth

243.00

315.90

 

(See prosthodontics section for inlays, onlays and pins.)

 

 

 

5. Posts

 

 

 

Posts, cast metal (including core) as a separate procedure

 

 

25711

Single section + L

320.80

417.04

25712

2 sections + L

427.20

555.36

25713

3 sections + L

488.80

635.44

 

Posts, cast metal (including core) concurrent with impression for crown

 

 

25721

Single section + L

166.40

216.32

25722

2 sections + L

272.80

354.64

25723

3 sections + L

333.60

433.68

 

Posts, prefabricated retentive (separate procedure)

 

 

25731

1 post

153.60

199.68

25732

2 posts same tooth

260.80

339.04

25733

3 posts same tooth

321.60

418.08

 

Posts, prefabricated, retentive and cast core

 

 

25741

1 post and cast core + L

180.96

256.64

25742

2 posts (same tooth) and cast core + L

470.40

611.52

25743

3 posts (same tooth) and cast core + L

511.20

664.56

 

Post, prefabricated, with core for crown restoration

 

 

25754

1 post, with composite core + pins

261.60

340.08

Crowns

Coverage guidelines apply (see preamble in the Dentists Guide).

Gold, butt margins (including collarless veneers), custom shading
or any aesthetics included in the lab fees are not insured.

 

1. Crowns, plastic (single units only)

 

 

 

Crowns, plastic, processed

 

 

27111

Crown, plastic, processed + L

520.80

677.04

27112

Crown, plastic, processed complicated (restorative, positional and/or aesthetic) + L

IC

IC

27113

Crown, plastic, transitional, indirect + L

176.80

229.84

 

Crowns, plastic, direct (not payable in addition to permanent crowns)

 

27121

Crown, plastic, direct, transitional (chairside)

169.60

220.48

 

2. Crowns, porcelain/ceramic/polymer glass

 

 

27201

Crown, porcelain/ceramic jacket + L

673.60

875.68

27202

Crown, porcelain/ceramic jacket complicated + L

IC

IC

 

3. Crowns, porcelain/ceramic fused to metal

 

 

27211

Crown, porcelain/ceramic fused to metal base + L

673.60

875.68

27212

Crown, porcelain/ceramic fused to metal base, complicated

808.00

1050.40

 

4. Recementation/rebonding, inlays/onlays/crowns/veneers/ posts/natural tooth fragments (maximum of 3 units per tooth)
For stainless steel crowns, recementation is payable after 120 days following original placement by same or different dentist.

 

29101

1 unit of time

72.00

93.60

29102

2 units of time

144.00

187.20

29103

3 units of time

216.00

280.80

Endodontics

 

1. Pulpotomy

 

 

 

Pulpotomy, vital, permanent teeth (as a separate emergency procedure)

 

 

32221

Anterior and bicuspid teeth

112.80

146.64

32222

Molar teeth

135.20

175.76

 

Pulpotomy, vital, primary teeth

 

 

32231

Primary tooth as a separate procedure

89.60

116.48

32232

Primary tooth, concurrent with restorations (but excluding final restorations)

80.80

105.04

 

2. Pulpectomy (as a separate emergency procedure)

 

 

 

Pulpectomy, permanent teeth/retained primary teeth

 

 

32311

1 canal

149.60

194.48

32312

2 canals

196.80

255.84

32313

3 canals

243.20

316.16

32314

4 or more canals

320.00

416.00

 

Pulpectomy, primary teeth

 

 

32321

Anterior tooth

93.60

121.68

32322

Posterior tooth

140.00

182.00

Root Canal Therapy

 

1. Root canals, permanent teeth, retained primary teeth (includes clinical procedures with appropriate radiographs, excluding final restoration)

 

33111

1 canal

428.00

556.40

33121

2 canals

616.80

801.84

33131

3 canals

793.00

1030.90

33141

4 or more canals

963.00

1251.90

 

2. Root canals, primary teeth

 

 

33401

1 canal

190.40

247.52

33402

2 canals

248.80

323.44

33403

3 or more canals

473.60

615.68

 

3. Apexification/apical closure/induction of hard tissue repair (including biomechanical preparation and placement of dentogenic media)

 

33601

1 canal

169.60

220.48

33602

2 canals

220.00

286.00

33603

3 canals

276.00

358.80

33604

4 or more canals

492.80

640.64

 

4. Re-insertion of dentogenic media per visit

 

 

33611

1 canal

71.20

92.56

33612

2 canals

71.20

92.56

33613

3 canals

71.20

92.56

33614

4 or more canals

71.20

92.56

Periapical Services

 

1. Apicoectomy/apical curettage

 

 

 

Maxillary anterior

 

 

34111

1 root

250.40

325.52

34112

2 roots

358.40

465.92

 

Maxillary bicuspid

 

 

34121

1 root

285.60

371.28

34122

2 roots

379.20

492.96

34123

3 or more roots

461.60

600.08

 

Maxillary molar

 

 

34131

1 root

320.00

416.00

34132

2 roots

425.60

553.28

34133

3 roots

536.80

697.84

34134

4 or more roots

IC

IC

 

Mandibular anterior

 

 

34141

1 root

248.80

323.44

34142

2 or more roots

356.80

463.84

 

Mandibular bicuspid

 

 

34151

1 root

285.60

371.28

34152

2 roots

379.20

492.96

34153

3 or more roots

474.40

616.72

 

Mandibular molar

 

 

34161

1 root

352.80

458.64

34162

2 roots

467.20

607.36

34163

3 roots

588.80

765.44

34164

4 or more roots

IC

IC

 

2. Retrofilling

 

 

 

Maxillary anterior

 

 

34211

1 canal

89.00

115.70

34212

2 or more canals

106.40

138.32

 

Maxillary bicuspid

 

 

34221

1 canal

105.60

137.28

34222

2 canals

132.00

171.60

34223

3 canals

145.60

189.28

34224

4 or more canals

157.00

204.10

 

Maxillary molar

 

 

34231

1 canal

128.00

166.40

34232

2 canals

159.20

206.96

34233

3 canals

175.20

227.76

34234

4 or more canals

185.60

241.28

 

Mandibular anterior

 

 

34241

1 canal

87.20

113.36

34242

2 or more canals

105.60

137.28

 

Mandibular bicuspid

 

 

34251

1 canal

104.00

135.20

34252

2 canals

128.00

166.40

34253

3 canals

143.20

186.16

34254

4 canals

154.40

200.72

 

Mandibular molar

 

 

34261

1 canal

128.00

166.40

34262

2 canals

159.20

206.96

34263

3 canals

175.20

227.76

34264

4 or more canals

185.60

241.28

Open and drain (separate emergency procedures)

39201

Anteriors and bicuspids

84.00

109.20

39202

Molars

84.00

109.20

Opening through artificial crown (in addition to procedures)

39212

Molars

148.00

192.40

Bleaching, non-vital

(maximum of 3 units payable)

 

Bleaching endodontically treated tooth/teeth

 

 

39311

1 unit of time

81.60

106.08

39312

2 units of time

163.20

212.16

39313

3 units of time

244.80

318.24


Part 4: Periodontics—40000–49999

DesensitizationThis may involve application and burnishing of medicinal aids on the root or the use of a variety of therapeutic procedures. More than 1 appointment may be necessary.

41301

1 unit of time

39.20

50.96

41302

2 units of time

78.40

101.92

41309

Each additional unit of time over 2

39.20

50.96

 

Periodontal Procedures, Gingival Curettage

 

 

42111

Per sextant

256.00

332.80

 

Periodontal Procedures, Gingivectomy

 

 

42311

Uncomplicated, per sextant

PA 297.60

386.88

42321

Complicated, per sextant

PA 324.00

421.20

42341

Soft tissue recontouring for crown lengthening

PA 154.40

200.72

 

Periodontal Surgery, Grafts

 

 

42551

Autograft (free connective tissue) for root coverage

PA 570.40

741.52

Periodontal Procedures, Adjunctive

 

1. Periodontal splinting or ligation, provisional, intra-coronal

 

 

“A” splint (acrylic, composite or amalgam, plus knurled wire)

 

 

43111

Per joint

74.00

96.20

 

2. Periodontal splinting or ligation, provisional, extra-coronal

 

 

Acid etch joint restorations (per joint)

 

 

43211

Per joint

74.00

96.20

 

Acid etch, interproximal enamel splint

 

 

43221

Per joint

74.00

96.20

 

Wire ligation

 

 

43231

Per joint

189.00

245.70

 

Wire ligation, acrylic covered

 

 

43241

Per joint

252.00

327.60

 

Dental floss ligation

 

 

43251

Per joint

PA

295.20

479.70

 

Orthodontic band splint

 

 

43261

Per band

IC

IC

 

Cast/soldered splint acid etch/resin bonded

 

 

43271

Per abutment + L

163.00

211.90

 

Periodontal Procedures, Root Planing Coverage guidelines apply

(see preamble in the Dentists Guide).

 

 

Root planing

 

 

43421

1 unit of time

41.00

53.30

43422

2 units of time

82.00

106.60

43423

3 units of time

123.00

159.90

43424

4 units of time

164.00

213.20

43425

5 units of time

205.00

266.50

43426

6 units of time

246.00

319.80

43427

One half unit of time

19.36

26.00

43429

Each additional unit over 6

41.00

53.30


Part 5: Prosthetics–Removable—50000–59999

(cast partials are not insured services)

Dentures, partial, acrylic, with wrought/cast clasps and/or rests

(covered only if required because of congenital condition or accident)

52301

Maxillary + L

542.00

704.60

52302

Mandibular + L

542.00

704.60


Part 6: Oral and Maxillofacial Surgery—70000–79999

Certain procedures included in this Part are also contained in Schedule C—Oral and Maxillofacial Surgery covering all eligible residents of the Province.

Refer to Schedule C for fees when dental surgical procedures are performed in hospital.

Removals (Extractions), Erupted Teeth

 

1. Removals, erupted teeth, uncomplicated

 

 

71101

Single tooth, uncomplicated

117.00

152.10

71109

Each additional tooth, same quadrant, same appointment

88.00

114.40

 

2. Removals, erupted teeth, complicated

 

 

71201

Odontectomy, (extraction), erupted tooth, surgical approach, requiring surgical flap and/or sectioning of tooth

225.00

292.50

71209

Each additional tooth, same quadrant

164.80

214.24

Removals (Extractions), Surgical

 

1. Removals, impactions, soft tissue coverage

 

 

 

Removals, impaction, requiring incision of overlying soft tissue and removal of the tooth

 

 

72111

Single tooth

225.00

292.50

72119

Each additional tooth, same quadrant

159.20

209.96

 

2. Removals, impactions, involving tissue and/or bone coverage (including removal of bone and tooth or sectioning and removal of tooth)

 

 

72211

Single tooth

252.00

351.00

72219

Each additional tooth, same quadrant

188.80

245.44

 

Removals, impaction, requiring incision of overlying soft tissue, elevation of a flap, removal of bone AND sectioning of tooth for removal

 

 

72221

Single tooth

373.00

484.90

72229

Each additional tooth, same quadrant

257.60

334.88

 

3. Removals (extractions), residual roots

 

 

 

Removals, residual roots, erupted

 

 

72311

First tooth

91.00

118.30

72319

Each additional tooth, same quadrant

67.20

87.36

 

Removals, residual roots, soft tissue coverage

 

 

72321

First tooth

164.00

213.20

72329

Each additional tooth, same quadrant

121.60

158.03

 

Removals, residual roots, bone tissue coverage

 

 

72331

First tooth

332.00

431.60

72339

Each additional tooth, same quadrant

241.60

314.08

Surgical Incisions

 

Surgical incision and drainage and/or exploration, intra-oral soft tissue

 

75111

Intra-oral, surgical exploration, soft tissue

132.00

171.60

75112

Intra-oral, abscess, soft tissue

132.00

171.60

75113

Intra-oral, abscess, in major anatomical area with drain

IC

IC

Treatment of Fractures

 

Replantation, avulsed tooth/teeth (including splinting)

 

 

76941

Replantation, first tooth

392.00

509.60

76949

Each additional tooth

200.00

260.00

 

Repositioning of traumatically displaced teeth

 

 

76951

1 unit of time

94.40

122.72

76952

2 units of time

188.80

245.44

76959

Each additional unit of time over 2

94.40

122.72

Hemorrhage, Control of

(covered only if the procedure is rendered by a dentist

other than the provider of the original service)

79403

Hemorrhage control, using compression and hemostatic agent

IC

IC

79404

Hemorrhage control, using hemostatic substance and sutures (including removal of bony tissue, if necessary)

IC

IC

Post-surgical Care

(excludes alveolitis)

79605

Post-surgical care, alveolitis, treatment of (without anesthesia)

76.03

98.97

79606

Post-surgical care, alveolitis, treatment of (with anesthesia)

76.03

98.97


Part 7: Adjunctive General Services—90000–99999

Anesthesia, Conscious Sedation

Coverage guidelines apply (see preamble in the Dentists Guide).

 

1. Nitrous oxide time is measured from the placement of the inhalation device and terminates with the removal of the inhalation device.

 

 

92411

1 unit of time

63.00

81.90

92412

2 units of time

128.00

166.40

92413

3 units of time

167.40

217.62

92414

4 units of time

200.70

260.91

 

2. Nitrous oxide with oral sedation, time measured with the administration of nitrous oxide and terminates with the release of the patient from the treatment/recovery room.

 

 

92431

1 unit of time

109.14

141.88

92432

2 units of time

215.62

280.31

92433

3 units of time

324.76

422.19

92434

4 units of time

433.91

564.08

 

 

 


 

Legislative History
Reference Tables

Insured Dental Services Tariff Regulations

N.S. Reg. 98/2022

Health Services and Insurance Act

Note:  The information in these tables does not form part of the regulations and is compiled by the Office of the Registrar of Regulations for reference only.

Source Law

The current consolidation of the Insured Dental Services Tariff Regulations made under the Health Services and Insurance Act includes all of the following regulations:

N.S.
Regulation

In force
date*

How in force

Royal Gazette
Part II Issue

98/20221

Jun 1, 2022

date specified

Jun 3, 2022

108/2023

Jul 4, 2023

date specified

Jun 30, 2023

109/2023

Jul 4, 2023

date specified

Jun 30, 2023

 

 

 

 

 

 

 

 

The following regulations are not yet in force and are not included in the current consolidation:

N.S.
Regulation

In force
date*

How in force

Royal Gazette
Part II Issue

 

 

 

 

 

 

 

 

 

 

 

 

*See subsection 3(6) of the Regulations Act for rules about in force dates of regulations.

Amendments by Provision

ad. = added
am. = amended

fc. = fee change
ra. = reassigned

rep. = repealed
rs. = repealed and substituted

Provision affected

How affected

Schedule A.......................................

am. 108/2023

Schedule B........................................

rs. 109/2023

Schedule E........................................

rs. 109/2023

 

 

 

 

Note that changes to headings are not included in the above table.

Editorial Notes and Corrections

 

Note

Effective
date

1

The ministerial order for N.S. Reg. 98/2022 was filed separately on May 26, 2022.

 

 

 

 

 

 

 

Repealed and Superseded

N.S.
Regulation

Title

In force
date

Repealed
date

87/2001

Insured Dental Services Tariff Regulations

Apr 1, 2001

Mar 31, 2013

62/2013

Insured Dental Services Tariff Regulations

Mar 31, 2013

Jan 15, 2019

9/2019

Insured Dental Services Tariff Regulations

Jan 15, 2019

Jun 1, 2022

Note:  Only regulations that are specifically repealed and replaced appear in this table.  It may not reflect the entire history of regulations on this subject matter.