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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. 2013-85 (March 26, 2013, effective March 31, 2013), N.S. Reg. 62/2013

as amended to O.I.C. 2015-227 (July 14, 2015), N.S. Reg. 279/2015

 

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

Insured dental services tariff

Limited coverage under Cleft Palate/Craniofacial Program, Children’s Oral Health Program and Mentally Challenged Program

 

Schedule A: Cleft Palate/Craniofacial Program

Part 1: Diagnostic—01000–09999

Examinations

Radiographs (including radiographic examination and interpretation)

Tests and Laboratory Examinations

Photographs, Diagnostic

Casts, Diagnostic

Part 2: Endodontics—30000–39999

Pulp Chamber, Treatment of (excluding final restoration)

Root Canal Therapy

Periapacal Services

Endodontic, Procedures, Miscellaneous

Part 3: Oral and Maxillofacial Surgery—70000–79999

Removals (Extractions), Erupted Teeth

Removals (Extractions), Surgical

Surgical Incisions

Treatment of Fractures

Hemorrhage, Control of

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, 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 Bridge Retainers

Fixed Prosthodontics, Abutments/Retainers, Miscellaneous Services

Fixed Prosthetics, Other Services

Part 9: Restorative Services—20000–29999

Caries, Trauma and Pain Control

Restorations, Amalgam

Restorations, Prefabricated, Full Coverage

Restorations, Tooth Coloured

Posts

Crowns

Copings, Metal/Plastic, Transfer (Thimble Type)

Veneers, Laboratory Processed

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

Restorative Procedures, Overdentures

Restorative Services, Other

 

Schedule B: Children’s 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

Fluoride Treatments

Preventive Services, Other

Space Maintainers (includes design, separation, fabrication, insertion and, if applicable, initial cementation and removal)

Part 3: Restorative Services—20000–29999

Caries, Trauma and Pain Control

Restorations, Amalgam

Restorations, Prefabricated, Full Coverage

Restorations, Tooth Coloured

Crowns

Endodontics

Root Canal Therapy

Periapacal 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

 

Schedule C: Dental Surgical Program

Removals

Removals (Extractions), Surgical

Remodelling and Recontouring Oral Tissues

Surgical Excision (not in conjunction with tooth removal, including biopsy)

Surgical Incisions

Sequestrectomy (for Osteomyelitis)

Mandibulectomy

Maxillectomy

Fractures, Treatment of

Maxillofacial Deformities, Treatment of

Temporomandibular Joint Dysfunctions, Treatment of

Oral Surgery Procedures, Other

Hemmorhage, 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: Mentally Challenged Program



Citation

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


Insured dental services tariff

2     The tariff of fees for insured dental services is as set out in the following schedules:

 

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

 

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

 

                (c)    Schedule C: Dental Surgical Program;

 

                (d)    Schedule D: Maxillofacial Prosthodontics Program; and

 

                (e)    Schedule E: Mentally Challenged Program.


Limited coverage under Cleft Palate/Craniofacial Program, Children’s Oral Health Program and Mentally Challenged Program

3     (1)    No amount is payable for any of the following services 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)    services listed in Schedule A: Cleft Palate/Craniofacial Program that are rendered under the Children’s Oral Health Program;

 

                (b)    services listed in Schedule B: Children’s Oral Health Program;

 

                (c)    services listed in Schedule E: Mentally Challenged Program.

 

       (2)    For further clarification, if a partial benefit for a service referred to in subsection (1) has been paid or would be payable 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.




Tariff of Fees for Insured Dental Services

Schedule A: Cleft Palate/Craniofacial Program


The Cleft Palate/Craniofacial Program provides insured services for residents (as defined in the MSI Regulations) with craniofacial anomalies that directly influence the growth and development of the dentoalveolar and craniofacial structures.


From birth to the end of the month in which the resident turns 15 years of age, 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.

Amended: O.I.C. 2013-276, N.S. Reg. 281/2013; O.I.C. 2014-181, N.S. Reg. 69/2014.


From age 15 until the end of the month in which the resident turns 23 years of age, additional services are insured under this Schedule on a pre-authorization basis depending on the treatment required. Specifically, treatment made necessary as a result of the anomaly is considered for coverage.

Amended: O.I.C. 2013-276, N.S. Reg. 281/2013; O.I.C. 2014-181, N.S. Reg. 69/2014.


There is no coverage for re-treatment under this program. Additional funding is considered only under extenuating circumstances, if the Department’s Cleft Palate/Craniofacial Team determines that a condition requiring re-treatment has resulted directly from the progression of the congenital or developmental craniofacial anomaly.


There is no coverage for a service listed in this Schedule that is performed outside of the Province.


Part 1: Diagnostic—01000–09999


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

 

01101      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.........................34.40         64.80


This service (01101) is allowed once in a patient’s lifetime, when continuity of treatment is maintained. If there is a gap in treatment of 2 years or more, a further complete oral examination is warranted and is covered under the Plan.


A complete oral examination performed by another dentist is permitted under the Plan, unless performed by a dentist who is established in a group practice with the dentist who performed the first examination. (A group practice in this case means a mode of practice in which patient records are available to all dentists in the group.)


If a patient has been referred to a specialist in the same group practice, complete oral examinations by both the dentist and dental specialist are allowed.

 

01102      Examination and diagnosis, complete, mixed dentition, including
extended examination and diagnosis on mixed dentition,
recording history, charting, treatment planning and case
presentation, including above description, and eruption
sequence, tooth size–jaw size assessment ......................................44.80         92.80

 

01103      Examination and diagnosis, complete, permanent dentition,
including extended examination and diagnosis on permanent
dentition, recording history, charting, treatment planning and
case presentation, including above description ..............................60.80       126.40

Schedule A, Part 1, Item 1 amended: O.I.C. 2015-227, N.S. Reg. 279/2015.

 

2              Examinations and diagnosis, limited oral

01201      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 01100...................................28.91         35.49

 

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, as for 01100........................................22.08         27.97


MSI: This service (01202) is allowed after a 335-day period has elapsed from the previous complete or recall examination. A recall is accepted if rendered more than 335 days following the complete or previous recall examination, but is rejected if the service is rendered any time within the 335 days.


If procedures or treatment services are provided during the same appointment, the fees for both the examination and the procedure(s) or treatment service(s) are allowed.

01204      Examination and diagnosis, specific:
examination, diagnosis and evaluation of a specific
situation in a localized area (MSI: includes x-rays).........................34.51         46.94

 

01205      Examination and diagnosis, emergency:
examination to investigate discomfort and/or
infection in a localized area (MSI: includes x-rays)........................34.51         46.94


The fee for a specific (01204) oral examination applies only when no treatment is rendered during the appointment. If a procedure or treatment service is also provided, only the fee for the procedure or treatment service is allowed (unless otherwise specified). If a procedure or treatment service is provided the same day as an emergency (01205) oral examination, the fee for the examination is paid at 50%.

 

05201      Consultation, MSI—specialist—in office .........................................NA         77.91

05202      Two units of time.............................................................................NA       148.00

05209      Each additional unit of time..............................................................NA         74.00

Schedule A, Part 1, Item 2 amended: O.I.C. 2015-227, N.S. Reg. 279/2015.


Radiographs
(including radiographic examination and interpretation)


The fees are intended to include both the technical and professional components of an x-ray service; however, non-readable films are not insured.


Procedural x-rays in connection with root canal therapy are not allowed separately as the fees for root canal therapy include procedural x-rays.


The Plan requires that an x-ray be made available on request and be retained for that purpose for at least 18 months following the date it was taken.

 

1              Radiographs, intra-oral

02101      Radiographs, intra-oral, pedodontic, complete series
(minimum of 12 films including bitewings)...................................99.97       101.97

 

02102      Radiographs, intra-oral, adult, complete series
(minimum of 16 films including bitewings)...................................99.97       101.97

 

2              Radiographs, intra-oral, periapical

02111      Single film.....................................................................................12.26         12.51

02112      2 films...........................................................................................16.10         16.42

02113      3 films...........................................................................................23.68         24.15

02114      4 films...........................................................................................28.29         28.86

02115      5 films...........................................................................................32.89         33.55

02116      6 films...........................................................................................37.63         38.38

02117      7 films...........................................................................................42.16         43.00

02118      8 films...........................................................................................46.84         47.78

02119      9 films...........................................................................................51.44         52.47

02120      10 films.........................................................................................56.12         57.24

02121      11 films.........................................................................................61.17         62.39

02122      12 films.........................................................................................66.65         67.98

02123      13 films.........................................................................................72.66         74.11

02124      14 films.........................................................................................79.19         80.77

02125      15 films.........................................................................................83.93         85.61

 

3              Radiographs, intra-oral, occlusal

02131      Single film.....................................................................................29.97         30.57

02132      2 films...........................................................................................46.84         47.78

02133      3 films...........................................................................................63.70         58.00

02134      4 films...........................................................................................80.50         70.00

 

4              Radiographs, intra-oral, bitewing

02141      Single film.....................................................................................12.26         12.51

02142      2 films...........................................................................................16.10         16.42

02143      3 films...........................................................................................23.68         24.15

02144      4 films...........................................................................................28.29         28.86

 

5              Radiographs, extra-oral

02201      Single film.....................................................................................29.97         30.57

02202      2 films...........................................................................................46.84         47.78

02203      3 films...........................................................................................63.70         64.97

02204      4 films...........................................................................................80.50         82.11

 

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

02301      Single film........................................................................................PA         30.57

02302      2 films...............................................................................................PA         47.78

02303      3 films...............................................................................................PA         64.97

02304      Sinus examination: minimum 4 films identified as:
(1) Waters (2) Calwell (3) Lateral Skull (4) Basal........................PA         82.11

 

7              Radiographs, sialography

02401      Single film........................................................................................PA            PA

02402      2 films...............................................................................................PA            PA

02409      Each additional film over 2................................................................PA            PA

 

8              Radiopaque dyes, use of, to demonstrate lesions

02411      1 unit of time.....................................................................................PA            PA

02412      2 units of time...................................................................................PA            PA

02419      Each additional unit of time over 2....................................................PA            PA

 

9              Radiographs, temporomandibular joint

02501      Single film........................................................................................PA         30.57

02502      2 films...............................................................................................PA         47.78

02503      3 films...............................................................................................PA         64.97

02504      4 films (minimum examination closed and open each side)...............PA         82.11

02509      Each additional film over 4................................................................PA            PA

 

10            Radiographs, panoramic

02601      Single film.....................................................................................51.51         52.54

 

11            Radiographs, cephalometric

02701      Single film.....................................................................................51.51         52.54

02702      2 films...........................................................................................83.87         85.55

 

12            Radiographs, cephalometric, tracing and interpretation

02751      1 unit of time.....................................................................................PA            PA

02752      2 units of time...................................................................................PA            PA

02759      Each additional unit of time over 2....................................................PA            PA

 

13            Radiographs, interpretation

(MSI: for radiographs exposed on hospital equipment)

02801      MSI: paid at 1/2 regular fee

 

14            Radiographs, hand and wrist

02921      Radiographs, hand and wrist (as a duplicate aid for dental
treatment) per case............................................................................PA            PA

 

15            Radiographs, tomography

02931      Single view.......................................................................................PA            PA

02932      2 views..............................................................................................PA            PA

02933      3 views..............................................................................................PA            PA

02934      4 views..............................................................................................PA            PA

02939      Each additional view over 4..............................................................PA            PA


Tests and Laboratory Examinations


Pulp vitality tests (general and specific) are intended to be included in the fee for an initial examination; therefore, no additional allowance is made for these tests when performed in conjunction with an initial examination.


Applicable fees for all tests and laboratory examinations, other than pulp vitality tests (general and specific), are payable in addition to the fee for an initial examination.



The Plan requires that a diagnostic cast be made available on request and be retained for that purpose for at least 18 months following the date it was taken

 

1              Tests, microbiological

04101      Microbiological test for the determination of
pathological agents + L..................................................................30.97         31.59

 

2              Tests, caries susceptibility

04201      Bacteriological test for the determination of dental caries
susceptibility + L...........................................................................30.29         30.90

 

3              Tests, histological

Test, histological, soft tissue

04311      Biopsy, soft oral tissue—by puncture + L.......................................72.36         73.81

04312      Biopsy, soft oral tissue—by incision + L........................................72.36         73.81

04313      Biopsy, soft oral tissue—by aspiration + L.....................................72.36         73.81

 

Tests, histological, hard tissue

04321      Biopsy, hard oral tissue—by puncture + L.....................................83.33         85.00

04322      Biopsy, hard oral tissue—by incision + L.......................................83.33         85.00

04323      Biopsy, hard oral tissue—by aspiration + L....................................83.33         85.00

 

4              Tests, cytological

04401      Cytological smear from the oral cavity + L....................................30.29         30.90

 

5              Tests, pulp vitality

04501      1 unit of time.................................................................................25.61         26.12

04509      Each additional unit of time...........................................................25.61         26.12

 

6              Reports, laboratory

04601      Report, microbiological by oral microbiologist..................................PA            PA

04602      Report, histological by oral pathologist..............................................PA            PA

04603      Report, cytological by oral pathologist...............................................PA            PA

04604      Reports, other....................................................................................PA            PA

 

7              Tests and laboratory examinations, miscellaneous
(All available by preauthorization)

Equilibration, casts, diagnostic (pilot equilibration) for extensive or complicated restorative dentistry + L

04711      1 unit of time.....................................................................................PA            PA

04712      2 units of time...................................................................................PA            PA

04713      3 units of time...................................................................................PA            PA

04714      4 units of time...................................................................................PA            PA

04719      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

04721      1 unit of time.....................................................................................PA            PA

04722      2 units of time...................................................................................PA            PA

04723      3 units of time...................................................................................PA            PA

04724      4 units of time...................................................................................PA            PA

04729      Each additional unit of time over 4....................................................PA            PA

 

Split cast mounting, diagnostic + L

04731      1 unit of time.....................................................................................PA            PA

04732      2 units of time...................................................................................PA            PA

04733      3 units of time...................................................................................PA            PA

04734      4 units of time...................................................................................PA            PA

04739      Each additional unit of time over 4....................................................PA            PA

 

Interpretation of models from another source

04741      First unit of time................................................................................PA            PA

04749      Each additional unit of time...............................................................PA            PA


Photographs, Diagnostic

 

04801      Single photograph..........................................................................15.88         16.20

04802      2 photographs................................................................................31.74         32.00

04803      3 photographs................................................................................47.63         37.00

04809      Each additional photograph over 3.................................................15.88          7.00


Casts, Diagnostic

 

1              Cast, diagnostic, unmounted

04911      Cast, diagnostic, unmounted + L....................................................30.97         43.45

04912      Cast, diagnostic, unmounted, duplicate + L........................................PA            PA

 

2              Cast, diagnostic, mounted

04921      Cast, diagnostic, mounted + L........................................................39.00            PA

04922      Cast, diagnostic, mounted using face bow transfer + L...................64.00            PA

04923      Cast, diagnostic, mounted, using face bow + occlusal records + L..87.14            PA

04924      Cast, diagnostic, mounted using fully adjustable articulator + L
(used with 04942).............................................................................PA            PA

 

3              Casts, diagnostic, orthodontic

04931      Cast, diagnostic, orthodontic (unmounted, angle trimmed
and soaped) + L.................................................................................PA         43.45


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............................................................71.74         87.74

32222      Molar teeth....................................................................................71.74         87.74

 

Pulpotomy, vital, primary teeth

32231      Primary tooth as a separate procedure ...........................................57.66         73.12

32232      Primary tooth, concurrent with restorations (but
excluding final restoration)............................................................57.66         71.69

 

2              Pulpectomy (as a separate emergency procedure)

Pulpectomy, permanent teeth/retained primary teeth

32311      1 canal...........................................................................................82.64         84.29

32312      2 canals.......................................................................................128.02       130.58

32313      3 canals.............................................................................................PA            PA

32314      4 canals or more................................................................................PA            PA

 

Pulpectomy, primary teeth

32321      Anterior tooth................................................................................75.00         84.29

32322      Posterior tooth.............................................................................111.00       122.35


Root Canal Therapy


Includes treatment plan, clinical procedures (e.g., pulpectomy, biomechanical preparation, chemotherapeutic treatment and obturation), with appropriate radiographs and follow-up care, excluding final restoration.

 

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

33111      1 canal.........................................................................................326.42       399.57

33121      2 canals.......................................................................................478.12       575.33

33131      3 canals.......................................................................................642.19       785.99

33141      4 or more canals..........................................................................797.28       941.32

 

2              Root canals, primary teeth

33401      1 canal.........................................................................................123.10       157.87

33402      2 canals.......................................................................................169.22       209.18

33403      3 canals or more..........................................................................226.69       280.29

 

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

33601      1 canal.........................................................................................124.33       152.16

33602      2 canals.......................................................................................164.62       219.58

33603      3 canals.......................................................................................209.65       287.93

33604      4 canals or more..........................................................................376.64       433.93

 

4              Re-insertion of dentogenic media per visit

33611      1 canal...........................................................................................55.42         65.32

33612      2 canals.........................................................................................55.42         65.32

33613      3 canals.........................................................................................55.42         65.32

33614      4 canals or more............................................................................55.42         65.32


Periapacal Services

 

1              Apicoectomy/apical curettage

Maxillary anterior

34111      1 root...........................................................................................170.50       208.72

34112      2 roots.........................................................................................243.61       284.03

 

Maxillary bicuspid

34121      1 root...........................................................................................228.00       296.42

34122      2 roots.........................................................................................303.00       353.90

34123      3 roots or more............................................................................379.00       411.24

 

Maxillary molar

34131      1 root...........................................................................................242.26       296.42

34132      2 roots.........................................................................................320.61       353.90

34133      3 roots.........................................................................................382.63       431.81

34134      4 or more roots............................................................................430.83       459.78

 

Mandibular anterior

34141      1 root...........................................................................................170.50       208.72

34142      2 or more roots............................................................................243.61       270.50

 

Mandibular bicuspid

34151      1 root...........................................................................................229.00       296.42

34152      2 roots.........................................................................................303.00       353.90

34153      3 or more roots............................................................................381.00       411.24

 

Mandibular molar

34161      1 root...........................................................................................242.26       296.42

34162      2 roots.........................................................................................320.61       353.90

34163      3 roots.........................................................................................382.63       411.24

34164      4 or more roots............................................................................430.83       459.78

 

2              Retrofilling

Maxillary anterior

34211      1 canal...........................................................................................67.78         82.96

34212      2 or more canals............................................................................82.13       103.43

 

Maxillary bicuspid

34221      1 canal...........................................................................................67.78         82.96

34222      2 canals.........................................................................................82.13       103.43

34223      3 canals.........................................................................................99.37       129.30

34224      4 or more canals..........................................................................111.40       145.44

 

Maxillary molar

34231      1 canal...........................................................................................69.73         82.96

34232      2 canals.........................................................................................86.06       103.43

34233      3 canals.........................................................................................99.37       135.76

34234      4 or more canals..........................................................................111.40       145.44

 

Mandibular anterior

34241      1 canal...........................................................................................67.78         82.96

34242      2 or more canals............................................................................82.13       103.43

 

Mandibular bicuspid

34251      1 canal...........................................................................................67.78         82.96

34252      2 canals.........................................................................................82.13       103.43

34253      3 canals.........................................................................................99.37       129.30

34254      4 canals.......................................................................................111.40       145.44

 

Mandibular molar

34261      1 canal...........................................................................................69.73         82.96

34262      2 canals.........................................................................................86.06       103.43

34263      3 canals.........................................................................................99.37       129.30

34264      4 or more canals..........................................................................111.40       145.44

 

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

34601      In previously filled tooth when root canal treatment
done by another practitioner..............................................................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)........................82.33       100.69

 

Open and drain (separate emergency procedures)

39201      Anteriors and bicuspids..................................................................66.00         71.47

39202      Molars...........................................................................................66.00         71.47

 

Opening through artificial crown (in addition to procedures)

39211      Anterior and bicuspids...................................................................81.57         83.20

39212      Molars...........................................................................................81.57         83.20

 

2              Bleaching, non vital

Bleaching endodontically treated tooth/teeth

39311      1 unit of time................................................................................ 53.81         54.89

39312      2 units of time................................................................................92.62         94.47

39313      3 units of time..............................................................................131.41       134.04

 

39319      Each additional unit of time over 1 (MSI: to a maximum of 3).......38.79         39.57


Part 3: Oral and Maxillofacial Surgery—70000–79999


Certain procedures included in this Part are also contained in the list of MSI dental surgical procedures (Schedule C: Dental Surgical Program) covering all eligible residents of the Province. These services continue as benefits of MSI and, accordingly, when a dental surgical procedure is performed in hospital, the claim for that service must be submitted with the fee code set out in Schedule C.


Unless otherwise specified, a bilateral procedure is paid at an additional fee equivalent to 50% of that shown for the unilateral procedure. When performed under separate an aesthetics, at an interval, the full fee is paid for each procedure.


When more than 2 quadrants are involved, the first 2 procedures will both be paid at 100% and subsequent procedures at 50% each.


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 (Extractions), Erupted Teeth

 

1              Removals, erupted teeth, uncomplicated

MSI: 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...........................................................64.70         62.76

71109      Each additional tooth, same quadrant, same appointment...............43.35         33.00

 

2              Removals, erupted teeth, complicated

71201      Odontectomy, (extraction), erupted tooth, surgical approach,
requiring surgical flap and/or sectioning of tooth..........................139.67       169.98

71209      Each additional tooth, same quadrant.............................................85.44         85.00


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.................................................................................139.67       169.98

72119      Each additional tooth, same quadrant.............................................86.06         85.00

 

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 (partial bone impaction)

72211      Single tooth.................................................................................169.22       280.09

72219      Each additional tooth, same quadrant...........................................103.65       140.05

 

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

72221      Single tooth.................................................................................231.98       311.48

72229      Each additional tooth, same quadrant...........................................143.86       155.75

 

3              Removals (extractions), residual roots

Removals, residual roots, erupted

72311      First tooth......................................................................................51.29         62.76

72319      Each additional tooth, same quadrant.............................................33.29         31.41

Removals, residual roots, soft tissue coverage

72321      First tooth .....................................................................................96.13       117.67

72329      Each additional tooth, same quadrant.............................................60.31         58.85

Removals, residual roots, bone tissue coverage

72331      First tooth....................................................................................199.93       244.66

72339      Each additional tooth, same quadrant...........................................123.76       122.33

 

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.................................................................................176.84       225.74

72519      Each additional tooth, same quadrant.............................................88.44       112.89

 

Surgical exposure, complex, hard tissue coverage

72521      Single tooth.................................................................................176.84       225.74

72529      Each additional tooth, same quadrant.............................................88.44       112.89

 

Surgical exposure, unerupted tooth, with orthodontic attachment

72531      Single tooth.................................................................................194.82       238.58

72539      Each additional tooth, same quadrant.............................................97.39       119.28

 

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

 

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

75111      Intra-oral, surgical exploration, soft tissue......................................71.74         96.80

75112      Intra-oral, abscess, soft tissue.........................................................71.74         96.80

75113      Intra-oral, abscess, in major anatomical area with drain..................71.74         96.80

 

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 the MSI Dental Surgical Benefit. However, independent consideration is given for fractures treated in a dental office. Explanation should be included on the claim form.

 

Fracture, alveolar, debridement, teeth removed

 

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

 

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

 

Replantation, avulsed tooth/teeth (including splinting)

76941      Replantation, first tooth................................................................207.31       215.35

76949      Each additional tooth...................................................................105.54       107.71

 

Repositioning of traumatically displaced teeth

76951      1 unit of time.................................................................................49.63         47.23

76952      2 units of time................................................................................99.26         94.46

76959      Each additional unit of time over 2................................................49.63         47.23


Hemorrhage, Control of

 

79403      Hemorrhage control, using compression and hemostatic agent.......49.98         61.24

79404      Hemorrhage control, using hemostatic substance and sutures
(including removal of bony tissue, if necessary).............................49.98         61.24


Post-Surgical Care


(Required by complications and unusual circumstances, refer to comment at beginning of Part 3.)

 

79605      Post-surgical care, alveolitis, treatment of (without anaesthesia).....42.32         51.93

79606      Post-surgical care, alveolitis, treatment of (with anaesthesia)..........42.32         51.93


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 payable by MSI)...............................................................PA            PA

79952      First stage surgical placement, mandible per implant
(+ E—not payable by MSI)...............................................................PA            PA

79953      Second stage exposure and temporization, maxilla per implant
(+ E—not payable by MSI)...............................................................PA            PA

79954      Second stage exposure and temporization, mandible per implant
(+ E—not payable by MSI)...............................................................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—MSI—not including brackets

80651      1 unit of time.................................................................................44.92         54.74


Appliances, Active, for Tooth Guidance or Minor Tooth Movement

 

1              Appliances, removable

Appliances, removable, space regaining

81113      Appliance, maxillary, bilateral + L...............................................492.86       643.60

81114      Appliance, mandibular, bilateral + L............................................492.86       643.60

 

Appliances, removable, cross-bite correction

81121      Appliance, maxillary, simple + L.......................................................PA     1180.34

81122      Appliance, mandibular, simple + L....................................................PA     1180.34

 

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       643.60

81212      Appliance, mandibular + L................................................................PA       643.60

 

Appliance, fixed, space regaining, unilateral

81221      Appliance, maxillary + L...................................................................PA       449.14

81222      Appliance, mandibular + L................................................................PA       449.14

 

Appliance, fixed, cross-bite correction—anterior

(MSI: as Phase I treatment)

81231      Appliance, maxillary + L...................................................................PA     1180.34

81232      Appliance, mandibular + L................................................................PA     1180.34

 

Appliance, fixed, cross-bite correction—posterior

(MSI: as Phase I treatment)

81241      Appliance, maxillary + L...................................................................PA     1180.34

81242      Appliance, mandibular + L................................................................PA     1180.34

81243      Appliance, two-molar band, hooked and elastics + L.........................PA     1180.34

 

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 (MSI: $60.00 lab maximum)......................PA       312.61

83102      Appliance, mandibular + L (MSI: $60.00 lab maximum)...................PA       312.61

83103      Appliance, tooth positioner + L (MSI: $60.00 lab maximum)............PA       312.61

 

Appliances, fixed/cemented, retention

83201      Appliance, maxillary + L (MSI: $60.00 lab maximum)......................PA       312.61

83202      Appliance, mandibular + L (MSI: $60.00 lab maximum)...................PA       312.61


Comprehensive Orthodontic Treatment

 

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

Permanent dentition

84101      Class I malocclusion (MSI: non-surgical case)...................................PA     5140.45

84101      Class I malocclusion (MSI: surgical case)..........................................PA     5648.26

84201      Class II malocclusion (MSI: non-surgical case)..................................PA     6005.26

84201      Class II malocclusion (MSI: surgical case).........................................PA     6362.28

84301      Class III malocclusion (MSI: non-surgical case).................................PA     7379.26

84301      Class III malocclusion (MSI: surgical case)........................................PA     8703.51

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.


(MSI: details as to rationale must accompany claim.)

 

41301      1 unit of time.................................................................................31.52         32.15

41302      2 units of time................................................................................63.03         64.29

41309      Each additional unit of time over 2................................................31.52         32.15


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

 

1              Periodontal surgery, gingival curettage

Surgical curettage, including definitive root planing

42111      Per sextant...................................................................................111.47       136.63

 

2              Periodontal surgery, gingivoplasty

42201      Per sextant.........................................................................................PA       195.37

 

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)

 

Gingivectomy, uncomplicated

42311      Per sextant.........................................................................................PA       140.21

 

Gingivectomy, with curettage

42321      Per sextant.........................................................................................PA       154.24

 

Gingival fiber incision (supra crestal fibrotomy)

42331      Per tooth............................................................................................PA         26.08

42339      Each additional tooth.........................................................................PA         26.08

 

Soft tissue recontouring for crown lengthening

42341      Limited recontouring of tissue, per tooth............................................PA         72.91

 

4              Periodontal surgery, flap approach

Flap approach, with osteoplasty/ostectomy

42411      Per sextant.........................................................................................PA       286.43

 

Flap approach, with curettage of osseous defect

42421      Per sextant.........................................................................................PA       286.43

 

Flap approach, with curettage of osseous defect and osteoplasty

42431      Per sextant.........................................................................................PA       320.74

 

Flap approach, exploratory (for diagnosis)

42441      Per site..............................................................................................PA         70.57

 

Flap approach, with osteoplasty/ostoectomy for crown lengthening

42451      Per site..............................................................................................PA       286.43

 

5              Periodontal surgery, grafts

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

42511      Per site..............................................................................................PA       318.31

42512      Periosteal stimulation in addition to 42511........................................PA       350.14

 

Grafts, soft tissue, pedicle (coronally positioned)

42521      Per site..............................................................................................PA       318.31

42522      Periosteal stimulation in addition to 42521........................................PA       350.14

 

Grafts, free soft tissue

42531      Per site..............................................................................................PA       318.31

 

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

42541      Per site..............................................................................................PA       318.31

 

Grafts, free connective tissue (for root coverage)

42551      Per site..............................................................................................PA       318.31

 

Grafts, free connective tissue (for ridge augmentation)

42561      Per site..............................................................................................PA       318.31

 

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

42571      Per site..............................................................................................PA       318.31

 

Grafts, gingival onlay, for ridge augmentation

42581      Per site..............................................................................................PA       318.31

 

6              Periodontal surgery, grafts, osseous tissue

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

42611      Per site..............................................................................................PA       274.84

 

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

42621      Per site (+ E—not payable by MSI)...................................................PA            PA

 

7              Periodontal surgery, miscellaneous procedures

Guided tissue regeneration (including re-entry)

42711      Per site (+ E—not payable by MSI)...................................................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 one 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 of the joint is utilized.

 

1              Periodontal splinting or ligation, provisional, intra-coronal

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

43111      Per joint............................................................................................PA         46.12

 

2              Periodontal splinting or ligation, provisional, extra-coronal

Acid etch joint restorations (per joint)

43211      Per joint............................................................................................PA         60.44

 

Acid etch, interproximal enamel splint

43221      Per joint............................................................................................PA         60.44

 

Wire ligation

43231      Per joint............................................................................................PA         60.44

 

Wire ligation, acrylic covered

43241      Per joint............................................................................................PA         60.44

 

Dental floss ligation

43251      Per joint............................................................................................PA         60.44

 

Orthodontic band splint

43261      Per band............................................................................................PA         60.44

 

Cast/soldered splint acid etch/resin bonded

43271      Per abutment + L...............................................................................PA         60.44

 

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.................................................................................49.44         60.44

16512      2 units of time................................................................................98.90       120.89

16513      3 units of time..............................................................................148.35       181.33

16514      4 units of time..............................................................................197.81       241.82

16517      1/2 unit of time..............................................................................24.73         30.23

16519      Each additional unit of time over 4................................................49.44         60.44


Root Planing, Periodontal

 

43421      1 unit of time.................................................................................49.44         60.44

43422      2 units of time................................................................................98.90       120.89

43423      3 units of time..............................................................................148.35       181.33

43424      4 units of time..............................................................................197.81       241.82

43425      5 units of time..............................................................................247.27       302.25

43426      6 units of time..............................................................................296.71       362.67

43427      1/2 unit of time..............................................................................24.73         30.23

43429      Each additional unit of time...........................................................49.44         60.44


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) and TMJ appliances (78700).)

 

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

 

Appliances, reline (including bruxism appliances)

14631      Reline, direct.....................................................................................PA            PA

14632      Reline, processed + L........................................................................PA            PA

 

2              Appliances, temporomandibular joint

Appliance, TMJ, diagnostic

14711      Maxillary appliance + L....................................................................PA            PA

14712      Mandibular appliance + L..................................................................PA            PA

 

Appliance, TMJ intra-oral repositioning

14721      Maxillary appliance + L...............................................................266.33       325.68

14722      Mandibular appliance + L............................................................266.33       325.68

 

Appliance, TMJ, periodic maintenance, adjustments, repairs

14731      1 unit of time + L...........................................................................44.89         54.98

14732      2 units of time + L.........................................................................89.78       109.95

14733      3 units of time + L.......................................................................134.65       164.91

14739      Each additional unit of time over 3................................................44.89         54.98

 

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, adjustments and 3 post-insertion adjustments

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

Item 3, “myofacial” replaced with “myofascial”, O.I.C. 2013-276, N.S. Reg. 281/2013.


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.................................................................................PAPA

Forced eruption—1 tooth...................................................................PAPA

Forced eruption—more than 1 tooth..................................................PAPA

Rapid extrusion—1 tooth..................................................................PAPA

Rapid extrusion—more than 1 tooth..................................................PAPA


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 by the specialist on a properly referred patient.


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              Polishing—see “Caries prevention service” below

 

2              Scaling

11111      1 unit of time.................................................................................30.29         30.90

11112      2 units of time................................................................................60.56         61.77

11113      3 units of time................................................................................90.82         92.64

11114      4 units of time..............................................................................121.10       123.52

11115      5 units of time..............................................................................151.46       154.49

11116      6 units of time..............................................................................181.43       185.06

11117      1/2 unit of time..............................................................................15.14         15.44

11119      Each additional unit of time...........................................................30.29         30.90

 

3              Fluoride treatments

12101      Fluoride treatment, topical application...........................................15.00         16.14


Preventive Services, Other

 

1              Nutritional dietary counselling (including recording and analysis of 7-day dietary intake and consultation) (MSI: maximum payable per lifetime is 1 series of 4 appointments.)

13101      1 unit of time.................................................................................25.00         30.90

 

2              Caries prevention service—MSI (previously MSI fee code 220) (Oral hygiene instruction/plaque control, including brushing and/or flossing and/or embrasure cleaning, including for MSI programs rubber cup polishing and minor scaling procedures.) (MSI: allowed once every 335 days.)

13211      1 unit of time.................................................................................30.29         30.90

 

3              Sealants, pit and fissure (acid etch preparation included. MSI: limited to 6-year molars that meet guidelines—1 application per tooth.)

13401      Each tooth.....................................................................................20.00         28.15

 

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

16201      1 unit of time.................................................................................37.58         37.58

16202      2 units of time................................................................................75.16         75.16

16203      3 units of time..............................................................................112.74       112.74


 

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........................124.33       169.60

15103      Space maintainer, band type, fixed, bilateral (soldered
lingual arch) + L..........................................................................149.00       258.04

15105      Space maintainer, band type, fixed, bilateral tubes and
locking wires + L.........................................................................181.00       282.20

 

2              Space maintainers, stainless steel crown type

15201      Space maintainer, stainless steel crown type, fixed + L.................160.00       196.43

 

3              Space maintainers, maintenance of

15601      Maintenance, space maintainer appliance, including adjustment
and/or recementation after 30 days post-insertion...........................53.00         59.28


Part 7: Prosthetics—Removable—50000–59999


Dentures, complete (including 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     1243.52

51202      Mandibular + L.................................................................................PA     1296.19

51204      Liners, resilient in addition to above + L............................................PA         61.35

 

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

51301      Maxillary + L..............................................................................562.70            PA

51302      Mandibular + L............................................................................562.70            PA

 

3              Dentures, complete, transitional (temporary)

51601      Maxillary + L....................................................................................PA       853.57

51602      Mandibular + L.................................................................................PA       853.57

 

4              Dentures, complete, overdenture

51701      Maxillary + L....................................................................................PA            PA

51702      Mandibular + L.................................................................................PA            PA

 

5              Dentures, complete, overdentures (immediate)

51801      Maxillary + L....................................................................................PA            PA

51802      Mandibular + L.................................................................................PA            PA

 

6              Dentures, complete, attached to implants

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..............................................................................174.55            PA

52102      Mandibular + L............................................................................174.55            PA

 

2              Dentures, partial, acrylic base (immediate)

52111      Maxillary + L....................................................................................PA            PA

52112      Mandibular + L.................................................................................PA            PA

 

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

52301      Maxillary + L..............................................................................342.90       430.37

52302      Mandibular + L............................................................................342.90       430.37

 

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

52311      Maxillary + L..............................................................................342.90       430.37

52312      Mandibular + L............................................................................342.90       430.37

 

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

52501      Maxillary + L....................................................................................PA            PA

52502      Mandibular + L.................................................................................PA            PA

 

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

52511      Maxillary + L....................................................................................PA            PA

52512      Mandibular + L.................................................................................PA            PA


Dentures, Partial, Cast with Acrylic Base

 

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

53101      Maxillary + L....................................................................................PA            PA

53102      Mandibular + L.................................................................................PA            PA

53104      Altered cast impression technique in conjunction with 53101,
53102, 53103 + L..............................................................................PA            PA

 

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

53201      Maxillary + L..............................................................................489.49            PA

53202      Mandibular + L............................................................................489.49            PA

 

3              Dentures, partial, cast, precision attachments

53401      Maxillary + L..............................................................................694.55            PA

53402      Mandibular + L............................................................................694.55            PA

 

4              Dentures, partial, cast, semi-precision attachments

53501      Maxillary + L....................................................................................PA            PA

53502      Mandibular + L.................................................................................PA            PA

 

5              Dentures, partial, cast, overdenture, removable

53701      Maxillary + L....................................................................................PA            PA

53702      Mandibular + L.................................................................................PA            PA

53704      Altered cast impression technique done in conjunction with 53701,
53702 and 53703 + L........................................................................PA            PA


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...........................................................................44.92         54.79

 

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

54301      Maxillary + L....................................................................................PA       302.92

54302      Mandibular + L.................................................................................PA       302.92


Dentures, Repairs/Additions

 

1              Denture, repair, complete denture, no impression required

55101      Maxillary + L................................................................................40.48         49.81

55102      Mandibular + L..............................................................................40.48         49.81

 

2              Denture, repair, complete denture, impression required

55201      Maxillary + L................................................................................81.71         99.88

55202      Mandibular + L..............................................................................81.71         99.88

 

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

55301      Maxillary + L................................................................................40.48         54.98

55302      Mandibular + L..............................................................................40.48         54.98

 

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

55401      Maxillary + L................................................................................81.71         99.88

55402      Mandibular + L..............................................................................81.71         99.88

 

5              Dentures, implant retained prosthesis, prophylaxis and polishing

55501      1 unit of time + L..............................................................................PA            PA

55509      Each additional unit of time...............................................................PA            PA


Dentures, Duplication, Relining, Rebasing, and Remaking

 

1              Dentures, duplication

Denture, duplication, complete denture

56111      Maxillary + L....................................................................................PA            PA

56112      Mandibular + L.................................................................................PA            PA

 

2              Dentures, relining

Denture, reline, direct, complete denture

56211      Maxillary.....................................................................................144.41       147.30

56212      Mandibular..................................................................................144.41       147.30

 

Denture, reline, direct, partial denture

56221      Maxillary.....................................................................................138.51       141.28

56222      Mandibular..................................................................................138.51       141.28

 

Denture, reline, processed, complete denture

56231      Maxillary + L..............................................................................179.69       183.28

56232      Mandibular + L............................................................................179.69       183.28

 

Denture, reline, processed, partial denture

56241      Maxillary + L..............................................................................105.87       107.99

56242      Mandibular + L............................................................................105.87       107.99

 

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

56261      Maxillary + L..............................................................................179.69       183.28

56262      Mandibular + L............................................................................179.69       183.28

 

3              Dentures, remake

Denture, remake, using existing framework, partial denture

56411      Maxillary + L....................................................................................PA            PA

56412      Mandibular + L.................................................................................PA            PA


Dentures, Tissue Conditioning

 

1              Denture, tissue conditioning, per appointment, complete denture

56511      Maxillary + L................................................................................87.94         89.70

56512      Mandibular + L..............................................................................87.94         89.70

 

2              Denture, tissue conditioning, per appointment, partial denture

56521      Maxillary + L..............................................................................101.74       103.77

56522      Mandibular + L............................................................................101.74       103.77


Dentures, Miscellaneous Services

 

56601      Resilient liner, in relined or rebased denture (in addition to reline
or rebase of denture) + L................................................................87.94         89.70

56602      Resetting of teeth (not including reline or rebase of denture) + L.......PA            PA


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       243.67

62102      Pontics, cast metal core with separate porcelain jacket pontic + L......PA       243.67

 

Pontics, porcelain/polymer glass

62501      Pontics, porcelain fused to metal + L.................................................PA       273.63

62502      Pontics, porcelain, aluminous + L......................................................PA       273.63

 

Pontics, acrylic/plastic/composite

62702      Pontics, acrylic/plastic/composite, processed indirect
(transitional) + L...............................................................................PA            PA

62703      Pontics, acrylic/plastic/composite, transitional direct..........................PA            PA

 

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              Master cast, facebow mounting

64101      Master cast, facebow mounting + L...................................................PA            PA

 

4              Repairs, removal

Removal, fixed bridge

66211      1 unit of time.................................................................................52.59         64.36

66212      2 units of time + L.......................................................................105.17       128.69

66213      3 units of time + L.......................................................................157.75       193.02

66219      Each additional unit of time ..........................................................52.59         64.36

 

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

66301      1 unit of time + L...........................................................................60.47         73.81

 

6              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


Fixed Bridge Retainers

 

1              Retainers, plastic/acrylic

67111      Retainer, plastic/acrylic, processed + L...........................................54.06         68.27

67112      Retainer, plastic processed to metal + L.........................................54.06         68.27

 

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

67121      First tooth..........................................................................................PA            PA

67129      Each additional tooth.........................................................................PA            PA

 

Retainers, plastic/acrylic, indirect, processed (transitional during healing)

67131      First tooth + L...................................................................................PA            PA

67139      Each additional tooth + L..................................................................PA            PA

 

Retainers, plastic/acrylic, indirect, processed, attached to implants

67141      First implant + L...............................................................................PA            PA

67149      Each additional implant + L..............................................................PA            PA

 

2              Retainers, porcelain/ceramic/polymer glass

67201      Retainer, porcelain/ceramic + L.........................................................PA            PA

 

Retainers, porcelain fused to metal

67211      Retainers, porcelain/ceramic fused to metal + L.................................PA       594.89

67212      Stress breaker and/or precision attachments, in

addition to above + L........................................................................PA169.83

 

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

67221      First implant + L...............................................................................PA            PA

67229      Each additional implant + L..............................................................PA            PA

 

3              Retainers, metal, cast

Retainers, metal full cast

67301      Retainers, metal full cast + L.............................................................PA       594.89

67302      Stress breaker and/or precision attachments, in

addition to above + L........................................................................PA169.83

 

Retainers, metal 3/4 cast

67311      Retainers, metal 3/4 cast + L.............................................................PA       594.89

67312      Stress breakers and/or precision attachments, in

addition to above + L........................................................................PA169.83

 

Retainers, metal inlay (used with broken stress technique)

67321      Retainer, metal inlay, 2 surfaces + L..................................................PA       452.49

67322      Retainer, metal inlay, 3 or more surfaces + L.....................................PA       567.67

 

Retainers, metal, onlay (internal retention type)

67331      Retainer, metal, onlay + L.................................................................PA       567.67

 

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 (25761) used with 67503

67351      Retainer + L and/or (+ E—not payable by MSI)................................PA            PA

67359      Each additional retainer + L and/or (+ E—not payable by MSI).........PA            PA


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       789.84

67503      Implant, each retentive bar attached by screws to implant (67351)
to retain removable prosthesis (see 51920 for prosthesis)...................PA            PA


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......................................................................26.98         27.52

69302      2 pins/restoration + L.....................................................................39.66         40.45

69303      3 pins/restoration + L.....................................................................53.52         54.59

69304      4 pins/restoration + L.....................................................................71.19         72.61

69305      5 pins or more/restoration + L......................................................100.38       102.39

 

4              Fixed prosthetics, provisional coverage (in extensive or complicated restorative dentistry)

69701      Abutment tooth + L.......................................................................56.12         68.32

69702      Pontic + L.........................................................................................PA            PA

 

5              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

 

Removal of implant screw—retained prosthesis for cleaning or repair

69831      1 unit of time.....................................................................................PA            PA

69839      Each additional unit of time...............................................................PA            PA

 

Reinsertion of implant screw—retained prosthesis

69841      1 unit of time + E and/or + L.............................................................PA            PA

69849      Each additional unit of time...............................................................PA            PA


Part 9: Restorative Services—20000–29999


MSI note:

The stipulated fees include pulp protection and local anaesthesia.


If at the same sitting, in order to conserve tooth structure, 2 separate restorations are performed on the same tooth, involving a common surface, when 1 restoration might have been done, this is considered as 1 restoration in assessing the fee.


Additional or similar restorative work done on the same tooth within 120 days of the original service requires an explanation on the claim.


If adjacent surfaces of a tooth are filled at the same appointment, the fee is at the appropriate level for multiple surfaces, as listed below. In cases of tooth-coloured etched/bonded restoration, if the above conditions exist, they will be paid at the complex level.


The replacement of an existing amalgam restoration with tooth-coloured etched/bonded restorations is an insured service only if the amalgam restoration has been fractured and/or there is recurrent caries.


Caries, Trauma and Pain Control

(MSI: 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......................................................................................61.86        75.79

 

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, as a separate procedure)

20121      First tooth......................................................................................84.00         85.68

 

Trauma control, smoothing of fractured surfaces per tooth

20131      First tooth......................................................................................32.00         37.00


Restorations, Amalgam

 

1              Restorations, amalgam, primary teeth

Restorations, amalgam, non-bonded, primary teeth

21111      1 surface........................................................................................43.97         50.09

21112      2 surfaces......................................................................................58.98         72.55

21113      3 surfaces......................................................................................67.77         82.98

21114      4 surfaces......................................................................................85.51       104.47

21115      5 surfaces or maximum surfaces per tooth....................................107.63       131.72

 

Restorations, amalgam, bonded, primary teeth

21121      1 surface........................................................................................45.23         50.09

21122      2 surfaces......................................................................................58.98         72.55

21123      3 surfaces......................................................................................67.77         82.98

21124      4 surfaces......................................................................................85.51       104.47

21125      5 surfaces or maximum surfaces per tooth....................................107.63       131.72

 

2              Restorations, amalgam, permanent teeth

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

21211      1 surface........................................................................................53.06         64.82

21212      2 surfaces......................................................................................79.61         96.82

21213      3 surfaces.....................................................................................100.19       122.00

21214      4 surfaces.....................................................................................129.66       164.64

21215      5 surfaces or maximum surfaces per tooth....................................159.19       193.85

 

Restorations, amalgam, non-bonded, permanent molars

21221      1 surface........................................................................................60.94         70.91

21222      2 surfaces......................................................................................86.56       105.63

21223      3 surfaces.....................................................................................113.43       138.00

21224      4 surfaces.....................................................................................156.19       191.32

21225      5 surfaces or maximum surfaces per tooth....................................207.84       250.00

 

Restorations, amalgam, bonded, permanent bicuspid and anteriors

21231      1 surface........................................................................................62.82         64.82

21232      2 surfaces......................................................................................79.61         96.82

21233      3 surfaces.....................................................................................100.19       122.19

21234      4 surfaces.....................................................................................129.66       164.64

21235      5 surfaces or maximum surfaces per tooth....................................159.19       193.85

 

Restorations, amalgam, bonded, permanent molars

21241      1 surface........................................................................................70.36         70.91

21242      2 surfaces......................................................................................86.56       105.63

21243      3 surfaces.....................................................................................113.43       138.00

21244      4 surfaces.....................................................................................156.19       191.32

21245      5 surfaces or maximum surfaces per tooth....................................207.84       253.17

 

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..............................................................................................15.97         16.29

21402      2 pins.............................................................................................27.96         28.52

21403      3 pins.............................................................................................35.39         36.10

21404      4 pins.............................................................................................43.73         44.60

21405      5 pins or more...............................................................................50.78         51.80

 

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...........................................................................122.50       155.79

22202      Primary anterior, open face..........................................................118.39       144.75

22211      Primary posterior.........................................................................122.50       155.79

22212      Primary posterior, open face.........................................................118.39       144.75

 

2              Restorations, prefabricated, metal, permanent dentition

22301      Permanent anterior.......................................................................122.50       155.79

22302      Permanent anterior, open face......................................................118.39       144.75

22311      Permanent posterior.....................................................................122.50       155.79

22312      Permanent posterior, open face....................................................118.39       144.75

 

3              Restorations, prefabricated, plastic, permanent dentition

22501      Permanent anterior.......................................................................128.00       171.00

22511      Permanent posterior.....................................................................128.00       171.00


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........................................................................................73.67         89.71

23112      2 surfaces (continuous)..................................................................96.17       117.41

23113      3 surfaces (continuous)................................................................112.01       137.20

23114      4 surfaces (continuous)................................................................178.31       220.79

23115      5 surfaces (continuous, maximum surfaces per tooth)...................178.31       220.79

 

2              Restorations, tooth coloured, veneer applications

23121      Tooth coloured veneer application, direct chaireside
prefabricated, acid etch/bond........................................................178.31       220.79

23122      Tooth coloured veneer application, non-prefabricated
direct buildup, acid etch/bond......................................................178.31       220.79

 

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

Tooth coloured, permanent bicuspids

23311      1 surface........................................................................................79.15         64.82

23312      2 surfaces......................................................................................98.00         96.82

23313      3 surfaces.....................................................................................131.92       122.19

23314      4 surfaces.....................................................................................162.08       164.64

23315      5 surfaces or maximum surfaces per tooth....................................185.32       193.85

 

Tooth coloured, permanent molars

23321      1 surface........................................................................................82.92         70.91

23322      2 surfaces......................................................................................99.26       105.63

23323      3 surfaces.....................................................................................135.69       138.00

23324      4 surfaces.....................................................................................164.59       191.32

23325      5 surfaces.....................................................................................207.84       253.17

 

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

23411      1 surface........................................................................................68.47         83.77

23412      2 surfaces (continuous)..................................................................68.47         83.77

23413      3 surfaces (continuous)..................................................................96.17       117.41

23414      4 surfaces (continuous)................................................................146.00       164.59

23415      5 surfaces (continuous or maximum surfaces per tooth)...............148.69       164.59

 

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

23511      1 surface........................................................................................56.64         50.19

23512      2 surfaces......................................................................................70.36         72.55

23513      3 surfaces......................................................................................86.06         82.98

23514      4 surfaces......................................................................................96.11       104.47

23515      5 surfaces or maximum surfaces per tooth....................................107.63       131.72

 

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

23601      Restoration, tooth coloured, core, in conjunction with crown........129.33       143.16

23602      Restoration, tooth coloured, acid etch/bonded, core,
in conjunction with crown............................................................129.33       143.16


Note: Please see prosthodontics section for inlays, onlays and pins.


Posts

 

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

25711      Single section + L........................................................................172.34       244.42

25712      2 sections + L..............................................................................233.06       244.42

25713      3 sections + L....................................................................................PA       469.48

 

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

25721      Single section + L........................................................................143.00       244.42

25722      2 sections + L..............................................................................172.34       244.42

25723      3 sections + L....................................................................................PA       469.48

 

Posts, prefabricated retentive (separate procedure)

25731      1 post...........................................................................................109.24       133.31

25732      2 posts same tooth.......................................................................137.58       133.31

27533      3 posts same tooth.......................................................................171.50       133.31

 

Posts, prefabricated, retentive and cast core

25741      1 post and cast core + L...............................................................172.34       244.42

25742      2 posts (same tooth) and cast core + L..........................................172.34       244.42

25743      3 posts (same tooth) and cast core + L..............................................NA       469.48

 

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...............................................179.03       219.13

25755      2 posts (same tooth) with composite core + pins................................PA            PA

25756      3 posts (same tooth) with composite core + pins................................PA            PA

 

Post removal

25781      1 unit of time.....................................................................................PA            PA


Crowns


Stainless steel crowns: 100% of the dental tariff applies to each of the first 3 stainless steel crowns performed at 1 sitting for a patient under general anaesthesia. 50% of the dental tariff applies to each additional stainless steel crown done at the same sitting.


Despite the previous paragraph, a dentist may, when submitting a claim, request independent consideration for payment of 100% of the dental tariff for 4 or more stainless steel crowns done at the same sitting for a patient under general anaesthesia. Such a request must be accompanied by the necessary x-rays.


Permanent crowns: Pre-determination of benefits is necessary before rendering services for permanent crowns. X-rays and/or study models must accompany the request for pre-determination.


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

 

1              Crowns, plastic (single units only)

Crowns, plastic, processed

27111      Crown, plastic, processed + L......................................................396.18       404.10

27112      Crown, plastic, processed complicated (restorative, positional
and/or aesthetic) + L..........................................................................PA            PA

27113      Crown, plastic, transitional, indirect + L............................................PA            PA

27114      Crown, plastic/metal base, processed + L.....................................486.48       595.46

 

Crowns, plastic, direct

27121      Crown, plastic, direct, transitional (chairside)...............................115.36       117.67

27122      Crown, transitional restoration of fractured anterior...........................PA            PA

 

2              Crowns, porcelain/ceramic/polymer glass

27201      Crown, porcelain/ceramic jacket + L............................................486.48       595.46

27202      Crown, porcelain/ceramic jacket complicated + L..............................PA            PA

 

Crowns, porcelain/ceramic fused to metal

27211      Crown, porcelain/ceramic fused to metal base + L.......................486.48       595.46

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 (not using 25761)

(+ L and/or + E)................................................................................PAPA

 

Crown, 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..................................441.64       540.56

27302      Crown, metal, full cast, complicated (restorative, positional) + L..441.64       540.56

 

Crowns, metal 3/4 partial veneer

27311      Crowns, metal 3/4 partial veneer + L...........................................486.48       595.46

27312      Crowns, metal 3/4 partial veneer, complicated + L.......................486.48       595.46

27313      Crowns, metal 3/4 partial veneer, with direct tooth
coloured corner + L.....................................................................486.48       595.46

 

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

27401      1 crown.........................................................................................55.42         56.53


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


Veneers, 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, plastic (single units)

27711      Repairs, plastic, direct.......................................................................PA            PA

 

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

27721      Repairs, porcelain/ceramic, direct......................................................PA            PA

27722      Repairs, porcelain/ceramic, indirect + L.............................................PA            PA


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


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

 

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) (MSI: maximum of 2 services)

29101      1 unit of time.................................................................................58.12         59.28

29102      2 unis of time...............................................................................116.21       118.53

29103      3 units of time..............................................................................174.31       177.80

 

2              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


“myofacial” replaced with “myofascial” and “esthetics” replaced with “aesthetics”: O.I.C. 2013-276, N.S. Reg. 281/2013.



Tariff of Fees for Insured Dental Services

Schedule B: Children’s Oral Health Program


The Children’s Oral Health Program provides insured diagnostic, preventive, and treatment services for residents (as defined in the MSI Regulations) until the end of the month in which the resident turns 15 years of age.

Amended: O.I.C. 2013-276, N.S. Reg. 281/2013; O.I.C. 2014-181, N.S. Reg. 69/2014.


Part 1: Diagnostic—01000–09999


Examinations

 

 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..............................................................34.40         64.80      40.00

01102      Examination and diagnosis, complete, mixed dentition.....44.80         92.80      51.00

01103      Examination and diagnosis, complete, permanent dentition60.80  126.40     70.00

Schedule B, Part 1, Item 1 amended: O.I.C. 2013-276, N.S. Reg. 281/2013; O.I.C. 2015-227, N.S. Reg. 279/2015.

 

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........................22.08         27.97      27.00

 

01204      Examination and diagnosis, specific: examination, diagnosis
and evaluation of a specific situation in a localized area
(MSI: details must accompany claim)...............................34.51         46.94      43.00

 

01205      Examination and diagnosis, emergency: examination to
investigate discomfort and/or infection in a localized area
(MSI: details must accompany claim, including x-rays)....34.51         46.94      43.00


If a procedure or treatment service is provided the same day as an emergency (01205) oral examination, the fee for the examination is paid at 50%.

Schedule B, Part 1, Item 2 amended: O.I.C. 2015-227, N.S. Reg. 279/2015.

 

05201      Consultation, in office (MSI: specialist other than orthodontist)
(Details must accompany claim.).........................................NA         77.91         NA


Radiographs
(including radiographic examinations and interpretation)

 

(a)      The fees are intended to include both the technical and professional components of an x-ray service; however, non-readable films are not insured.

 

(b)      Fees for diagnostic x-rays periapicals or bitewings must not exceed $16.10 Generalist or $16.42 Specialist per child per year (whether same or different dentist), excluding panoramic or cephalometric films.

 

(c)      Procedural x-rays in connection with root canal therapy are not allowed separately, as the fees for root canal therapy include procedural x-rays.

 

(d)      All x-rays are to be made available to the Plan on request and therefore should be retained for 5 years following the service.

 

1              Radiographs, intra-oral, periapical

02111      Single film.......................................................................12.26         12.51      14.00

02112      2 films..............................................................................16.10         16.42      19.00

 

2              Radiographs, intra-oral, bitewing

02141      Single film.......................................................................12.26         12.51      14.00

02142      2 films..............................................................................16.10         16.42      19.00

 

3              Radiographs, panoramic

02601      Single film (MSI: once per lifetime, only in connection with a specific request
for a consultation with a specialist other than an orthodontist. This fee is not
payable if the service was provided for reasons related to spacing, crowding,
eruption, timing, and other orthodontic-related concerns.)
(Details must accompany all claims.)................................51.51         52.54      56.00

 

4              Radiographs, cephalometric

02701      Single film (MSI: once per lifetime, only in connection with a specific request
for a consultation with a specialist other than an orthodontist. This fee is not
payable if the service was provided for reasons related to spacing, crowding,

eruption, timing, and other orthodontic-related concerns.)
(Details must accompany all claims.)................................51.5152.5456.00

 

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

02801      MSI: paid at 1/2 regular fee


Tests and Laboratory Examinations


Coverage guidelines apply; see the preamble to the COHP.

 

1              Tests, microbiological

04101      Microbiological test for the determination of pathological
agents + L........................................................................30.97         31.59      37.00

 

2              Tests, caries susceptibility

04201      Bacteriological test for the determination of dental caries
susceptibility + L..............................................................30.29         30.90      34.00

 

3              Tests, histological

Test, histological, soft tissue

04311      Biopsy, soft oral tissue, by puncture + L...........................72.36         73.81      83.00

04312      Biopsy, soft oral tissue, by incision + L............................72.36         73.81      83.00

04313      Biopsy, soft oral tissue, by aspiration + L.........................72.36         73.81      83.00

 

Tests, histological, hard tissue

04321      Biopsy, hard oral tissue, by puncture + L..........................83.33         85.00      98.00

04322      Biopsy, hard oral tissue, by incision + L...........................83.33         85.00      98.00

04323      Biopsy, hard oral tissue, by aspiration + L........................83.33         85.00      98.00

 

4              Tests, cytological

04401      Cytological smear from the oral cavity + L.......................30.29         30.90      34.00

 

5              Tests, pulp vitality

04501      1 unit...............................................................................25.61         26.12      52.00


Casts, Diagnostic


MSI notes:

(a)      When diagnostic casts are prepared, a detailed explanation must be included on the claim.

(b)      Diagnostic casts are to be available to the Plan upon request and accordingly, should be retained for a period of 5 years following the service.

(c)      Fees for diagnostic casts are not payable in conjunction with orthodontic cases and preventive orthodontic services.

 

1              Cast, diagnostic, unmounted

04911      Cast, diagnostic, unmounted + L......................................30.97         43.45      21.00

04912      Cast, diagnostic, unmounted, duplicate + L..........................PA            PA         PA

2              Cast, diagnostic, mounted

04921      Cast, diagnostic, mounted + L..........................................39.00            PA      40.00

04922      Cast, diagnostic, mounted using face bow transfer + L.....64.00            PA      67.00

04923      Cast, diagnostic, mounted, using face bow +
occlusal records + L.........................................................87.14            PA      99.00


Part 2: Preventive Services—10000–19999


Topical fluoride applications: coverage guidelines apply (see preamble to the COHP).


Fluoride Treatments

 

12101      Fluoride treatment, topical application..............................15.00         16.14      16.00


Polishing: Please see “Caries prevention service” below.


Preventive Services, Other

 

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

13101      1 unit of time...................................................................25.00         30.90      30.00

 

2              Caries prevention service (MSI: Caries prevention service (13211) is allowed once per lifetime of the patient. Includes, for MSI program, rubber cap polishing and minor scaling procedures.)

13211      1 unit of time...................................................................30.29         30.29      30.00

 

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

(MSI: limited to 6-year and 12-year molars that meet guidelines. One application per tooth per year. Second sealant claimed within the same quadrant will be paid as procedure code 13409.)

13401      Each tooth........................................................................20.00         28.15      20.00

13409      Each additional tooth within the same quadrant................14.00         19.15      14.00

Schedule B, Part 2, Item 3 amended: O.I.C. 2013-276, N.S. Reg. 281/2013.

   

4              Disking of teeth, interproximal (MSI: maximum 3 units per lifetime, primary teeth only)

16201      1 unit of time...................................................................53.81         54.89      58.00

16202      2 units of time................................................................107.65       109.80    116.00

16203      3 units of time................................................................161.45       164.68    174.00


Space Maintainers
(includes design, separation, fabrication, insertion and,
if applicable, initial cementation and removal)


MSI:

While space maintainers are not insured services, they are considered for coverage under special consideration (financial) for children eligible under the Children’s Oral Health Program. Specifically, applications for space maintainers will be accepted in cases in which primary teeth (excluding anterior teeth) are lost early due to decay. Please note that space maintainers to replace primary incisors are not considered for coverage.

 

All units must be preauthorized by MSI and supporting diagnostic aids may be requested. An application is complete when the parent’s application and the dentist’s treatment plan are received by MSI.

 

1              Space maintainers, band type

15101      Space maintainer, band type, fixed, unilateral + L...........124.33       169.60    138.00

15103      Space maintainer, band type, fixed, bilateral (soldered
lingual arch) + L.............................................................149.00       258.04    151.00

15105      Space maintainer, band type, fixed, bilateral tubes and
locking wires + L...........................................................181.00       282.20    183.00

 

2              Space maintainers, stainless steel crown type

15201      Space maintainer, stainless steel crown type, fixed + L...160.00       196.43    162.00


Space Maintainers, Maintenance of


MSI: This fee is payable by MSI only in cases in which the original placement of the space maintainer unit was funded by MSI under special consideration (financial). It is not intended, in such cases, to address necessary repairs and adjustments after 30 days following the original placement. It is not payable for routine removals done to accompany regular cleaning and fluoride application services.

 

3              Space maintainers, maintenance of

15601      Maintenance, space maintainer appliance, including adjustment
and/or recementation after 30 days post-insertion..............53.00         59.28      55.00


Part 3: Restorative Services—20000–29999


If at the same sitting, in order to conserve tooth structure, 2 separate restorations are performed on the same tooth, involving a common surface, when 1 restoration might have been done, this is not considered as 1 restoration in assessing the fees.


Additional or similar restorative services on the same tooth within 120 days of the original services require an explanation on the claim.


If adjacent surfaces of a tooth are filled at the same appointment, the fee is at the appropriate level for multiple surfaces, as listed below, in the case of tooth-coloured etched/bonded restorations. If the above conditions exist, they will be paid at the complex level.


The replacement of an existing amalgam restoration with tooth coloured etched/bonded restorations is an insured service only if the amalgam restoration has been fractured and/or there is recurrent caries.


Caries, Trauma and Pain Control

(MSI: permanent teeth only)

 

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

20111      First tooth.........................................................................61.86         75.79      85.00

 

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

20121      First tooth.........................................................................84.00         85.68      96.00

20131      Trauma control, first tooth................................................32.00         37.00      35.00


Restorations, Amalgam

 

1              Restorations, amalgam, primary teeth

Restorations, amalgam, non-bonded, primary teeth

21111      1 surface..........................................................................43.97         50.09      76.00

21112      2 surfaces.........................................................................58.98         72.55      99.00

21113      3 surfaces.........................................................................67.77         82.98    110.00

21114      4 surfaces.........................................................................85.51       104.47    121.00

21115      5 surfaces or maximum surfaces per tooth......................107.63       131.72    147.00

 

Restorations, amalgam, bonded, primary teeth

21121      1 surface..........................................................................45.23         50.09      78.00

21122      2 surfaces.........................................................................58.98         72.55    100.00

21123      3 surfaces.........................................................................67.77         82.98    112.00

21124      4 surfaces.........................................................................85.51       104.47    131.00

21125      5 surfaces or maximum surfaces per tooth......................107.63       131.72    161.00

 

2              Restorations, amalgam, permanent teeth

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

21211      1 surface..........................................................................53.06         64.82      90.00

21212      2 surfaces.........................................................................79.61         96.82    119.00

21213      3 surfaces.......................................................................100.19       122.00    144.00

21214      4 surfaces.......................................................................129.66       164.64    173.00

21215      5 surfaces or maximum surfaces per tooth......................159.19       193.85    206.00

 

Restorations, amalgam, non-bonded, permanent molars

21221      1 surface..........................................................................60.94         70.91    103.00

21222      2 surfaces.........................................................................86.56       105.63    118.00

21223      3 surfaces.......................................................................113.43       138.00    159.00

21224      4 surfaces.......................................................................156.19       191.32    202.00

21225      5 surfaces or maximum surfaces per tooth......................207.84       250.00    264.00

 

Restorations, amalgam, bonded, permanent bicuspids and anteriors

21231      1 surface..........................................................................62.82         64.82    108.00

21232      2 surfaces.........................................................................79.61         96.82    126.00

21233      3 surfaces.......................................................................100.19       122.19    158.00

21234      4 surfaces.......................................................................129.66       164.64    179.00

21235      5 surfaces or maximum surfaces per tooth......................159.19       193.85    217.00

 

Restorations, amalgam, bonded, permanent molars

21241      1 surface..........................................................................70.36         70.91    121.00

21242      2 surfaces.........................................................................86.56       105.63    141.00

21243      3 surfaces.......................................................................113.43       138.00    186.00

21244      4 surfaces.......................................................................156.19       191.32    225.00

21245      5 surfaces or maximum surfaces per tooth......................207.84       253.17    277.00

 

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

21401      1 pin................................................................................15.97         16.29      22.00

21402      2 pins...............................................................................27.96         28.52      35.00

21403      3 pins...............................................................................35.39         36.10      40.00

21404      4 pins...............................................................................43.73         44.60      47.00

21405      5 pins or more..................................................................50.78         51.80      57.00


Restorations, Prefabricated, Full Coverage


MSI: Please note that a single surface restoration is payable concurrently with open-faced stainless steel crowns.

 

1              Restorations, prefabricated, metal, primary dentition

22201      Primary anterior.............................................................122.50       155.79    131.00

22202      Primary anterior, open face..................................................NA            NA         NA

22211      Primary posterior............................................................122.50       155.79    128.00

22212      Primary posterior, open face...........................................118.39       144.75    139.00

 

2              Restorations, prefabricated, metal, permanent dentition

22301      Permanent anterior.........................................................122.50       159.79    146.00

22302      Permanent anterior, open face..............................................NA       144.75        NA

22311      Permanent posterior........................................................122.50       155.79    128.00

22312      Permanent posterior, open face............................................NA       144.75        NA

 

3              Restorations, prefabricated, plastic, permanent dentition

22501      Permanent anterior.........................................................128.00       171.00    131.00

22511      Permanent posterior........................................................128.00       171.00    131.00


Restorations, Tooth Coloured


(MSI: Fee codes 23113, 23114, 23115, 23413, 23414, 23415 include reattachment of fractured tooth fragments.)


1

23111      1 surface..........................................................................73.67         89.71    109.00

23112      2 surfaces (continuous).....................................................96.17       117.41    124.00

23113      3 surfaces (continuous)...................................................112.01       137.20    151.00

23114      4 surfaces (continuous)...................................................178.31       220.79    199.00

23115      5 surfaces (continuous, maximum surfaces per tooth).....178.31       220.79    268.00

 

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

Tooth coloured, permanent bicuspids

23311      1 surface..........................................................................79.15         64.82    130.00

23312      2 surfaces.........................................................................98.00         96.82    160.00

23313      3 surfaces.......................................................................131.92       122.19    217.00

23314      4 surfaces.......................................................................162.08       164.64    266.00

23315      5 surfaces or maximum surfaces per tooth......................185.32       193.85    305.00

 

Tooth coloured, permanent molars

23321      1 surface..........................................................................82.92         70.91    133.00

23322      2 surfaces.........................................................................99.26       105.63    160.00

23323      3 surfaces.......................................................................135.69       138.00    219.00

23324      4 surfaces.......................................................................164.59       191.32    266.00

23325      5 surfaces.......................................................................207.84       253.17    334.00

 

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

23411      1 surface..........................................................................68.47         83.77      91.00

23412      2 surfaces (continuous).....................................................68.47         83.77    110.00

23413      3 surfaces (continuous).....................................................96.17       117.41    138.00

23414      4 surfaces (continuous)...................................................146.00       164.59    151.00

23415      5 surfaces (continuous or maximum surfaces per tooth)..148.69       164.59    157.00

 

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

23511      1 surface..........................................................................56.64         50.19      90.00

23512      2 surfaces.........................................................................70.36         72.55    112.00

23513      3 surfaces.........................................................................86.06         82.98    137.00

23514      4 surfaces.........................................................................96.11       104.47    154.00

23515      5 surfaces or maximum surfaces per tooth......................107.63       131.72    160.00


Note: please see prosthodontics section for inlays, onlays and pins.

 

5              Posts

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

25711      Single section + L..........................................................172.34       244.42    279.00

25712      2 sections + L.................................................................233.06       244.42    378.00

25713      3 sections + L......................................................................PA       469.48         PA

 

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

25721      Single section + L..........................................................143.00       244.42    145.00

25722      2 sections + L.................................................................172.34       244.42    229.00

25723      3 sections + L......................................................................PA       469.48         PA

 

Posts, prefabricated retentive (separate procedure)

25731      1 post.............................................................................109.24       133.31    133.00

25732      2 posts same tooth..........................................................137.58       133.31    224.00

27533      3 posts same tooth..........................................................171.50       133.31    280.00

 

Posts, prefabricated, retentive and cast core

25741      1 post and cast core + L.......................................................NA       244.42        NA

25742      2 posts (same tooth) and cast core + L.................................NA       244.42        NA

25743      3 posts (same tooth) and cast core + L.................................NA       469.48        NA

 

Post, prefabricated, with core for crown restoration

25754      1 post, with composite core + pins..................................179.03       219.13    221.00


Crowns


MSI note: Gold, butt margins (including collarless veneers), custom shading or any aesthetics included in the lab fees are not insured. Please submit a copy of the lab invoice upon completion of the services.

“Esthetics” replaced with “aesthetics”; O.I.C. 2013-276, N.S. Reg. 281/2013.


Stainless steel crowns: 100% of the dental tariff applies to each of the first 3 stainless steel crowns performed at 1 sitting for a patient under general anaesthesia. 50% of the dental tariff applies to each additional stainless steel crown done at the same sitting.

 

Despite the previous paragraph, a dentist may, when submitting a claim, request independent consideration for payment of 100% of the dental tariff for 4 or more stainless steel crowns done at the same sitting for a patient under general anaesthesia. Such a request must be accompanied by the necessary x-rays.

 

Permanent crowns: payable on permanent anterior teeth only. Pre-determination of benefits must be requested before rendering services for permanent anterior crowns. Please provide x-rays and/or study models.

 

1              Crowns, plastic (single units only)

Crowns, plastic, processed

27111      Crown, plastic, processed + L.........................................396.18       404.10    458.00

27112      Crown, plastic, processed complicated (restorative, positional
and/or aesthetic) + L............................................................NA            PA         NA

27113      Crown, plastic, transitional, indirect + L...............................PA            PA         PA

27114      Crown, plastic/metal base, processed + L............................NA            NA         NA

 

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

27121      Crown, plastic, direct, transitional (chairside).................115.36       117.67    145.00

27122      Crown, transitional restoration of fractured anterior.............NA            NA         NA

 

2              Crowns, porcelain/ceramic/polymer glass

27201      Crown, porcelain/ceramic jacket + L..............................486.48       595.46    591.00

27202      Crown, porcelain/ceramic jacket complicated + L................NA            PA         NA

 

3              Crowns, porcelain/ceramic fused to metal

27211      Crown, porcelain/ceramic fused to metal base + L..........486.48       595.46    591.00

27212      Crown, porcelain/ceramic fused to metal base, complicated.PA            PA         PA

 

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

(MSI: maximum of 3 units per tooth.)

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

29101      1 unit of time...................................................................58.12         59.28      68.00

29102      2 units of time................................................................116.21       118.53    136.00

29103      3 units of time................................................................174.31       177.80    204.00

 

Endodontics

 

Pulpotomy

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

32221      Anterior and bicuspid teeth...............................................71.74         87.74      90.00

32222      Molar teeth.......................................................................71.74         87.74    107.00

 

Pulpotomy, vital, primary teeth

32231      Primary tooth as a separate procedure ..............................57.66         73.12      72.00

32232      Primary tooth, concurrent with restorations (but excluding
final restoration)...............................................................57.66         73.12      72.00

 

2              Pulpectomy (as a separate emergency procedure)

Pulpectomy, permanent teeth/retained primary teeth

32311      1 canal.............................................................................82.64         84.29    122.00

32312      2 canals..........................................................................128.02       130.58    187.00

32313      3 canals................................................................................PA            PA         PA

32314      4 canals or more..................................................................PA            PA         PA

 

Pulpectomy, primary teeth

32321      Anterior tooth...................................................................75.00         84.29      77.00

32322      Posterior tooth................................................................111.00       122.35    114.00

 

Root Canal Therapy

 

Includes treatment plan, clinical procedures (e.g., pulpectomy, biomechanical preparation, chemotherapeutic treatment and obturation), with appropriate radiographs and follow-up care, excluding final restoration.

 

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

33111      1 canal...........................................................................326.42       399.57    362.00

33121      2 canals..........................................................................478.12       575.33    513.00

33131      3 canals..........................................................................642.19       785.99    668.00

33141      4 or more canals.............................................................797.28       941.32    812.00

 

2              Root canals, primary teeth

33401      1 canal...........................................................................123.10       157.87    153.00

33402      2 canals..........................................................................169.22       209.18    203.00

33403      3 canals or more..................................................................NA       280.29        NA

 

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

33601      1 canal...........................................................................124.33       152.16    136.00

33602      2 canals..........................................................................164.62       219.58    179.00

33603      3 canals..........................................................................209.65       287.93    229.00

33604      4 canals or more.............................................................376.64       433.93    409.00

 

4              Re-insertion of dentogenic media per visit

33611      1 canal.............................................................................55.42         65.32      57.00

33612      2 canals............................................................................55.42         65.32      57.00

33613      3 canals............................................................................55.42         65.32      57.00

33614      4 canals or more...............................................................55.42         65.32      57.00

 

Periapacal Services

 

1              Apicoectomy/apical curettage

Maxillary anterior

34111      1 root.............................................................................158.74       208.72    204.00

34112      2 roots............................................................................238.09       284.03    292.00

 

Maxillary bicuspid

34121      1 root.............................................................................228.00       296.42    233.00

34122      2 roots............................................................................303.00       353.90    309.00

34123      3 roots or more...............................................................379.00       411.24    383.00

 

Maxillary molar

34131      1 root.............................................................................242.26       296.42    261.00

34132      2 roots............................................................................320.61       353.90    347.00

34133      3 roots............................................................................382.63       431.81    438.00

34134      4 or more roots...............................................................430.83       459.78          IC

[“IC” means Independent Consideration]

Mandibular anterior

34141      1 root.............................................................................170.50       208.72    203.00

34142      2 or more roots...............................................................243.61       270.50    291.00

 

Mandibular bicuspid

34151      1 root.............................................................................229.00       296.42    233.00

34152      2 roots............................................................................303.00       353.90    309.00

34153      3 or more roots...............................................................381.00       411.24    387.00

 

Mandibular molar

34161      1 root.............................................................................242.26       296.42    288.00

34162      2 roots............................................................................320.61       353.90    381.00

34163      3 roots............................................................................382.63       411.24    480.00

34164      4 or more roots...............................................................430.83       459.78          IC

[“IC” means Independent Consideration]

2              Retrofilling

Maxillary anterior

34211      1 canal.............................................................................67.78         82.96      77.00

34212      2 or more canals...............................................................82.13       103.43     92.00

 

Maxillary bicuspid

34221      1 canal.............................................................................67.78         82.96      92.00

34222      2 canals............................................................................82.13       103.43    115.00

34223      3 canals............................................................................99.37       129.30    127.00

34224      4 or more canals.............................................................111.40       145.44    137.00

 

Maxillary molar

34231      1 canal.............................................................................69.73         82.96    112.00

34232      2 canals............................................................................86.06       103.43    139.00

34233      3 canals............................................................................99.37       135.76    153.00

34234      4 or more canals.............................................................111.40       145.44    162.00

 

Mandibular anterior

34241      1 canal.............................................................................67.78         82.96      76.00

34242      2 or more canals...............................................................82.13       103.43     92.00

 

Mandibular bicuspid

34251      1 canal.............................................................................67.78         82.96      91.00

34252      2 canals............................................................................82.13       103.43    112.00

34253      3 canals............................................................................99.37       129.30    125.00

34254      4 canals..........................................................................111.40       145.44    135.00

 

Mandibular molar

34261      1 canal.............................................................................69.73         82.96    112.00

34262      2 canals............................................................................86.06       103.43    139.00

34263      3 canals............................................................................99.37       129.30    153.00

34264      4 or more canals.............................................................111.40       145.44    162.00

 

Open and drain (separate emergency procedures)

39201      Anteriors and bicuspids....................................................66.00         71.47      67.00

39202      Molars.............................................................................66.00         71.47      67.00

 

Opening through artificial crown (in addition to procedures)

39211      Anterior and bicuspids........................................................NA         83.20         NA

39202      Molars.............................................................................81.57         83.20    128.00

 

Bleaching, non-vital
(MSI: maximum of 3 units payable per patient)

Bleaching endodontically treated tooth/teeth

39311      1 unit of time...................................................................53.81         54.89      65.00

39312      2 units of time..................................................................92.62         94.47    130.00

39313      3 units of time................................................................131.41       134.04    195.00

 

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...................................................................31.52         32.15      33.00

41302      2 units of time..................................................................63.03         64.29      66.00

41309      Each additional unit of time over 2...................................31.52         32.15      33.00

 

Periodontal Procedures, Adjunctive

 

1              Periodontal splinting or ligation, provisional, intra-coronal

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

43111      Per joint...........................................................................38.95         46.12      65.00

 

2              Periodontal splinting or ligation, provisional, extra-coronal

Acid etch joint restorations (per joint)

43211      Per joint...........................................................................45.05         60.44      65.00

 

Acid etch, interproximal enamel splint

43221      Per joint...........................................................................45.05         60.44      65.00

 

Wire ligation

43231      Per joint...........................................................................99.26         60.44    165.00

 

Wire ligation, acrylic covered

43241      Per joint.........................................................................132.55        60.44    220.00

 

Dental floss ligation

43251      Per joint..............................................................................NA         60.44         NA

 

Orthodontic band splint

43261      Per band..............................................................................NA         60.44         NA

 

Cast/soldered splint acid etch/resin bonded

43271      Per abutment + L..............................................................85.44         60.44    141.00

 

Part 5: Prosthetics—Removable—50000-59999

 

Preamble: Cast partials are not insured services.

 

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

(MSI: Payable only if required because of congenital condition or accident.)

52301      Maxillary + L.................................................................342.90       430.37    480.00

52302      Mandibular + L..............................................................342.90       430.37    480.00

 

Part 6: Oral and Maxillofacial Surgery—70000–79999

 

Certain procedures included in this Part are also contained in the list of MSI dental surgical procedures (Schedule C: Dental Surgical Program) covering all eligible residents of the Province. These services continue as benefits of MSI and, accordingly, when a dental surgical procedure is performed in hospital, the claim for that service must be submitted with the fee code set out in Schedule C.

 

A bilateral procedure done under the same general anaesthetic, other than an uncomplicated extraction, is paid at 50% of the tariff for a unilateral procedure.

 

A bilateral procedure done under local anaesthetic or conscious sedation is paid at 100% of the tariff for a unilateral procedure.

 

When more than 2 quadrants are involved, the first 2 procedures will be paid at 100% and subsequent procedures at 50%.

 

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 (Extractions), Erupted Teeth

 

1              Removals, erupted teeth, uncomplicated

MSI: Extractions are insured only in a case of:

                1)     unrestorable caries, demonstrable pain, (excluding pain associated with crowding), infection, trauma,

                2)     ankylosis

                3)     supernumerary teeth

71101      Single tooth, uncomplicated.............................................64.70         62.76    106.00

71109      Each additional tooth, same quadrant, same appointment..43.35         33.00      71.00

 

2              Removals, erupted teeth, complicated

71201      Odontectomy, (extraction), erupted tooth, surgical approach,
requiring surgical flap and/or sectioning of tooth............139.67       169.98    210.00

71209      Each addition tooth, same quadrant..................................85.44         85.00    140.00

 

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....................................................................139.67       169.98    210.00

72119      Each additional tooth, same quadrant...............................86.06         85.00    140.00

 

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

72211      Single tooth....................................................................169.22       280.09    253.00

72219      Each additional tooth, same quadrant..............................103.65       140.05    169.00

 

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

72221      Single tooth....................................................................231.98       311.48    350.00

72229      Each additional tooth, same quadrant..............................143.86       155.75    234.00

 

3              Removals (extractions), residual roots

Removals, residual roots, erupted

72311      First tooth.........................................................................51.29         62.76      82.00

72319      Each additional tooth, same quadrant...............................33.29         31.41      54.00

 

Removals, residual roots, soft tissue coverage

72321      First tooth.........................................................................96.13       117.67    148.00

72329      Each additional tooth, same quadrant...............................60.31         58.85      99.00

 

Removals, residual roots, bone tissue coverage

72331      First tooth.......................................................................199.93       244.66    303.00

72339      Each additional tooth, same quadrant..............................123.76       122.33    202.00

 

Surgical Incisions

 

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

75111      Intra-oral, surgical exploration, soft tissue.........................71.74         96.80    117.00

75112      Intra-oral, abscess, soft tissue............................................71.74         96.80    117.00

75113      Intra-oral, abscess, in major anatomical area with drain.......NA         96.80         NA

 

Treatment of Fractures

 

Replantation, avulsed tooth/teeth (including splinting)

76941      Replantation, first tooth..................................................207.31       215.35    343.00

76949      Each additional tooth......................................................105.54       107.71    175.00

 

Repositioning of traumatically displaced teeth

76951      1 unit of time...................................................................49.63         47.23      82.00

76952      2 units of time..................................................................99.26         94.46    164.00

76959      Each additional unit of time over 2...................................49.63         47.23      82.00

 

Hemorrhage, Control of

 

(MSI: payable 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...................................................................................NA         61.24         NA

79404      Hemorrhage control, using hemostatic substance and
sutures (including removal of bony tissue, if necessary).......NA         61.24         NA

 

Post-Surgical Care

 

(MSI: excludes alveolitis, details must accompany claim.)

 

Required by complications and unusual circumstances, refer to comment at beginning of Part 6.

 

79605      Post-surgical care, alveolitis, treatment of
(without anaesthesia)...........................................................NA         51.93         NA

79606      Post-surgical care, alveolitis, treatment of
(with anaesthesia)................................................................NA         51.93         NA

 

 


Insured Dental Services Tariff

Schedule C: Dental Surgical Program

 

The Dental Surgical Program provides insured dental surgical services for a resident as defined in the M.S.I. Regulations if the condition of the resident is such that the services are medically required to be rendered in hospital.

 

Part 1: Diagnostic—01000–09999

 

01601      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.................................................61.15

 

(MSI: Payable only for hospital in-patients, when requested by a physician or dentist.)

 

94102      Hospital admission............................................................................................64.50

(MSI: Admission to hospital when no surgical treatment is rendered, details must be provided on each claim.)

 

94302      Hospital visit.....................................................................................................36.27

(MSI: For non-surgical admitted patient only. A maximum of 14 daily visits are payable in connection with a hospital admission. Notes on the necessity of the visit must be provided on each claim. If the patient, at any time within the 14 days, becomes a surgical patient, this service is no longer payable.)

 

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..............................................................................62.76

71109      Each additional tooth, same quadrant................................................................33.00

 

2              Removals, erupted teeth, complicated

71201      Odontectomy, (extraction), erupted tooth, surgical approach, requiring
surgical flap and/or sectioning of tooth..............................................................89.36

71209      Each additional tooth, same quadrant................................................................44.71

 

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.....................................................................................................161.64

72119      Each additional tooth, same quadrant................................................................80.82

 

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 sectioning and removal of tooth (partial bone impaction)

72211      Single tooth.....................................................................................................161.64

72219      Each additional tooth, same quadrant................................................................80.82

 

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

72221      Single tooth.....................................................................................................161.64

72229      Each additional tooth, same quadrant................................................................80.82

 

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.....................................................................................................161.64

72239      Each additional tooth, same quadrant................................................................80.82

 

5              Removals (extractions), residual roots

Removals, residual roots, erupted

72311      First tooth..........................................................................................................95.56

72319      Each additional tooth, same quadrant................................................................47.78

 

Removals, residual roots, soft tissue coverage

72321      First tooth..........................................................................................................95.56

72329      Each additional tooth, same quadrant................................................................47.78

 

Removals, residual roots, bone tissue coverage

72331      First tooth..........................................................................................................95.56

72339      Each additional tooth, same quadrant................................................................47.78

 

6              Surgical movement of teeth

Transplantation of erupted tooth

72611      First tooth........................................................................................................312.48

72619      Each additional tooth.......................................................................................156.23

 

Remodelling 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........................101.70

 

Remodelling of bone

73141      Mylohyoid ridge remodelling..........................................................................101.70

73142      Genial tubercles remodelling...........................................................................101.70

 

Excision of bone

73151      Nasal spine, excision.......................................................................................152.56

73152      Torus palatinus, excision.................................................................................293.38

73153      Torus mandibularis, unilateral, excision...........................................................217.61

73154      Torus mandibularis, bilateral, excision.............................................................351.24

 

Removal of bone, exostosis, multiple

73161      Per quadrant....................................................................................................152.56

 

Reduction of bone, tuberosity

73171      Unilateral, reduction........................................................................................152.56

73172      Bilateral, reduction..........................................................................................228.83

 

Augmentation of bone

73181      Unilateral, pterygomaxillary tuberosity, augmentation + E...............................531.00

73182      Bilateral, pterygomaxillary tuberosity, augmentation + E...............................1053.00

73183      Unilateral, mandibular ridge, augmentation + E...............................................531.00

73184      Bilateral, mandibular ridge, augmentation + E...............................................1061.00

 

2              Gingivoplasty and/or stomatoplasty, oral surgery

Independent procedure

73211      Per sextant........................................................................................................93.40

 

Miscellaneous procedures

73222      Excision of vestibular hyperplasia (per sextant)...............................................140.05

73223      Surgical shaving of papillary hyperplasia of the palate.....................................210.08

73224      Excision of pericoronal gingiva (for retained teeth) per tooth/implant..............140.05

 

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

73231      Per sextant........................................................................................................93.40

 

Removal, mucosa, excess (complete removal without dissection)

73241      Per sextant........................................................................................................93.40

 

3              Remodelling, floor of the mouth

73301      Full arch lowering of the floor of the mouth....................................................572.92

73302Partial arch lowering of the floor of the mouth       572.92

73303      Reinsertion of the mylohyoid muscle...............................................................572.92

 

4              Vestibuloplasty

Vestibuloplasty, sub-mucous

73411      Per sextant......................................................................................................151.52

 

Sulcus deepening and ridge reconstruction

73421      Per sextant......................................................................................................151.52

 

Vestibuloplasty, with secondary epithelization

73431      Per sextant......................................................................................................151.52

 

Vestibuloplasty, with labial inverted flap

73441      Per sextant......................................................................................................190.98

 

Vestibuloplasty, with skin graft

73451      Per sextant......................................................................................................190.98

 

Vestibuloplasty, with mucosal graft

73461      Per sextant......................................................................................................190.98

 

5              Reconstruction, alveolar ridge

Reconstruction, alveolar ridge, with autogenous bone

73511      Per sextant + E................................................................................................312.53

 

Reconstruction, alveolar ridge, with alloplastic material

73521      Per sextant + E................................................................................................156.26

 

6              Extensions, mucous folds

Extensions, mucous folds with secondary epithelization

73611      Per sextant......................................................................................................190.98

 

Extensions, mucous folds, with skin grafts

73621      Per sextant......................................................................................................190.98

 

Extensions, mucous folds, with mucous graft

73631      Per sextant......................................................................................................190.98

 

Surgical Excision
(not in conjunction with tooth removal, including biopsy)

 

1              Surgical excision, tumors, benign

Tumors, benign, scar tissue, inflammatory or congenital lesions of soft tissue of the oral cavity

74111      1 cm and under................................................................................................130.43

74112      1-2 cm.............................................................................................................130.43

74113      2-3 cm.............................................................................................................130.43

74114      3-4 cm.............................................................................................................325.81

74115      4-6 cm.............................................................................................................325.81

74116      6-9 cm.............................................................................................................325.81

74117      9-15 cm...........................................................................................................511.53

74118      15 cm and over................................................................................................511.53

 

Tumors, benign, bone tissue

74121      1 cm and under................................................................................................157.82

74122      1-2 cm.............................................................................................................157.82

74123      2-3 cm.............................................................................................................157.82

74124      3-4 cm.............................................................................................................294.98

74125      4-6 cm.............................................................................................................394.98

74126      6-9 cm.............................................................................................................394.98

74127      9-15 cm...........................................................................................................620.16

74128      15 cm and over................................................................................................620.16

 

2              Surgical excision, tumors, malignant

Tumors, malignant, soft tissue, oral cavity

74211      1 cm and under................................................................................................130.43

74212      1-2 cm.............................................................................................................130.43

74213      2-3 cm.............................................................................................................130.43

74214      3-4 cm.............................................................................................................325.81

74215      4-6 cm.............................................................................................................325.81

74216      6-9 cm.............................................................................................................325.81

74217      9-15 cm...........................................................................................................511.53

74218      15 cm and over................................................................................................511.53

 

Tumors, malignant, bone tissue

74221      1 cm and under................................................................................................157.82

74222      1-2 cm.............................................................................................................157.82

74223      2-3 cm.............................................................................................................157.82

74224      3-4 cm.............................................................................................................394.98

74225      4-6 cm.............................................................................................................394.98

74226      6-9 cm.............................................................................................................394.98

74227      9-15 cm...........................................................................................................620.16

74228      15 cm and over................................................................................................620.16

 

3              Cheiloplasty (lip shave)

74301      Cheiloplasty, partial...........................................................................................53.74

74302      Cheiloplasty, total............................................................................................161.27

 

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................................................................................................150.21

74612      1-2 cm.............................................................................................................150.21

74613      2-3 cm.............................................................................................................150.21

74614      3-4 cm.............................................................................................................150.21

74615      4-6 cm.............................................................................................................187.69

74616      6-9 cm.............................................................................................................187.69

74617      9-15 cm...........................................................................................................187.69

74618      15 cm and over................................................................................................294.64

 

Marsupialization

74621      Cyst, marsupialization.....................................................................................161.27

 

Excision of cyst

74631      1 cm and under................................................................................................150.21

74632      1-2 cm.............................................................................................................150.21

74633      2-3 cm.............................................................................................................150.21

74634      3-4 cm.............................................................................................................150.21

74635      4-6 cm.............................................................................................................187.69

74636      6-9 cm.............................................................................................................187.69

74637      9-15 cm...........................................................................................................187.69

74638      15 cm and over................................................................................................294.64

 

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..........................................................62.93

75112      Intra-oral, abscess, soft tissue.............................................................................62.93

75113      Intra-oral, abscess, in major anatomical area with drain.....................................62.93

 

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

75121      Intra-oral, abscess, hard tissue, trephination and drainage...................................81.55

75122      Intra-oral, surgical exploration, hard tissue.........................................................81.55

75123      Intra-oral, abscess, hard tissue, trephination and drainage in major anatomical area81.55

 

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.........................................................................125.74

75212      Extra-oral, abscess, deep..................................................................................125.74

 

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

75221      Extra-oral, surgical exploration, hard tissue.....................................................152.12

 

3              Surgical incision for removal of foreign bodies

75301      Removal, from skin or subcutaneous areolar tissue..........................................140.05

75302      Removal, of reaction producing foreign bodies................................................140.05

75303      Removal, of needle from musculoskeletal system............................................152.56

 

Sequestrectomy (for Osteomyelitis)

 

75401      Intra-oral sequestrotomy..................................................................................236.14

75402      Saucerization...................................................................................................236.14

75403      Osteomyelitis, non-surgical treatment of............................................................86.24

 

Extra-oral sequestrotomy

75411      3 cm and less...................................................................................................314.83

75412      3-4 cm.............................................................................................................314.83

75413      4-6 cm.............................................................................................................472.28

75414      6-9 cm.............................................................................................................472.28

75415      9 cm and over.................................................................................................472.28

 

Mandibulectomy

 

75511      3 cm or less.....................................................................................................615.51

75512      3-4 cm.............................................................................................................615.51

75513      4-6 cm.............................................................................................................615.51

75514      6-9 cm.............................................................................................................615.51

75515      9-12 cm...........................................................................................................615.51

75516      12-15 cm.........................................................................................................615.51

75517      15 cm and over................................................................................................966.32

75518      Total mandibulectomy...................................................................................1600.86

 

Maxillectomy

 

75611      3 cm or less.....................................................................................................615.51

75612      3-4 cm.............................................................................................................615.51

75613      4-6 cm.............................................................................................................615.51

75614      6-9 cm.............................................................................................................615.51

75615      9-12 cm...........................................................................................................615.51

75616      12-15 cm.........................................................................................................615.51

75617      15 cm and over................................................................................................966.32

75618      Total maxillectomy.......................................................................................1600.86

 

Fractures, Treatment of

 

1              Fractures, reductions, mandibular

76201      Reduction, mandibular, closed.........................................................................314.83

76202      Reduction, mandibular, open, simple...............................................................550.89

76203      Reduction, mandibular, open, double...............................................................826.32

76204      Reduction, mandibular, open, multiple..........................................................1101.73

 

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

76301      Reduction, maxillary, closed............................................................................314.83

76302      Reduction, maxillary, open, simple..................................................................550.89

76303      Reduction, mandibular, open, double...............................................................826.32

76304      Reduction, maxillary, open, multiple.............................................................1101.73

76305      Reduction, compound fracture or maxilla (requiring reduction
and soft tissue repair)......................................................................................629.70

 

3              Fractures, reductions, maxilla, pyramidal Le Fort’s II

76401      Reduction, maxillary, closed............................................................................314.83

76402      Reduction, maxillary, open, unilateral..............................................................629.70

76403      Reduction, maxillary, open, bilateral................................................................629.70

 

4              Fractures, reductions, naso-orbital

76501      Reduction, unilateral.......................................................................................944.51

76502      Reduction, bilateral.........................................................................................944.51

76503      Reduction, naso-orbital, open, external approach.............................................944.51

76504      Reduction, naso-orbital, open, sinusal approach...............................................944.51

76505      Reduction, naso-orbital, open, orbital approach with insertion of
subperiosteal implant.......................................................................................944.51

76506      Exploration, of orbital blowout fracture...........................................................944.51

76507      Exploration, of orbital blowout fracture and reconstruction with insertion
of a subperiosteal implant................................................................................944.51

 

5              Fractures, reductions, malar bone

76601      Reduction, malar bone, closed.........................................................................157.49

76602      Reduction, malar bone, open, by simple elevation...........................................157.49

76603      Reduction, malar bone, open, by osteosynthesis...............................................314.83

76604      Reduction, malar bone, open, by sinus approach..............................................472.28

76605      Reduction, malar bone, simple fracture, (open reduction with
antrostomy and packing).................................................................................472.28

 

6              Fractures, reductions, zygomatic arch

76701      Reduction, zygomatic arch, intra-oral approach...............................................157.49

76702      Reduction, zygomatic arch, temporal approach................................................157.49

76703      Reduction, zygomatico-maxillary fracture dislocation, complex,
closed reduction..............................................................................................314.83

76704      Reduction, zygomatico-maxillary fracture dislocation, open reduction.............472.28

 

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.....................................................944.51

76802      Reduction, craniofacial dysfunction, open........................................................944.51

 

8              Fractures, reductions alveolar

Fracture, alveolar, debridement, teeth removed

76911      3 cm or less.....................................................................................................175.45

76912      3-6 cm.............................................................................................................175.45

76913      6 cm and over.................................................................................................314.83

 

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

76921      3 cm or less.....................................................................................................175.45

76922      3-6 cm.............................................................................................................175.45

76923      6-9 cm.............................................................................................................314.83

76924      9 cm and over.................................................................................................314.83

 

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

76931      3 cm and less...................................................................................................314.83

76932      3-6 cm.............................................................................................................314.83

76933      6-9 cm.............................................................................................................550.89

76934      9 cm and over.................................................................................................550.89

 

Replantation, avulsed tooth/teeth (including splinting)

76941      Replantation, first tooth.....................................................................................89.36

76949      Each additional tooth.........................................................................................44.71

 

Repositioning of traumatically displaced teeth

76951      1 unit of time....................................................................................................47.23

76952      2 units of time...................................................................................................94.46

76959      Each additional unit of time over 2....................................................................47.23

 

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

76961      2 cm or less.......................................................................................................62.93

76962      2-4 cm..............................................................................................................62.93

76963      4-6 cm..............................................................................................................62.93

76964      6-9 cm..............................................................................................................62.93

76965      9-12 cm.............................................................................................................62.93

76966      12-16 cm.........................................................................................................153.38

76967      16-20 cm.........................................................................................................153.38

76968      20-25 cm.........................................................................................................153.38

76969      25 cm and over................................................................................................153.38

 

Repairs, lacerations, through and through

76971      2 cm or less.....................................................................................................157.49

76972      2-4 cm.............................................................................................................157.49

76973      4-6 cm.............................................................................................................157.49

76974      6-9 cm.............................................................................................................258.04

76975      9-12 cm...........................................................................................................258.04

76976      12-16 cm.........................................................................................................258.04

76977      16-20 cm.........................................................................................................258.04

76978      20-25 cm.........................................................................................................258.04

76979      25 cm and over................................................................................................258.04

 

Repairs, lacerations, complicated (local tissue shifts)

76981      2 cm or less.....................................................................................................157.49

76982      2-4 cm.............................................................................................................157.49

76983      4-6 cm.............................................................................................................157.49

76984      6-9 cm.............................................................................................................258.04

76985      9-12 cm...........................................................................................................258.04

76986      12-16 cm.........................................................................................................258.04

76987      16-20 cm.........................................................................................................258.04

76988      20-25 cm.........................................................................................................258.04

76989      25 cm and over................................................................................................258.04

 

Maxillofacial Deformities, Treatment of

 

1              Osteotomy/ostectomy, ramus of the mandible

77101      Osteotomy, subcondylar, closed.......................................................................551.03

77102      Osteotomy, subcondylar, open.......................................................................1333.93

77103      Osteotomy, ramus of the mandibule, oblique, extra-oral................................1333.93

77104      Osteotomy, ramus of the mandible, oblique, intra-oral...................................1333.93

77105      Osteotomy/ostectomy, body of the mandible..................................................1333.93

77106      Osteotomy, coronoidectomy..........................................................................1333.93

77107      Osteotomy, condylar neck.............................................................................1333.93

77108      Osteotomy, sagittal split................................................................................1333.93

 

2              Osteotomy, miscellaneous

77201      Osteotomy, oblique with bone graft...............................................................1600.86

77202      Osteotomy, inverted “L”................................................................................1333.93

77203      Osteotomy, “C”.............................................................................................1333.93

 

3              Osteotomy, maxilla

77301      Osteotomy, maxilla, total...............................................................................1333.93

77302      Osteotomy, maxilla, total with bone graft......................................................1600.86

77303      Osteotomy, maxilla, Le Forte II with bone graft.............................................1333.93

77304      Osteotomy, maxilla, Le Forte III....................................................................1600.86

77305      Additional to the above osteotomy requiring 3 segments...................................73.04

77306      Additional to the above osteotomy requiring 4 segments.................................109.56

77307      Additional to the above osteotomy requiring a cranial flap...............................146.07

77308      Closure of cleft fistula (alveolar)......................................................................479.88

77309      Closure of cleft fistula (palatal)........................................................................640.19

77311      Pharyngoplasty................................................................................................384.18

77312      Submucous resection.......................................................................................256.09

 

4              Osteotomy, maxillary/mandibular, segmental

Osteotomy, segmental, maxilla

77411      Osteotomy, segmental, anterior........................................................................968.89

77412      Osteotomy, segmental, posterior......................................................................968.89

77413      Osteotomy, midpalatal split, anterio.................................................................968.89

77414      Osteotomy, midpalatal split, complete.............................................................968.89

 

Osteotomy, segmental, mandible

77421      Osteotomy, segmental, anterior with transfer of mental eminence....................968.89

77422      Osteotomy, segmental, anterior, without the transfer of mental eminence.........968.89

77423      Osteotomy, segmental, posterior......................................................................968.89

77424      Osteotomy, lower border, mandible.................................................................968.89

77425      Osteotomy, total dento-alveolar, mandible.......................................................968.89

 

5              Genioplasty

77501      Genioplasty, sliding, reduction or augmentation...............................................968.89

77502      Genioplasty, reduction (vertical)......................................................................968.89

77503      Genioplasty, augmentation with graft (see grafting codes)................................968.89

77504      Myotomy, suprahyoid......................................................................................968.89

 

6              Miscellaneous treatment of maxillofacial deformities

77601      Corticotomy....................................................................................................152.56

77602      Interdental septotomy......................................................................................152.56

77603      Surgical expansion of the palate......................................................................968.89

 

7              Palatorrhaphy

77701      Palatorrhaphy, anterior (closure of palatine fissure)..........................................810.00

77702      Palatorrhaphy, posterior...................................................................................810.00

77703      Palatorrhaphy, total.........................................................................................968.89

77704      Palatorrhaphy, with bone graft.........................................................................968.89

77705      Palatorrhaphy, bone graft to anterior alveolar ridge..........................................968.89

 

8              Glossectomy

77901      Glossectomy, partial, anterior wedge...............................................................325.81

77902      Glossectomy, partial, for orthodontic purposes................................................325.81

77903      Glossectomy, full posterior-anterior wedge......................................................325.81

 

9              Cleft surgery

77911      Primary unilateral cleft lip repair.....................................................................937.55

77912      Secondary unilateral cleft lip repair..................................................................937.55

77913      Primary bilateral cleft lip repair.....................................................................1406.30

77914      Secondary bilateral cleft lip repair..................................................................1406.30

77917      Closure of alveolar cleft (see grafting codes)....................................................937.55

 

10            Oral nasal fistula

77921      Primary closure at time of initial surgery.........................................................625.10

77922      Secondary closure with palatal flap..................................................................625.10

77923      Secondary closure with pharyngeal flap...........................................................625.10

77924      Secondary closure with tongue flap.................................................................625.10

77925      Secondary closure with buccal flap..................................................................625.10

 

Temporomandibular Joint Dysfunctions, Treatment of

 

1              Temporomandibular joint, dislocation, management of

78101      Dislocation, open reduction.............................................................................393.64

78102      TMJ, dislocation, closed reduction, uncomplicated............................................47.23

78103      TMJ, dislocation, closed reduction, under general anesthetic.............................47.23

78104      TMJ, luxation, reduction without anesthesia......................................................47.23

78105      TMJ, luxation, reduction under anesthesia.........................................................47.23

78106      TMJ, manipulation, under anesthesia.................................................................47.23

 

2              Temporomandibular joint, capsule, management of

78201      Condyloplasty.................................................................................................472.28

78202      Condylotomy..................................................................................................472.28

78203      Cyndylectomy.................................................................................................472.28

78204      Eminoplasty....................................................................................................416.67

78205      Re-contour of glenoid fossa.............................................................................416.67

78206      Menisectomy...................................................................................................625.10

78207      Plication of meniscus......................................................................................833.57

78208      Repair of meniscus..........................................................................................833.57

78209      Replacement of meniscus................................................................................833.57

 

3              Temporomandibular joint, arthrotomy for major reconstruction

78301      Fossa replacement (see grafting codes)............................................................916.83

78302      Condylar replacement (see grafting codes).......................................................916.83

78303      Gap arthroplasty for ankylosis (see grafting codes)..........................................916.83

 

4              Temporomandibular joint, arthrocentesis (puncture and aspiration)

78501      1 unit of time....................................................................................................78.74

78502      2 units of time.................................................................................................157.48

78509      Each additional unit of time over 2....................................................................78.74

 

5              Temporomandibular joint, management by injections

78601      Injection, with anti-inflammatory drugs.............................................................78.74

78602      Injection, with sclerosing agent..........................................................................78.74

 

Oral Surgery Procedures, Other

 

1              Salivary glands, treatment of

79101      Salivary duct, dilation of...................................................................................26.87

79102      Salivary duct, insertion of polyethylene tube......................................................27.45

79103      Salivary duct, sialodochoplasty........................................................................322.53

79104      Salivary duct, reconstruction of.......................................................................322.53

 

Salivary duct, sialolithotomy

79111      Sialolithotomy, anterior 1/3 of canal..................................................................94.46

79112      Sialolithotomy, posterior 2/3 of canal..............................................................283.32

79113      Sialolithotomy, external approach....................................................................377.68

 

Salivary gland, excisions

79121      Excision of submaxillary gland........................................................................377.68

79122      Excision of sublingual gland............................................................................377.68

79123      Excision of mucocele......................................................................................145.24

79124      Excision of ranula...........................................................................................188.99

79125      Marsupialization of ranula...............................................................................188.99

 

Salivary gland, removal

79131      Salivary gland, removal, parotid (sub total)......................................................566.77

79132      Salivary gland, removal, parotid (radical, including facial nerve).....................755.67

 

2              Neurological disturbances, treatment of

Neurological disturbances, trigeminal nerve

79211      Trigeminal nerve, injection for destruction........................................................78.74

79212      Trigeminal nerve, avulsion at periphery...........................................................312.77

79213      Trigeminal nerve, total avulsion of a branch....................................................312.77

79214      Trigeminal nerve, alcoholization of a branch.....................................................78.74

79215      Trigeminal nerve, infiltration of a branch for diagnosis......................................78.74

79217      Trigeminal nerve, neurolysis or tumor excision of trigeminal nerve
branch in soft tissue.........................................................................................312.77

79218      Trigeminal nerve, neurolysis or tumor excision of trigeminal nerve
branch in bone (mandibule, maxilla or orbit) (not to include osteotomy)..........312.77

 

Neurological disturbances, inferior dental nerve

79231      Inferior dental nerve, complete avulsion..........................................................312.77

79232      Inferior dental nerve, decompression in the canal.............................................312.77

 

Neurological disturbances, surgery

79246      Excision of tumor or neuroma.........................................................................312.77

 

3              Antral surgery

Antral surgery, recovery, foreign bodies

79311      Antral surgery, immediate recovery of a dental root or foreign body
from the antrum..............................................................................................188.99

79312      Antral surgery, immediate closure of antrum by another dental surgeon...........152.56

79313      Antral surgery, delayed recovery of a dental root with oral antrostomy.............472.28

79314      Antral sugery with nasal antrostomy................................................................472.28

 

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

79331      Oro-antral fistula closure with buccal flap........................................................472.28

79332      Oro-antral fistula closure with gold plate.........................................................472.28

79333      Oro-antral fistula closure with palatal flap.......................................................472.28

 

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

79341      Oro-antral fistula closure with buccal flap........................................................472.28

79342      Oro-antral fistula closure with gold plate.........................................................472.28

79343      Oro-antral fistula closure with palatal flap.......................................................472.28

 

Hemmorhage, Control of

 

(MSI: Payable if procedure rendered by dentist other than the provider of the original service.)

 

79403      Hemorrhage control, using compression and hemostatic agent...........................50.98

79404      Hemorrhage control, using hemostatic substance and sutures
(including removal of bony tissue, if necessary).................................................50.98

 

Post-Surgical Care

 

(MSI: excludes alveolitis, details must accompany claim.)

 

Required by complications and unusual circumstances, refer to comment under section heading 70000.

 

79602      Post-surgical care, minor, by other than treating dentist.....................................50.84

 

Emergency Office Procedures

 

79701      Emergency procedure, tracheotomy........................................................................IC

79702      Emergency procedure, crico-thyroidotomy.............................................................IC

[“IC” means Independent Consideration]

 

 


Insured Dental Services Tariff

Schedule D: Maxillofacial Prosthodontics Program

 

The Maxillofacial Prosthodontics Program provides insured dental services for residents (as defined in the M.S.I. Regulations) whose maxillofacial prosthodontic needs are the result of congenital facial disorders, cancer, surgery, trauma, and neurological deficit.

 

The following services are payable at $53.90 per 15-minute time unit:

 

Part 1: Examination and Diagnosis

 

01702      Examination and diagnosis, prosthodontic, specific

 

Part 2: 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

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

51701      Maxillary + L

51702      Mandibular + L

 

5              Dentures, complete, overdentures (immediate)

51801      Maxillary + L

51802      Mandibular + L

 

6              Dentures, complete, attached to implants

Dentures, removable, tissue bone, with independent attachments secured 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, 53103 + 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, removeable

53701      Maxillary + L

53702      Mandibular + L

53704      Altered cast impression technique done in conjunction with 53701, 53702 and
53703 + L

 

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

 


Insured Dental Services Tariff

Schedule E: Mentally Challenged Program

 

The Mentally Challenged Program provides the insured dental services set out for the Children’s Oral Health Program in Schedule B for residents (as defined in the M.S.I. Regulations) who are considered by a physician to be mentally handicapped.

 

The fee for an insured dental service provided under this Schedule to a mentally handicapped resident is the fee set out in the Nova Scotia Dental Association Schedule of Fees at the general practitioner rate, unless the service is provided in a hospital, in which case the fee is the fee set out in the Nova Scotia Dental Association Schedule of Fees at the general practitioner rate, plus 30%.

 

In order for an insured dental service to be provided in a hospital, a physician must indicate that a hospital setting is required to meet the resident’s dental needs.

 

If major restorative treatment is required, pre-authorization must be obtained from the Corporation that administers the M.S.I. Plan for the Province before beginning treatment.

 

There is no coverage under the Mentally Challenged Program for services performed outside the Province.