Alberta Blue Cross Usual and Customary dental fees

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1 Alberta Blue Cross Usual and Customary dental fees Why Usual and Customary dental fees? In Alberta, individual dental providers set their own prices. As a result, dental offices across the province charge widely varying prices for dental services. Usual and Customary dental fees are based on recent data from actual marketplace billings by Alberta dental offices for over 1,800 procedure codes claimed by Alberta Blue Cross group dental plan members. By using Usual and Customary dental fees as a basis of payment for claims, your plan coverage levels match the fees accepted by most dental offices, most of the time, across Alberta today and this helps to ensure that your plan will remain viable and affordable both today and into the future. Examples of typical Usual and Customary fees Each person has unique dental needs, so your dental treatment may be different from the examples shown here. Please note that some procedures listed here may not be covered by your particular dental plan. Decisions about treatment remain between you and your dental provider. The fees indicated are those of a general practitioner, amounts charged by a specialist or a denturist may be different. Adults Recall and cleaning costs Recall exam - Procedure $ Bitewing Radiographs - Procedure $ Time Units Scaling - Procedure $ Time Unit Polishing - Procedure $68.00 TOTAL $ Restorations (fillings) 4 surface amalgam (silver) filling permanent molar - Procedure $ pins for filling - Procedure $46.34 TOTAL $ Children Recall and cleaning costs Recall exam - Procedure $ Bitewing Radiographs - Procedure $ Time Unit Scaling - Procedure $ Time Unit Polishing - Procedure $68.00 Fluoride - Procedure $33.50 TOTAL $ Crown Porcelain fused to metal crown - Procedure $923.00* Post cast metal - Procedure $194.00* TOTAL $1,117.00* *Dentist s fees only: lab charges may apply Three Unit bridge Retainer, (crown) for fixed bridge - Procedure Retainer, (crown) for fixed bridge - Procedure Pontic, for fixed bridge (to replace missing tooth) - Procedure $938.00* $938.00* $462.00* TOTAL $2, *Dentist s fees only: lab charges may apply Root canal therapy Three root, root canal therapy - Procedure $1, Example denturist fees General prosthodontic exam - Procedure Complete upper denture - Procedure Complete lower denture - Procedure Partial upper denture - Procedure Complete upper denture repair - Procedure Complete upper denture reline (processed) - Procedure *Denturist fees only: lab charges may apply $66.50 $659.70* $659.70* $702.60* $60.00* $198.80* ABC 81304_uc R2016/01 - Page 1

2 Maximum amounts the Usual & Customary schedule allows for common dental procedures. Some procedures listed on the following pages may not be covered by your particular plan. Please consult your plan contract or benefit booklet for more information. All Alberta dental offices have access to complete copies of the 2016 Usual and Customary Dental Fees. Your dental provider also has quick and easy access to information about your dental coverage through CDAnet or DACnet, a national electronic system. Procedure Procedure Code Maximum allowed Diagnostic New Patient, Complete Exam, Primary Teeth New Patient, Complete Exam, Mixed Teeth New Patient, Complete Exam, Permanent Teeth $ $ $ Limited Oral Examination, new patient $75.64 Limited Oral Exam, Recall $72.50 Specific Exam $72.66 Emergency Exam $72.00 Specific Periodontal Exam $88.00 General Surgical Exam $ Specific Surgical Exam $ General Prosthodontic Exam $ Specific Endodontic Exam $ General Orthodontic Exam $400.00* Specific Orthodontic Exam $86.00 Periapical Radiographs single image $30.00 Periapical Radiographs two images $49.00 Periapical Radiographs three images $67.00 Periapical Radiographs four images $84.00 Bitewing Radiographs single image $30.00 Bitewing Radiographs two images $49.00 Bitewing Radiographs four images $86.68 Panoramic Radiograph single image $96.00 Preventive Polishing one unit $68.00 Polishing one half unit $34.00 Scaling one unit $72.18 ABC 81304_uc R2016/01 - Page 2

3 Scaling two units $ Scaling three units $ Scaling four units $ Scaling five units $ Scaling one half unit $36.09 Fluoride $33.50 Pit and Fissure Sealants first tooth $35.00 Pit and Fissure Sealants each additional tooth in same quadrant $18.00 Periodontal appliance $406.00* Restorative Caries/Trauma/Pain control $ Amalgam Filling - primary teeth two surfaces Amalgam Filling- permanent anteriors and bicuspids two surfaces one surface two surfaces three surfaces four surfaces $ $ $ $ $ $ Retentive Pins one pin $32.00 Retentive Pins two pins $46.34 Prefabricated Metal Filling primary posterior - permanent anterior one surface - permanent anterior two surfaces $ $ $ permanent anterior three surfaces - permanent anterior four surfaces - permanent anterior five surfaces - permanent bicuspids one surface Tooth Coloured Filling - Acid Etch/Bond - permanent bicuspids two surfaces - permanent bicuspids three surfaces $ $ $ $ $ $ ABC 81304_uc R2016/01 - Page 3

4 - permanent bicuspids four surfaces - permanent bicuspids five surfaces - permanent molars one surface - Permanent Molars two surfaces - permanent molars three surfaces - permanent molars four surfaces - permanent molars five surfaces - primary posterior one surface - primary posterior two surfaces Tooth Coloured Core/Plastic with Silver fillings, Cores - Tooth Coloured Tooth Coloured Core/Plastic with Silver fillings, Cores - Acid Etch/Bonded $ $ $ $ $ $ $ $ $ $ $ Cast metal Posts $194.00* Prefabricated Posts $155.00* Crowns $953.00* Crowns $923.00* Crowns $932.14* Recementation/ Rebonding $84.00* Endodontics Pulpotomy - Primary Toothconcurrent with restorations $82.00 Root Canal - one canal $ Root Canal - two canals $1, Root Canal - three canals $1, Periodontics Desensitization one unit $73.00 Periodontal Surgery gingival curettage, per sextant $ Root planing one unit $78.00 Root planing two units $ Root planing three units $ Root planing four units $ ABC 81304_uc R2016/01 - Page 4

5 Prosthodontics Complete Standard Denture upper $900.00* Complete Standard Denture lower $900.00* Partial Denture - lower $875.00* Denture Adjustment one unit $71.93* Denture Repair - upper $77.31* Denture Repair lower $77.00* Denture Reline upper $238.00* Denture Reline lower $238.00* Pontic - porcelain fused to metal $462.00* Retainer porcelain/ceramic fused to metal $938.00* Oral Surgery Removal of Erupted Teeth uncomplicated $ Removal of Erupted Teeth each additional tooth same quadrant Surgical Removal of Single Erupted tooth requiring surgical flap and/or sectioning of tooth Surgical Removal of Impacted tooth partial bone impaction Surgical Removal of Impacted Teeth complete bone impaction Surgical Removal of Impacted Teeth unusual difficulties and circumstances $ $ $ $ $ Orthodontics Orthodontic Treatment (Braces) Class 1 malocclusion Orthodontic Treatment (Braces) Class 2 malocclusion Orthodontic Treatment (Braces) Malocclusions not requiring complete banding Variable Variable Variable Adjunctive General Services General Anesthesia six units $ Anesthetic Facilities six units $ ABC 81304_uc R2016/01 - Page 5

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