SUGGESTED FEE GUIDE FOR DENTAL SERVICES

Transcription

1 NOVA SCOTIA DENTAL ASSOCIATION SUGGESTED GUIDE FOR DENTAL SERVICES PROVIDED BY GENERAL PRACTITIONERS February 2008 Not to be reproduced in whole or in part without the consent of the Nova Scotia Dental Association

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3 Nova Scotia Dental Association Suggested Fee Guide for Dental Services Provided by General Practitioners Revised January 2008 Table of Contents Foreword i - ii CDA Guidelines Conversion Chart for Basic Restorations Diagrams I.D. System for Arches, Quadrants, Sextants & Joints iii - iv v vi vii - viii Diagnostic Services DIAG 1 Preventive Services PREV 9 Restorative Services REST 15 Endodontics ENDO 23 Periodontal Services PERIO 29 Prosthodontics - Removable PROS-REM 33 Prosthodontics - Fixed PROS-FIXED 39 Surgical Services SURG 45 Orthodontics ORTHO 51 Other Services ADJ 55 Implants IMPLANTS 63 Index INDEX 73

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5 FOREWORD This guide is prepared by the Nova Scotia Dental Association to provide, to whom it may concern, a list of fees which are considered fair and just. This guide is not binding on any general practitioner, and each is expected to determine his/her own fees, as it relates to his/her own special set of circumstances. The aim of this guide is not to determine fees but to accurately reflect the average practice and, to some extent, allow for changes in economic conditions over the past 12 months. This guide: 1. reflects the value of a dental service; 2. equates different services in order that these resultant fees may bear a reasonable relationship to each other. The fees appearing are those determined to be reasonable under normal or typical operating conditions and are determined for the average dental office, i.e. average gross and net income and average overhead. It is considered fair and just that an altered fee may be rendered: a) b) c) d) e) f) in cases presenting unusual complications; in cases demanding exceptional skill and/or time; in cases requiring acceptance of special responsibilities; in cases where immediate attention is demanded, at the sacrifice of regular office routine; in cases where the regular fee might be a financial hardship to the patient; in chronic or prolonged cases where attention is provided at the convenience of the dentist. The current guide of suggested fees uses a logical orientation towards dental services. Dental services are assigned a relative scale of values (weights) and placed in a relative value system, where both similar and dissimilar services can be evaluated and compared. This Fee Guide is formulated using information from the: 1. annual economic survey; 2. procedure frequency studies; 3. procedure time studies; 4. responsibility factors; 5. state of the economy and economic forecasts. This is the Fee Guide formula: = (Tx C) + (Tx R x P) + Lab T R is the time factor for the procedure (in 1/4 hour units) as established in the time studies. is the responsibility factor related to the complexity, stress and risk of the procedure and the care, skill and judgement required to complete it. C is the cost of office overhead, including salaries and employee fringe benefits, rent, utilities, dental materials and supplies, equipment costs, administrative expenses, continuing education costs, etc. (adjusted for inflation). P is the value of the dentist's time, as determined from salaries of individuals working at a comparable level in business, industry or government, and includes fringe benefits such as retirement plans, insurance programs, etc. ( i )

6 If this Fee Guide is used to assist the general practitioner in determining a professional fee, it is essential that certain procedures be followed in order to eliminate the possibility of patient misunderstandings regarding the fees for dental treatment Perform a thorough oral examination for the patient. Explain carefully to the patient, parent or guardian, the particular problems encountered in the patient's mouth. Describe your treatment plan and prognosis in a manner which the patient, parent or guardian can fully understand. Assure yourself that the patient, parent or guardian has understood the presentation. It should be recognized that the patients are often not familiar with some of the terms we commonly use in our practice. As far as possible, explanations concerning treatment service should be made in terms a layman understands, particularly when fees are involved. Present your fee for treatment before commencement of treatment. Arrange financial commitments in such a manner that the patient understands his obligations. If there is any question as to why this fee must be charged, explain at this time. Describe, explain and note any conditions which may require an extra fee. For patients who require a removable prosthetic service, two pertinent points must be emphasized: a) the length of time adjustments will be provided at no additional fee; and b) whether or not the initial fee includes the cost of necessary relines. In all areas of treatment, your fee must be guided by the skill, judgement and experience which you have attained, but more important is their application. ( ii )

7 UNIFORM SYSTEM OF CODING AND LIST OF SERVICES (Prepared and Published by the Third Party Dental Plans Committee of the Canadian Dental Association) Revised Edition 2008 GUIDELINES All corporate members of the CDA are strongly encouraged to use this system for their own Uniform Codes. The Uniform System of Codes and List of Services is a numerical listing of all recognized procedures performed by a dentist in the performance of the practice of dentistry. The U.S.C. and L.S. does not denote or imply approval or disapproval of any services. The numbers assigned accurately describe the services provided and are divided into various disciplines of dentistry. The classification is as follows: DIAGNOSTIC PREVENTIVE RESTORATIVE ENDODONTICS PERIODONTICS PROSTHODONTICS - REMOVABLE PROSTHODONTICS - FIXED ORAL SURGERY ORTHODONTICS ADJUNCTIVE GENERAL SERVICES 5. The numbers used to describe a service must accurately conform to the following principles, where FIRST DIGIT designates the CATEGORY OF SERVICE SECOND DIGIT designates the CLASSIFICATION OF SERVICE THIRD DIGIT designates the SUB-CLASSIFICATION OF SERVICE FOURTH DIGIT designates the GENERAL SERVICE TITLE ONLY (when applicable) FIFTH DIGIT designates the SPECIFIC SERVICE Example: "2" 1221 represents the Category "RESTORATIVE" 2 "l" 221 represents the Classification "AMALGAM RESTORATIONS" 21 "2" 21 represents the Sub-Classification "AMALGAMS PERMANENT DENTITION" 212 "2" 1 represents the Service Title "PERMANENT MOLARS" 2122 "1" represents the Specific Service "PERMANENT MOLARS ONE SURFACE" ( iii )

8 6. The UNITS OF TIME and/or the LETTERS following procedures must conform to the following principles: (also see procedure codes in the U.S.C. and L.S.) Where the: LETTER "L" follows a procedure code, the designation is that of "LABORATORY PROCEDURES EXTRA" UNITS OF TIME follows a procedure code, the designation is that of "FIFTEEN MINUTE INTERVALS" LETTER "E" follows a procedure code, the designation is that of "EXPENSES EXTRA" The numbers and services described in the Uniform System of Codes and List of Services cannot be varied. Changes to the Uniform System of Codes and List of Services will be considered only upon receipt of a request from the governing body or the delegate authority of a corporate body, signifying its approval and support for such new numbers or modified numbers or descriptions of procedures. A clear written statement, supporting and substantiating the creation or modification of each number, must accompany each request. ( iv )

9 CONVERSION CHART FOR BASIC RESTORATIONS G.V. BLACK SYSTEM vs. CONTINUOUS SURFACE RESTORATIONS Class I becomes 1 surface Class III becomes 2 continuous surfaces Class IV becomes 3 continuous surfaces NOT involving proximal contacts (e.g., MIL MIV*) (e.g., DIL DIV) or: 4 continuous surfaces, when it involves proximal contacts (e.g., MILV) (e.g., DILV) Double Class IV becomes 5 continuous surfaces Class V becomes 1 surface * Please note: V (VESTIBULAR) is to be used in place of either Buccal or Labial ( v )

10 1. ONE SURFACE RESTORATION (See Figures 1, 2 and 3) CLASS I CLASS III (If not extended beyond the line angle) CLASS V Vestibular or Lingual CLASS VI Incisal Mesial Lingual Pit Vestibular (facial or labial) Figure 1 Figure 2 Figure 3 2. TWO SURFACE CONTINUOUS RESTORATION (See Figure 4) CLASS III (If extended beyond the line angle due to caries, vestibular or lingual in a continuous fashion) Interproximal and Vestibular Figure 4 3. THREE SURFACE CONTINUOUS RESTORATION (See Figure 5) Three Continuous Surfaces, such as: MIL, MIV, DIL, or DIV, where the restoration does not extend past the remaining line angle 4. FOUR SURFACE CONTINUOUS RESTORATION (See Figure 6) This restoration includes incisal, vestibular, interproximal (but not lingual) surfaces Figure 5 Four Continuous Surfaces, such as: MILV or DILV, if extended beyond the remaining line angle Extends both lingually and vestibularly as well as restoring the interproximal and incisal surfaces 5. FIVE SURFACE CONTINUOUS RESTORATION OR SURFACES PER TOOTH (See Figures 7 and 8) Figure 6 Five Continuous Surfaces such as: MIDLV or a combination of MILV and DILV together on the same tooth or Figure 7 Figure 8 ( vi )

11 IDENTIFICATION SYSTEM FOR ARCHES, QUADRANTS, SEXTANTS, JOINTS Where grouping of treatment by teeth / sites are indicated in the Suggested Fee Guide, the following codes are used in the "International Tooth Code" column on the standard dental claim form: For Quadrants: For Sextants: 00 designates Full Mouth 01 designates Maxillary Arch 02 designates Mandibular Arch 10 designates the Upper Right Quadrant 20 designates the Upper Left Quadrant 30 designates the Lower Left Quadrant 40 designates the Lower Right Quadrant 03 designates from designates from designates from designates from designates from designates from For Joints: When per joint is designated, the corresponding tooth code is represented by the mesial of the tooth involved, except at the midline, where the tooth to the right is utilized. ( vii )

12 IDENTIFICATION SYSTEM FOR TEETH ARCH QUADRANT SEXTANT Supernumary Tooth 99 ( viii )

13 DIAGNOSTIC DIAG 1 EXAMINATION AND DIAGNOSIS, CLINICAL ORAL EXAMINATION AND DIAGNOSIS, COMPLETE ORAL, to include: (a) History, medical and dental (b) Clinical examination and diagnosis of hard and soft tissues, including carious lesions, missing teeth, determination of sulcular depth, gingival contours, mobility of teeth, interproximal tooth contact relationships, occlusion of teeth, TMJ, pulp vitality tests/analysis, where necessary, and any other pertinent factors (c) Radiographs extra, as required Examination and Diagnosis, Complete, Primary Dentition, to include: Extended examination and diagnosis on primary dentition, recording history, charting, treatment planning and case presentation, including above description Examination and Diagnosis, Complete, Mixed Dentition, to include: (a) Extended examination and diagnosis on mixed dentition, recording history, charting, treatment planning and case presentation, including above description (b) Eruption sequence, tooth size - jaw size assessment Examination and Diagnosis, Complete, Permanent Dentition to include: Extended examination and diagnosis on permanent dentition, recording history, charting, treatment planning and case presentation, including above description EXAMINATION AND DIAGNOSIS, LIMITED ORAL Examination and Diagnosis, Limited, Oral, New Patient Examination and diagnosis with mirror and explorer of hard and soft tissues, including checking of occlusion and appliances, but not including specific tests / analysis as for series (may include PSR) Examination and Diagnosis, Limited Oral, Previous Patient (recall) Examination of hard and soft tissues, including checking of occlusion and appliances, but not including specific tests/analysis, as for Examination and Diagnosis, Specific Examination and evaluation of a specific situation Examination and Diagnosis, Emergency Examination and diagnosis for the investigation of discomfort and/or infection in a localized area Analysis, Mixed Dentition 21.00

14 DIAG EXAMINATION AND DIAGNOSIS, STOMATOGNATHIC Examination and Diagnosis, Stomatognathic, Dysfunctional, Comprehensive, to include: (a) History, medical, dental, pain / dysfunction (b) Clinical examination to include general appraisal, examination of head and neck, musculoskeletal system (static and functional); Intraoral examination of hard and soft tissues, including occlusal analysis, consultation with other health care professionals, review of previous records, including radiographs, ordering of appropriate tests/analysis and consultations Examination and Diagnosis, Stomatognathic, Dysfunctional, Limited EXAMINATION AND DIAGNOSIS, ORAL PATHOLOGY Examination and Diagnosis, Oral Pathology, General, to include: (a) History, medical, dental (b) Clinical examination including in-depth analysis of medical status, initial consultation, with referring dentist or physician, evaluation of the diagnosis and prognosis and formulation of a treatment plan Examination and Diagnosis, Oral Pathology, Specific (or repeat examination within 90 days for the same illness) EXAMINATION AND DIAGNOSIS, PERIODONTAL Examination and Diagnosis, Periodontal, General Recording History, Charting, Treatment Planning and Case Presentation: (a) (b) History, medical, and dental Clinical examination includes evaluation of topography of the gingiva and related structures; degree of gingival inflammation; location, extent, sulcular depth; furcation involvement, mobility of teeth; tooth contact relationships; evaluation of occlusion; TMJ, examination of oral soft tissue pathosis; evaluation of the existing restorative and/or prosthetic appliances; caries and pulpal vitality Examination and Diagnosis, Periodontal, Limited (previous patient) EXAMINATION AND DIAGNOSIS, PROSTHODONTIC Edentulous, to include: Extended examination of the Edentulous Mouth, including detailed Medical and Dental (including prosthetic) History, visual and digital examination of the oral structures, head and neck (including TMJ), lips, oral mucosa, tongue, oral pharynx, salivary glands and lymph nodes, and including evaluation for implant-supported or retained prosthesis

15 DIAG 3 RADIOGRAPHS (Including radiographic examination, diagnosis and interpretation) RADIOGRAPHS, INTRAORAL (where 2-pack films are utilized, it is appropriate to add a +E) Radiographs, Intraoral, Pedodontic, Complete Series (minimum of 12 films including bitewings) Radiographs, Intraoral, Adult, Complete Series (minimum of 16 films including bitewings) Radiographs, Intraoral, Periapical Single film Two films Three films Four films Five films Six films Seven films Eight films Nine films Ten films Eleven films Twelve films Thirteen films Fourteen films Fifteen films Radiographs, lntraoral, Occlusal Single film Two films Three films Four films Radiographs, Intraoral, Bitewing Single film Two films Three films Four films RADIOGRAPHS, EXTRAORAL Single film Two films Three films Four films RADIOGRAPHS, TEMPOROMANDIBULAR JOINT Single film Two films Three films Four films (minimum examination and diagnosis, closed and open each side) Each additional film over four 13.00

16 DIAG RADIOGRAPHS, PANORAMIC Single film RADIOGRAPHS, CEPHALOMETRIC Single film Two films Radiographs, Cephalometric, Tracing and Interpretation One unit of time Two units Each additional unit over two RADIOGRAPHS, COMPUTERIZED AXIAL TOMOGRAMS (C.A.T.), POSITRON EMISSION TOMOGRAPHY (P.E.T.), MAGNETIC RESONANCE IMAGES (M.R.I.), INTERPRETATION (either the radiographs, CAT scans, PET scans, MRI scans, or the interpretation must be received from another source) One unit of time + E Two units + E Half unit of time + E Each additional unit over two + E RADIOGRAPHS, OTHER Radiographs, Duplications Single film Two films Three films Four films Five films Six films Seven films Eight films Each additional film over eight 4.00 Duplication of a Complete Series of Radiographs Duplication of a Complete Series of 12 Radiographs I.C Duplication of a Complete Series of 13 or more Radiographs I.C. Radiographs, Hand and Wrist Radiograph, Hand and Wrist (as a diagnostic aid for dental treatment) per case Radiographic Guide [includes diagnostic wax-up, with radio-opaque markers for pre-surgical assessment of alveolar bone and vital structures as potential osseo-integrated implant site(s)] Maxillary Guide + L + E I.C Mandibular Guide + L + E I.C. TEMPLATE, SURGICAL (includes diagnostic wax-up. Also used to locate and orient osseo-integrated implants) Maxillary Template + L + E I.C Mandibular Template + L + E I.C.

17 DIAG 5 TESTS / ANALYSIS / LABORATORY PROCEDURES / INTERPRETATION AND/OR REPORTS TEST / ANALYSIS, MICROBIOLOGICAL (technical procedure only) Microbiological Test / Analysis for the Determination of Pathological Agents + L TEST / ANALYSIS, CARIES SUSCEPTIBILITY (technical procedure only) Bacteriological Test / Analysis for the Determination of Dental Caries Susceptibility + L TEST / ANALYSIS, HISTOPATHOLOGICAL (technical procedure only) Soft Tissue Biopsy, Soft Oral Tissue - by Puncture + L Biopsy, Soft Oral Tissue - by Incision + L Biopsy, Soft Oral Tissue - by Aspiration + L Hard Tissue Biopsy, Hard Oral Tissue - by Puncture + L Biopsy, Hard Oral Tissue - by Incision + L Biopsy, Hard Oral Tissue - by Aspiration + L TEST / ANALYSIS, CYTOLOGICAL (technical procedure only) Cytological Smear from the Oral Cavity + L + E Vital Staining of Oral Mucosal Tissues + E I.C. TEST / ANALYSIS, PULP VITALITY AND INTERPRETATION One unit of time Each additional unit INTERPRETATION AND/OR REPORTS, LABORATORY Interpretation and/or Report, Microbiological by Oral Microbiologist + L I.C Interpretation and/or Report, Histopathological by Oral Pathologist I.C. or Microbiologist + L Interpretation and/or Report, Cytological by Oral Pathologist + L I.C Reports, Other I.C. SUPPLEMENTARY DIAGNOSTIC PROCEDURES (interpretation only) Equilibration, Casts, Diagnostic (pilot equilibration) for Extensive or Complicated Restorative Dentistry One unit of time + L Two units + L Three units + L Four units + L

18 DIAG Wax-up, Diagnostic (to evaluate cosmetic and/or preparation design and/or occlusal considerations) (gnathological wax-up) One unit of time + L Two units + L Three units + L Four units + L Split Cast Mounting, Diagnostic One unit of time + L Two units + L Interpretation of Diagnostic Casts One unit of time PHOTOGRAPHS, DIAGNOSTIC (technical procedure only) Single photograph Two photos Three photos Each additional photo over three 5.00 CASTS, DIAGNOSTIC (technical procedure only) Casts, Diagnostic, Unmounted Casts, Diagnostic, Unmounted + L Casts, Diagnostic, Unmounted, Duplicate + L Casts, Diagnostic, Mounted Casts, Diagnostic, Mounted + L Casts, Diagnostic, Mounted, using Face Bow Transfer + L Casts, Diagnostic, Mounted, using Face Bow Occlusal Records + L Casts, Diagnostic, Mounted, using Fully I.C. Adjustable Articulator + L (used with and 04942) Casts, Diagnostic, Orthodontic Casts, Diagnostic, Orthodontic (unmounted, angle trimmed and soaped) + L Casts, Diagnostic, Miscellaneous Procedures Transverse Axis Location and Transfer, used in Conjunction with I.C , 04923, and L Three Dimensional Recordings of Patient's Dynamic Movements I.C. for Programming of Fully Adjustable Articulators

19 DIAG 7 CASE PRESENTATION / TREATMENT PLANNING TREATMENT PLANNING This service is only for extra time spent on unusually complicated cases or where the patient demands unusual time in explanation or where diagnostic material is received from another source. Usual case presentation time and usual treatment planning time are implicit in the examination and diagnosis fee and in the radiographic interpretation fee One unit of time Two units CONSULTATION, with patient One unit of time Two units Each additional unit over two 36.00

20 PREVENTION PREV 9 It is appropriate to bill for all the time that caregivers attend to the patient. Procedures billed on a perunit-of-time basis should reflect the predominant service performed during each unit (or half unit) of time. The time billed for each procedure should be rounded to the nearest unit (or half unit) of time as long as the total time billed to the patient does not exceed the total time the caregivers attend to the patient. The total time that can be billed on a per-unit-of-time basis should exclude treatment time billed on a per-procedure basis. (For billing purposes, a unit of time is 15 minutes.) POLISHING One unit of time Two units One half unit Each additional unit over two SCALING One unit of time Two units Three units Four units Five units Six units One half unit Each additional unit over six FLUORIDE TREATMENTS Fluoride Treatment, Topical Application Fluoride Treatment, Supervised, Self-Administered Brush-in 9.00 PREVENTIVE SERVICES, OTHER NUTRITIONAL COUNSELLING including: recording and analysis up to seven day dietary intake and consultation One unit of time Two units ORAL HYGIENE INSTRUCTION / PLAQUE CONTROL to include: brushing and/or flossing and/or embrasure cleaning Individual Instruction (one instructor to one patient), Excluding Audio-Visual Time One unit of time Two units Three units One half unit of time Each additional unit over three Re-instruction (within 6 months), Excluding Audio-Visual Time One unit of time Two units One half unit of time 6.00

21 PREV Oral Hygiene Instruction - Audio Visual One unit of time Two units One half unit of time 6.00 PIT AND FISSURE SEALANTS (mechanical and/or chemical preparation included) First tooth Each additional tooth same quadrant Preventive Restorative Resin (procedure that involves some preparation of the pits and/or fissures in tooth enamel and may extend into dentin in limited areas) First tooth Each additional tooth same quadrant TOPICAL APPLICATION TO HARD TISSUE OF AN ANTIMICROBIAL AGENT One unit of time + E Two units + E Each additional unit over two + E APPLIANCES APPLIANCES, REMOVABLE, CONTROL OF ORAL HABITS Appliance, Maxillary + L Appliance, Mandibular + L Appliances, Maxillary plus Mandibular + L APPLIANCES, FIXED / CEMENTED, CONTROL OF ORAL HABITS Appliance, Maxillary + L Appliance, Mandibular + L CONTROL OF ORAL HABITS, MISCELLANEOUS Motivation of Patient - Psychological Approach (e.g., thumb sucking, lip biting, etc.) - per visit + L Myofunctional Therapy (e.g., to correct mouth breathing, abnormal swallowing, tongue thrust, etc.) First unit of time per visit + L Two units + L Each additional unit over two + L APPLIANCES, CONTROL OF ORAL HABITS - ADJUSTMENTS, REPAIRS, MAINTENANCE One unit of time + L Two units + L APPLIANCES, PROTECTIVE MOUTH GUARDS Appliance, Protective Mouth Guard, Processed + L 55.00

22 PREV 11 APPLIANCES, PERIODONTAL (see separate codes for Control of Oral Habits 14000, Protective Mouth Guards and TMJ ) Appliances, Periodontal (including bruxism appliance); includes impression, insertion and insertion adjustment (no post-insertion adjustments) Maxillary Appliance + L Mandibular Appliance + L Appliances, Adjustment, Repair One unit of time + L Two units + L Three units + L Each additional unit over three + L Appliances, Reline Reline, Direct Reline, Processed + L APPLIANCES, TEMPOROMANDIBULAR JOINT Appliance, TMJ Intraoral Repositioning; includes impression, insertion and insertion adjustment (no post insertion adjustments) Maxillary Appliance + L Mandibular Appliance + L Appliance, TMJ, Periodic Maintenance, Adjustment, Repair One unit of time + L Two units + L Three units + L Each additional unit over three + L Appliance, TMJ, Relines Reline, Direct Reline, Indirect + L APPLIANCES, MYOFASCIAL PAIN DYSFUNCTION SYNDROME (conditions that originate outside the temporomandibular joint) Appliances, Myofascial Pain Dysfunction Syndrome (to include: models, gnathological determinants) Appliance Construction Only, and Insertion Adjustment (no post-insertion adjustments) Maxillary Appliance + L Mandibular Appliance + L Appliance, Myofascial Pain Dysfunction Syndrome, Periodic Maintenance, Adjustment and Repairs One unit of time + L Two units + L Three units + L Each additional unit over three + L 50.00

23 PREV SPACE MAINTAINERS (includes the design, separation, fabrication, insertion and where applicable initial cementation and removal) SPACE MAINTAINERS, BAND TYPE Space Maintainer, Band Type, Fixed, Unilateral + L Space Maintainer, Band Type, Fixed, Unilateral with lntra-alveolar Attachment + L Space Maintainer, Band Type, Fixed, Bilateral (soldered lingual arch) + L Space Maintainer, Band Type, Fixed, Bilateral (soldered lingual arch) with Teeth Attached + L Space Maintainer, Band Type, Fixed, Bilateral Tubes and Locking Wires + L SPACE MAINTAINERS, STAINLESS STEEL CROWN TYPE Space Maintainer, Stainless Steel Crown Type, Fixed + L SPACE MAINTAINERS, CAST TYPE Space Maintainer, Cast Type, Fixed + L Space Maintainer, Cast Type, Fixed, with Intra Alveolar Attachment + L SPACE MAINTAINERS, ACRYLIC, REMOVABLE Space Maintainer, Acrylic, Removable, Bilateral Clasps, Retaining Wires + L Space Maintainer, Acrylic Removable, No Clasps + L SPACE MAINTAINERS, BONDED, PONTIC TYPE Space Maintainer, Bonded, Pontic Type + L SPACE MAINTAINERS, MAINTENANCE OF Maintenance, Space Maintainer Appliance, to include: adjustment and/or recementation after 30 days from insertion Maintenance, Space Maintainer Appliances, Addition of Clasps and/or Activating Wires + L Repairs, Space Maintainer Appliances (includes recementation) + L Removal of Fixed Space Maintainer Appliances by Second Dentist 51.00

24 PREV 13 ANATOMIC MODIFICATIONS (Reshaping, recontouring, or occlusal modifications of a natural tooth or teeth, single or multiple restorations, or the inter-articulation of the teeth) FINISHING RESTORATIONS to include: polishing, removal of overhangs, refining marginal ridges and occlusal surfaces, etc. (when restorations were performed by another dentist or restorations are over two years old) One unit of time Two units Three units Four units Each additional unit over four DISKING OF TEETH, Interproximal One unit of time Two units Three units RECONTOURING OF NATURAL TEETH FOR AESTHETIC REASONS One unit of time Each additional unit of time RECONTOURING OF TEETH FOR FUNCTIONAL REASONS (not associated with delivery of a single or multiple prosthesis) One unit of time Each additional unit of time 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) Not to be used in conjunction with the delivery and post-insertion care of fixed or removable prosthesis (50000 & code series) by the same dentist for a period of three months One unit of time Two units Three units Four units Each additional unit over four 62.00

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26 RESTORATION REST 15 CARIES, TRAUMA AND PAIN CONTROL Caries / Trauma / Pain Control (removal of carious lesions or existing restorations or gingivally attached tooth fragment and placement of sedative / protective dressings, includes pulp caps when necessary, as a separate procedure) First tooth Each additional tooth same quadrant Caries / Trauma / Pain Control (removal of carious lesions or existing restorations or gingivally attached tooth fragment 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) First tooth Each additional tooth same quadrant Trauma Control, Smoothing of Fractured Surfaces, per Tooth First tooth Each additional tooth same quadrant RESTORATIONS, AMALGAM RESTORATIONS, AMALGAM, NON-BONDED, PRIMARY TEETH One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth RESTORATIONS, AMALGAM, BONDED, PRIMARY TEETH One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth RESTORATIONS, AMALGAM, PERMANENT TEETH Restorations, Amalgam, Non-Bonded, Permanent Bicuspids and Anteriors One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth

27 REST Restorations, Amalgam, Non-Bonded, Permanent Molars One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth Restorations Amalgam, Bonded, Permanent Bicuspids and Anteriors One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth Restorations, Amalgam, Bonded, Permanent Molars One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth RESTORATIONS, AMALGAM CORES Restoration, Amalgam Core, Non-Bonded, in Conjunction with Crown Restoration, Amalgam Core, Bonded, in Conjunction with Crown PINS, RETENTIVE per Restoration (for amalgams and tooth coloured restorations) One pin Two pins Three pins Four pins Five pins or more RESTORATIONS MADE TO A TOOTH SUPPORTING AN EXISTING PARTIAL DENTURE CLASP (additional to restoration) Per restoration RESTORATIONS, PREFABRICATED, FULL COVERAGE RESTORATIONS, PREFABRICATED, METAL, PRIMARY TEETH Primary Anterior Primary Posterior Primary Posterior - Open Face RESTORATIONS, PREFABRICATED, METAL, PERMANENT TEETH Permanent Anterior Permanent Posterior RESTORATIONS, PREFABRICATED, PLASTIC, PRIMARY TEETH Primary Anterior Primary Posterior

28 REST 17 RESTORATIONS, PREFABRICATED, PLASTIC, PERMANENT TEETH Permanent Anterior Permanent Posterior RESTORATIONS, TOOTH COLOURED / PLASTIC WITH / WITHOUT SILVER FILLINGS RESTORATIONS, PERMANENT ANTERIORS, BONDED TECHNIQUE (not to be used for veneer applications or diastema closures) One surface Two surfaces (continuous) Three surfaces (continuous) Four surfaces (continuous) Five surfaces (continuous, maximum surfaces per tooth) RESTORATIONS, TOOTH COLOURED, VENEER APPLICATIONS Tooth Coloured Veneer Application - Direct Chairside Prefabricated, Bonded Tooth Coloured Veneer Application - Non Prefabricated Direct Buildup, Bonded Tooth Coloured Veneer Application - Diastema Closure, Interproximal Only - Bonded RESTORATIONS, TOOTH COLOURED, PERMANENT POSTERIORS, BONDED Permanent Bicuspids One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth Permanent Molars One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth RESTORATIONS, TOOTH COLOURED, PRIMARY, ANTERIOR, BONDED TECHNIQUE One surface Two surfaces (continuous) Three surfaces (continuous) Four surfaces (continuous) Five surfaces (continuous or maximum surfaces per tooth) RESTORATIONS, TOOTH COLOURED, PRIMARY, POSTERIOR, BONDED TECHNIQUE One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth

29 REST RESTORATIONS, TOOTH COLOURED / PLASTIC WITH / WITHOUT SILVER FILLINGS, CORES Restoration, Tooth Coloured, Bonded, Core, in Conjunction with Crown RESTORATIONS, FOIL, GOLD RESTORATIONS, FOIL, GOLD, POSTERIORS Class I Class V RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS Inlays, Metal One surface + L Two surfaces + L Three surfaces + L Three surfaces, modified + L Inlays, Composite / Compomer, Indirect (Bonded) One surface + L Two surfaces + L Three surfaces + L Three surfaces, modified + L Inlays, Porcelain / Ceramic / Polymer Glass (Bonded) One surface + L Two surfaces + L Three surfaces + L Three surfaces, modified + L RESTORATIONS, ONLAYS (where one or more cusps are restored) Onlays, Cast Metal, Indirect Onlay, Cast Metal, Indirect + L Onlays, Composite / Compomer, Indirect (Bonded) Onlay, Composite / Compomer, Indirect (Bonded) + L Onlays, Porcelain / Ceramic / Polymer Glass (Bonded) Onlay, Porcelain / Ceramic / Polymer Glass (Bonded) + L PINS, RETENTIVE (for inlays, onlays and crowns per tooth) One pin / tooth + L Two pins / tooth + L Three pins / tooth + L Four pins / tooth + L Five or more pins / tooth + L 97.00

30 REST 19 POSTS Posts, Cast Metal, (including core) as a Separate Procedure Single section + L Two sections + L Three sections + L Posts, Cast Metal (including core) Concurrent with Impression for Crown Single section + L Two sections + L Three sections + L Posts, Prefabricated Retentive One post + E Two posts same tooth + E Three posts same tooth + E Posts, Prefabricated, with Non-Bonded Core for Crown Restoration [including pin(s) where applicable] One post, with non-bonded amalgam core + pins + E Two posts (same tooth), with non-bonded amalgam core + pins + E Three posts (same tooth), with non-bonded amalgam core + pins + E One post, with non-bonded composite core + pins + E Two posts (same tooth), with non-bonded composite core + pins + E Three posts (same tooth), with non-bonded composite core + pins + E Posts, Prefabricated, with Bonded Core for Crown Restoration [including pin(s) where applicable] One post, with bonded amalgam core + pins + E Two posts (same tooth), with bonded amalgam core + pins + E Three posts (same tooth), with bonded amalgam core + pins + E One post, with bonded composite/compomer core + pins + E Two posts (same tooth), with bonded composite/compomer core + pins + E Three posts (same tooth), with bonded composite/compomer core + pins + E Post Removal One unit of time Two units Three units Four units Each additional unit over four 68.00

31 REST CROWNS, SINGLE UNITS (only) CROWNS, ACRYLIC / COMPOSITE / COMPOMER (with or without Cast or Prefabricated Metal Bases) Crowns, Acrylic / Composite / Compomer, Indirect Indirect + L Provisional (long term), Indirect (lab fabricated / relined intra-orally) + L Crowns, Acrylic / Composite / Compomer, Direct Direct, Provisional (chairside) + E Crowns, Acrylic / Composite / Compomer / Cast Metal Base Indirect + L Implant-supported + L + E I.C. CROWNS, PORCELAIN / CERAMIC / POLYMER GLASS Crown, Porcelain / Ceramic / Polymer Glass + L Crown, Porcelain / Ceramic / Polymer Glass, Implant-supported + L + E I.C. Crowns, Porcelain / Ceramic / Polymer Glass, Fused to Metal Base Crown, Porcelain / Ceramic / Polymer Glass Fused to Metal Base + L Crown, Porcelain / Ceramic / Polymer Glass Fused to Metal Base, I.C. Complicated (restorative, positional and/or aesthetic) + L Crown, Porcelain / Ceramic / Polymer Glass, Fused to Metal Base, I.C. with Porcelain Margin + L Crown, Porcelain / Ceramic Fused to Metal Base, Implant-supported + L + E I.C. Crowns, 3/4, Porcelain / Ceramic / Polymer Glass Crown, 3/4, Porcelain / Ceramic / Polymer Glass + L Crown, 3/4, Porcelain / Ceramic / Polymer Glass, Complicated + L I.C. CROWNS, FULL, CAST METAL Crown, Full, Cast Metal + L Crown, Full, Cast Metal, Complicated (restorative, positional) + L I.C Crown, Full, Cast Metal, Implant-supported + L + E I.C. Crowns, 3/4, Cast Metal Crown, 3/4, Cast Metal + L Crown, 3/4, Cast Metal, Complicated + L I.C. CROWNS MADE TO AN EXISTING PARTIAL DENTURE CLASP (additional to crown) One crown Each additional crown COPINGS, METAL / ACRYLIC, TRANSFER (thimble type) Coping, Metal / Acrylic, Transfer (thimble) as a Separate Procedure + L

32 REST 21 VENEERS, LABORATORY PROCESSED Veneer, Porcelain / Ceramic / Polymer Glass, Bonded + L REPAIRS, (single units only, does not include removal and recementation) Repairs, Inlays, Onlays or Crowns, Acrylic / Composite / Compomer (single units) Direct Repairs, Inlays, Onlays or Crowns, Porcelain / Ceramic / Polymer Glass, Porcelain/Ceramic/Polymer Glass/Fused to Metal base Direct Indirect + L RECONTOURING OF EXISTING CROWNS, per tooth One unit of time Each additional unit of time RESTORATIVE PROCEDURES, OVERDENTURES OVERDENTURES, DIRECT Natural Tooth Preparation, Placement of Pulp Chamber Restoration (amalgam or composite) and Fluoride Application, Endodontically Treated Tooth Natural Tooth Preparation and Fluoride Application, Vital Tooth Prefabricated Attachment, as an Internal / External Overdenture Retentive Device, Direct to a Natural Tooth + L and/or + E (used with the appropriate denture code) per tooth Implant-supported Prefabricated Attachment as an Overdenture I.C. Retentive Device, Direct + L + E OVERDENTURES, INDIRECT Coping Crowns, Cast Metal, No Attachments, Indirect No Attachment, Indirect + L Implant-supported, Indirect + L + E I.C. Coping Crowns, Cast Metal, with Attachments, Indirect With Attachment, Indirect + L and/or + E Implant-supported with Attachment + L + E I.C.

33 REST RESTORATIVE SERVICES, OTHER RECEMENTATION / REBONDING, INLAYS / ONLAYS / CROWNS/ VENEERS POSTS / NATURAL TOOTH FRAGMENTS (+ L where laboratory charges are incurred during repair of the unit) One unit of time + L + E Two units + L + E Three units + L + E Four units + L + E REMOVAL, INLAYS / ONLAYS / CROWNS / VENEERS (single units only) One unit of time Two units Three units Four units STAINING, PORCELAIN (chairside) One unit of time + L Two units + L Three units + L Four units + L

34 ENDODONTICS ENDO 23 Pulp Capping (refer to Code Series 20100) PULP CHAMBER, TREATMENT OF (excluding final restoration) PULPOTOMY Pulpotomy, Permanent Teeth (as a separate emergency procedure) Anterior and Bicuspid Tooth Molar Tooth Pulpotomy, Primary Teeth Primary Tooth as a Separate Procedure Primary Tooth, Concurrent with Restorations (but excluding final restoration) PULPECTOMY (an emergency procedure and/or as a pre-emptive phase to the preparation of the root canal system for obturation) Pulpectomy, Permanent Teeth / Retained Primary Teeth One Canal Two Canals Three Canals I.C Four Canals or more I.C Exceptional anatomy / difficult access in addition to I.C. Pulpectomy, Primary Teeth Anterior Tooth Posterior Tooth ROOT CANAL THERAPY To include: treatment plan, clinical procedures (i.e., pulpectomy, biomechanical preparation, chemotherapeutic treatment and obturation), with appropriate radiographs and excluding final restoration Definitions: Uncomplicated Virtually straight canal penetrated by size #15 file Difficult Access Limited jaw opening, unfavourable tooth inclination, through complex restorations, e.g. crowns, post / core buildups Exceptional Anatomy Canal size same as uncomplicated but made complicated by virtue of shape and anatomy, e.g. dilacerated, s-shaped, arborized, taurodont, dens-in-dente or partially developed roots, internal / external resorption Calcified Canals Unable to penetrate with size #10 file and not clearly discernible on a radiograph Retreatment Retreatment of previously completed therapy Continuing Treatment Treatment having been aborted by referring / previous dentist due to blocked canals, ledged canals, zipped canals, separated instruments, perforations, etc.

35 ENDO ROOT CANALS, PERMANENT TEETH / RETAINED PRIMARY TEETH Includes: clinical procedures with appropriate radiographs, excluding final restoration ONE Canal One canal Difficult access Exceptional anatomy Calcified canal Retreatment of previously completed therapy Continuing treatment having been aborted by referring / previous dentist TWO Canals Two canals Difficult access Exceptional anatomy Calcified canals Retreatment of previously completed therapy Continuing treatment having been aborted by referring / previous dentist THREE Canals Three canals Difficult access Exceptional anatomy Calcified canals Retreatment of previously completed therapy Continuing treatment having been aborted by referring / previous dentist FOUR or More Canals Four or more canals Difficult access Exceptional anatomy Calcified canals Retreatment of previously completed therapy Continuing treatment having been aborted by referring / previous dentist ROOT CANALS, PRIMARY TEETH One canal More than one canal APEXIFICATION / APEXOGENESIS / INDUCTION OF HARD TISSUE REPAIR (to include biomechanical preparation and placement of dentogenic media) One canal Two canals Three canals Four canals or more Difficult access in addition to I.C.

36 ENDO 25 Re-insertion of Dentogenic Media per visit One canal Two canals Three canals Four canals or more APICOECTOMY / APICAL CURETTAGE PERIAPICAL SERVICES Maxillary Anterior One root Two roots Maxillary Bicuspid One root Two roots Three roots Maxillary Molar One root Two roots Three roots Four or more roots I.C. Mandibular Anterior One root Two or more roots Mandibular Bicuspid One root Two roots Three or more roots Mandibular Molar One root Two roots Three roots Four or more roots I.C. RETROFILLING Maxillary Anterior One canal Two or more canals Maxillary Bicuspid One canal Two canals Three canals Four or more canals

37 ENDO Maxillary Molar One canal Two canals Three canals Four or more canals Mandibular Anterior One canal Two or more canals Mandibular Bicuspid One canal Two canals Three canals Four or more canals Mandibular Molar One canal Two canals Three canals Four or more canals RETREATMENT, APICOECTOMY / APICAL CURETTAGE Maxillary Anterior One root Two roots Maxillary Bicuspid One root Two roots Three roots Four or more roots I.C. Maxillary Molar One root Two roots Three roots Four or more roots I.C. Mandibular Anterior One root Two or more roots Mandibular Bicuspid One root Two roots Three roots Four or more roots I.C.

38 ENDO 27 Mandibular Molar One root Two roots Three roots Four or more roots I.C. AMPUTATIONS, ROOT (includes recontouring tooth and furca) One root Two roots HEMISECTION Maxillary Bicuspid Maxillary Molar Mandibular Molar ENDODONTIC, PROCEDURES, MISCELLANEOUS ISOLATION OF ENDODONTIC TOOTH / TEETH FOR ASEPSIS Banding and/or Coronal Buildup of Tooth / Teeth and/or Contouring of Tissue Surrounding Tooth / Teeth to Maintain Aseptic Operating Field (per tooth) OPEN AND DRAIN (separate emergency procedures) Anteriors and Bicuspids Molars Opening Through Artificial Crown (In addition to procedures) Molars BLEACHING, NON VITAL Bleaching Endodontically Treated Tooth / Teeth One unit of time Two units Three units Each additional unit over three EXPLORATORY ACCESS THROUGH CLINICAL CROWN OF PREVIOUSLY TREATED TOOTH Exploratory Access Anterior Bicuspid Molar

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40 PERIODONTICS PERIO 29 ORAL DISEASE, Management of PERIODONTAL SERVICES, NON SURGICAL Oral Manifestations, Oral Mucosal Disorders Mucocutaneous disorders and diseases of localized mucosal conditions, e.g. lichen planus, aphthous stomatitis, benign mucous membrane pemphigoid, pemphigus, salivary gland tumours, leukoplakia with and without dysphasia, neoplasms, hairy leukoplakia, polyps, verrucae, fibroma, etc One unit of time Two units Three units Four units Each additional unit over four Nervous and Muscular Disorders Disorders of facial sensation and motor dysfunction at the jaw, e.g. trigeminal neuralgia, atypical facial pain, atypical odontologia, burning mouth syndrome, dyskenesia, post injection trismus, muscular and joint pain syndrome One unit of time Two units Three units Four units Each additional unit over four Oral Manifestations of Systemic Disease Oral manifestations of systemic diseases or complications of medical therapy, e.g. complications of chemotherapy, radiation therapy, post operative neuropathics, post surgical or radiation therapy, dysfunction, oral manifestations of lupus erythematosis and systemic disease, including leukaemia, diabetes and bleeding disorders (e.g. haemophilia) One unit of time Two units Three units Four units Each additional unit over four DESENSITIZATION (This may involve application and burnishing of medicinal aids on the root or the use of a variety of therapeutic procedures. More than one appointment may be necessary.) One unit of time Two units Each additional unit over two 30.00