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

41 PERIO PERIODONTAL SERVICES, SURGICAL (includes local anaesthetic, suturing and the placement and removal of initial surgical dressing. A surgical site is an area that lends itself to one or more procedures. It is considered to include a full quadrant, sextant or a group of teeth or in some cases a single tooth.) PERIODONTAL SURGERY, GINGIVAL CURETTAGE Surgical Curettage, to Include Definitive Root Planing Per sextant PERIODONTAL SURGERY, GINGIVOPLASTY Per sextant 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 Per sextant Gingivectomy, with Curettage Per sextant Gingival Fiber Incision (supra crestal fibrotomy) First tooth Each additional tooth Soft Tissue Re-contouring for Crown Lengthening Limited Re-contouring of Tissue per Tooth PERIODONTAL SURGERY, FLAP APPROACH Flap Approach, with Osteoplasty / Ostectomy Per sextant Flap Approach, with Curettage of Osseous Defect Per sextant Flap Approach, with Curettage of Osseous Defect and Osteoplasty Per sextant I.C. Flap Approach, Exploratory (for diagnosis) Per site Flap Approach, with Osteoplasty / Ostectomy for Crown Lengthening Per site

42 PERIO 31 PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts, Soft Tissue, Pedicle (including apically or lateral sliding and rotated flaps) Per site Periosteal Stimulation in Addition to I.C. Grafts, Soft Tissue, Pedicle (coronally positioned) Per site Periosteal Stimulation in Addition to I.C. Grafts, Free Soft Tissue Per site Grafts, Free Connective Tissue (for root coverage) Per site Grafts, Osseous, Allograft (including flap entry and closure) Per site + E PERIODONTAL SURGERY, MISCELLANEOUS PROCEDURES Proximal Wedge Procedure (as a separate procedure) With Flap Curettage, per site With Flap Curettage and Ostectomy / Osteoplasty, per site Post Surgical Periodontal Treatment Visit per Dressing Change One unit of time Two units Three units Each additional unit over three Periodontal Abscess or Pericoronitis (includes any of the following procedures: lancing, scaling, curettage, surgery or medication) One unit of time Two units Three units Four units Each additional unit over four 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) PERIODONTAL SPLINT OR LIGATION, PROVISIONAL, INTRA CORONAL NOTE: This procedure is in addition to the usual code for the tooth preparation on either side of the joint "A" Splint (acrylic, composite or amalgam, plus knurled wire) Per joint + E 60.00

43 PERIO PERIODONTAL SPLINT OR LIGATION, PROVISIONAL, EXTRA CORONAL Bonded Joint Restorations Per joint (may include reinforcement) + E Bonded, Interproximal Enamel Splint Per joint Wire Ligation Per joint Wire Ligation, Acrylic Covered Per joint Cast / Soldered / Ceramic / Polymer Glass, Splint, Bonded Per Abutment + L Removal of Fixed Periodontal Splints One unit of time Each additional unit of time ROOT PLANING, PERIODONTAL Root Planing One unit of time Two units Three units Four units Five units Six units One half unit of time Each additional unit over six CHEMOTHERAPEUTIC AND/OR ANTIMICROBIAL AGENTS Chemotherapeutic and/or Antimicrobial Agents, Topical Application One unit of time Each additional unit of time Chemotherapeutic and/or Antimicrobial Agents, Intra-sulcular application One unit of time + E Each additional unit of time + E 46.00

44 PROSTHODONTICS - REMOVABLE PROS-REM 33 DENTURES, COMPLETE (includes: impressions, initial and final jaw relation records, try-in evaluation and check records, insertion and adjustments, including three months post-insertion care) DENTURES, COMPLETE, STANDARD Maxillary + L Mandibular + L DENTURES, COMPLETE, COMPLEX (includes remounted equilibration on a semi-adjustable articulator) Maxillary + L Mandibular + L DENTURES, SURGICAL, STANDARD (IMMEDIATE) (includes first tissue conditioner, but not a processed reline) Maxillary + L Mandibular + L DENTURES, COMPLETE, PROVISIONAL Maxillary + L Mandibular + L Maxillary plus Mandibular (combined) + L DENTURES, COMPLETE, OVERDENTURES Dentures, Complete, Overdentures, Tissue Borne, Supported by Natural Teeth with or without Coping Crowns, No Attachments Maxillary + L Mandibular + L Maxillary plus Mandibular (combined) + L I.C. Dentures, Complete, Overdentures (immediate), Tissue Borne, Supported by Natural Teeth with or without Coping Crowns, No Attachments (includes first tissue conditioner, but not a processed reline) Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Complete, Overdentures, Tissue Borne, with Independent Attachments Secured to Natural Teeth with or without Coping Crowns Maxillary + L Mandibular + L Maxillary plus Mandibular (combined) + L I.C.

45 PROS-REM DENTURES, PARTIAL, ACRYLIC Dentures, Partial, Acrylic Base (Provisional) (with or without clasps) Maxillary + L Mandibular + L Dentures, Partial, Acrylic Base (immediate) (includes first tissue conditioner, but not a processed reline) Maxillary + L Mandibular + L Maxillary plus Mandibular (combined) + L I.C. Dentures, Partial, Acrylic, with Metal Wrought / Cast Clasps and/or Rests Maxillary + L Mandibular + L Dentures, Partial, Acrylic, with Metal Wrought / Cast Clasps and/or Rests (immediate) (includes first tissue conditioner, but not a processed reline) Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Partial (flexible non metal, non acrylic) Maxillary + L Mandibular + L Maxillary plus Mandibular (combined) + L I.C. Dentures, Partial, Overdentures, Acrylic, with Cast / Wrought Clasps and/or Rests Supported by Natural Teeth with or without Coping Crowns, No Attachments Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Partial, Overdentures (Immediate), Acrylic, with Cast / Wrought Clasps and/or Rests Supported by Natural Teeth with or without Coping Crowns, No Attachments (includes first tissue conditioner, but not a processed reline) Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Partial, Overdentures, Acrylic, with Cast / Wrought Clasps and/or Rests with Independent Attachments, Secured by Attachments to Natural Teeth with or without Coping Crowns Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C.

46 PROS-REM 35 Dentures, Partial, Overdentures, Acrylic, with Cast / Wrought Clasps and/or Rests, with Retention from a Retentive Bar, Secured to Coping Crowns, Supported by Natural Teeth (see for Retentive Bar) Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. DENTURES, PARTIAL, CAST WITH ACRYLIC BASE Dentures, Partial, Free End, Cast Frame / Connector, Clasps and Rests Maxillary + L Mandibular + L Altered Cast Impression Technique in Conjunction with and L Dentures, Partial, Tooth Borne, Cast Frame / Connector, Clasps and Rests Maxillary + L Mandibular + L Dentures, Partial, Cast, Precision Attachments Maxillary + L 1, Mandibular + L 1, Dentures, Partial, Cast, Overdentures, Supported by Natural Teeth with or without Coping Crowns, No Attachments Maxillary + L Mandibular + L Altered Cast Impression Technique done in Conjunction with and L Dentures, Partial, Cast, Overdentures (Immediate), Supported by Natural Teeth with or without Coping Crowns, No Attachments (includes first tissue conditioner, but not a processed reline) Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C Altered Cast Impression Technique done in conjunction with above I.C. mentioned codes Dentures, Partial, Cast, Overdentures, with Independent Attachments Secured to Natural Teeth, with or without Coping Crowns Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Partial, Cast, Overdentures, with Retention from a Retentive Bar, Secured to Coping Crowns Supported by Natural Teeth (see for Retentive Bar) Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C.

47 PROS-REM DENTURES, ADJUSTMENTS (after three months insertion or by other than the dentist providing prosthesis) DENTURE ADJUSTMENTS, PARTIAL OR COMPLETE DENTURE, MINOR One unit of time + L Two units + L Each additional unit over two DENTURE ADJUSTMENTS, PARTIAL OR COMPLETE DENTURE, REMOUNT AND OCCLUSAL EQUILIBRATION Maxillary + L Mandibular + L Maxillary plus Mandibular (combined) + L DENTURES, REPAIRS / ADDITIONS DENTURES, REPAIRS, COMPLETE DENTURE, NO IMPRESSION REQUIRED Maxillary + L Mandibular + L DENTURES, REPAIRS, COMPLETE DENTURE, IMPRESSION REQUIRED Maxillary + L Mandibular + L DENTURES, REPAIRS / ADDITIONS, PARTIAL DENTURE, NO IMPRESSION REQUIRED Maxillary + L Mandibular + L DENTURES, REPAIRS / ADDITIONS, PARTIAL DENTURE, IMPRESSION REQUIRED Maxillary + L Mandibular + L DENTURES / IMPLANT RETAINED PROSTHESIS, PROPHYLAXIS AND POLISHING One unit of time + L Each additional unit of time DENTURES, REPLICATION, RELINING AND REBASING DENTURES REPLICATION, PROVISIONAL Denture, Replication, Complete Denture, Provisional (no intra-oral impression required) Maxillary + L Mandibular + L DENTURES, RELINING (does not include remount - see series) Denture, Reline, Direct, Complete Denture Maxillary Mandibular

48 PROS-REM 37 Denture, Reline, Direct, Partial Denture Maxillary Mandibular Denture, Reline, Processed, Complete Denture Maxillary + L Mandibular + L Denture, Reline, Processed, Partial Denture Maxillary + L Mandibular + L DENTURES, REBASING (where the vestibular tissue-contacting surfaces are modified) Denture, Rebase, Complete Denture Maxillary + L Mandibular + L Denture, Rebase, Partial Denture Maxillary + L Mandibular + L DENTURES, REMAKE Denture, Remake, Using Existing Framework, Partial Denture (equilibration) Maxillary + L Mandibular + L DENTURES, THERAPEUTIC TISSUE CONDITIONING Denture, Therapeutic Tissue Conditioning, per Appointment Complete Denture Maxillary Mandibular Denture, Therapeutic Tissue Conditioning, per Appointment, Partial Denture Maxillary Mandibular PROSTHESIS, TEMPOROMANDIBULAR JOINT Exercisers, Trismus, Therapy + L Splints, Permanent Cast Occlusal + L

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50 PROSTHODONTICS - FIXED PROS-FIXED 39 FIXED BRIDGES (each abutment, each retainer and each pontic constitutes a separate unit in a bridge, with a separate code number) PONTICS, BRIDGE PONTICS, CAST METAL Pontics, Cast Metal + L Pontics, Cast Metal Framework with Separate Porcelain / Ceramic / I.C. Polymer Glass Jacket Pontic + L Pontics, Prefabricated Attachable Facing + L Pontics, Retentive Bar, Pre-fabricated or Custom (Dolder or Hader) I.C. Bar, Attached to Retainer + L + E Pontics, Retentive Bar, Pre-fabricated or Custom (Dolder or Hader) I.C. Bar, Attached to Implant-supported Retainer to Retain Removable Prosthesis, Each Bar + L + E PONTICS, PORCELAIN / CERAMIC / POLYMER GLASS Pontics, Porcelain / Ceramic / Polymer Glass, Fused to Metal + L Pontics, Porcelain / Ceramic / Polymer Glass, Aluminous + L PONTICS, ACRYLIC / COMPOSITE / COMPOMER Pontics, Acrylic / Composite / Compomer, Processed to Metal + L Pontics, Acrylic / Composite / Compomer, Indirect (provisional) + L PONTICS, NATURAL TOOTH Pontics, Natural Tooth Crown, Direct, Bonded to Adjacent Teeth (provisional) RECONTOURING OF RETAINERS / PONTICS (of existing bridgework) One unit of time Each additional unit of time MASTER CAST TECHNIQUES MASTER CAST, TECHNIQUES, MAXILLO-MANDIBULAR REGISTRATIONS Master Cast Techniques, Arbitrary Terminal Hinge Axis Registration and Transfer One unit of time + L Each additional unit of time + L 70.00

51 PROS-FIXED MASTER CAST MOUNTING TECHNIQUES Master Cast Mounting with Arbitrary Facebow Transfer One unit of time + L I.C. Master Cast Gnathological Wax-up One unit of time + L REPAIRS, REPLACEMENT REPAIRS Replace Broken Prefabricated Attachable Facings One unit of time + L Two units + L Three units + L Each additional unit over three + L REPAIRS, REMOVAL OF EXISTING FIXED BRIDGE / PROSTHESIS Repairs, Removal, Fixed Bridge / Prosthesis - to be recemented One unit of time Two units Three units Four units Each additional unit over four Repairs, Removal, Fixed Bridge / Prosthesis - To be replaced by a new prosthesis One unit of time Two units Three units Four units Each additional unit over four Repairs, Sectioning of an Abutment or a Pontic plus Polishing Remaining Portion (existing bridge) One unit of time Two units Three units Four units Each additional unit over four REPAIRS, REINSERTION / RECEMENTATION (+L where laboratory charges are incurred during repair of bridge) One unit of time + L Two units + L Three units + L Four units + L Each additional unit over four + L 60.00

52 PROS-FIXED 41 Repairs, Re-insertion / Recementation, Implant-supported Bridge / Prosthesis One unit of time + L and/or +E I.C Two units + L and/or + E I.C Three units + L and/or + E I.C Four units + L and/or + E I.C Each additional unit over four + L and/or + E I.C. REPAIRS, FIXED BRIDGE / PROSTHESIS Repairs, Fixed Bridge / Prosthesis, Porcelain / Ceramic / Polymer Glass / Acrylic / Composite / Compomer, Direct First tooth I.C Each additional tooth I.C. Repairs, Solder Indexing to Repair Broken Solder Joint One unit of time + L Each additional unit of time + L Repair Fractured Porcelain / Metal Pontic with Telescoping Type Crown (pontic prepared, impression made and processed crown seated over metal) First pontic + L I.C Each additional pontic + L I.C. FIXED BRIDGE RETAINERS RETAINERS, ACRYLIC / COMPOSITE / COMPOMER, WITH OR WITHOUT CAST OR PREFABRICATED METAL BASES Retainer, Acrylic, Composite / Compomer, Indirect + L I.C Retainer, Acrylic / Composite / Compomer, Direct (provisional during healing, done at chairside) + E Retainer, Composite / Compomer, Resin / Acrylic, Processed to Cast Metal, Indirect + L Retainer, Acrylic / Composite / Compomer, Two Surface Inlay, Bonded I.C. Indirect + L Retainer, Acrylic / Composite / Compomer, Three Surface Inlay, Bonded I.C. Indirect + L Retainer, Acrylic / Composite / Compomer, Onlay, Bonded, Indirect + L I.C. RETAINERS, PORCELAIN / CERAMIC / POLYMER GLASS, FULL COVERAGE Retainer, Porcelain / Ceramic / Polymer Glass, Full Coverage + L

53 PROS-FIXED RETAINERS, PORCELAIN / CERAMIC / POLYMER GLASS, FUSED TO METAL BASE Retainer, Porcelain / Ceramic / Polymer Glass, Fused to Metal Base + L Retainer, Porcelain / Ceramic / Polymer Glass, Fused to Metal Base, Complicated + L Semi-precision Rest (Interlock) (in addition to retainer) + L + E I.C Semi-precision or Precision Attachment, RPD Retainer (in addition I.C. to retainer) + L + E Retainer, Porcelain / Ceramic / Polymer Glass, Two Surface Inlay, I.C. Bonded + L Retainer, Porcelain / Ceramic / Polymer Glass, Three Surface Inlay, I.C. Bonded + L Retainer, Porcelain / Ceramic / Polymer Glass, Onlay, Bonded + L I.C. RETAINERS, FULL, CAST METAL Retainer, Full, Cast Metal + L RETAINERS, 3/4, CAST METAL Retainer, 3/4, Cast Metal + L Semi-precision Rest (interlock) (in addition to I.C. retainer) + L + E Semi-precision or Precision Attachments, RPD Retainer (in addition I.C. to retainer) + L + E Retainers, Cast Metal, Inlay (used with broken stress technique) Retainer, Cast Metal Inlay, Two Surfaces + L Retainer, Cast Metal Inlay, Three or More Surfaces + L Retainers, Cast Metal, Onlay (internal retention type) Retainer, Cast Metal, Onlay + L Retainers, Cast Metal, Onlay (bonded external retention / partial coverage, e.g. Maryland Bridge) Retainer, Cast Metal, Onlay, with or without Perforations, Bonded to Abutment Tooth (pontic extra) + L FIXED PROSTHETICS, ABUTMENTS / RETAINERS, MISCELLANEOUS SERVICES Abutment Preparation under Existing Partial Denture Clasp (in addition to retainer codes) + L Telescoping Crown Unit + L I.C. `

54 PROS-FIXED 43 FIXED PROSTHETICS, OTHER SERVICES FIXED PROSTHETICS, SPLINTING Splinting, for Extensive or Complicated Restorative I.C. Dentistry (per tooth) + L FIXED PROSTHETICS, RETENTIVE PINS (for retainers in addition to restoration) One pin / restoration + L Two pins / restoration + L Three pins / restoration + L Four pins / restoration + L Five pins or more / restoration + L STAINING, PORCELAIN (chairside) One unit of time Each additional unit of time FIXED PROSTHETICS, PROVISIONAL COVERAGE (in extensive or complicated restorative dentistry) Abutment Tooth + L Pontic + L FIXED PROSTHODONTIC FRAMEWORKS, OSSEO-INTEGRATED IMPLANT-SUPPORTED Fixed Prosthodontic Frameworks, Osseo-integrated, Attached with Screws and Incorporating Teeth (denture teeth and acrylic) Maxillary + L I.C Mandibular + L I.C.

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56 ORAL AND MAXILLOFACIAL SURGERY SURGERY 45 The following surgical services include necessary local anesthetic, removal of excess gingival tissue, suturing and one post-operative treatment, when required. A surgical site is an area that lends itself to one or more procedures. It is considered to include a full quadrant, sextant or a group of several teeth, or in some cases a single tooth. REMOVALS (EXTRACTIONS), ERUPTED TEETH REMOVALS, ERUPTED TEETH, UNCOMPLICATED Single tooth, uncomplicated Each additional tooth, same quadrant, same appointment REMOVALS, ERUPTED TEETH, COMPLICATED Odontectomy (extraction), Erupted Tooth, Surgical Approach, Requiring Surgical Flap and/or Sectioning of Tooth Single tooth Each additional tooth, same quadrant Requiring Elevation of a Flap, Removal of Bone and/or Sectioning of Tooth for Removal of Tooth Single tooth Each additional tooth, same quadrant REMOVALS (EXTRACTIONS), SURGICAL REMOVALS, IMPACTIONS, SOFT TISSUE COVERAGE Removal, Impaction, Requiring Incision of Overlying Soft Tissue and Removal of the Tooth Single tooth Each additional tooth, same quadrant REMOVALS, IMPACTIONS, INVOLVING TISSUE AND / OR BONE COVERAGE Removal, Impaction, Requiring Incision of Overlying Soft Tissue, Elevation of a Flap and EITHER Removal of Bone and Tooth OR Sectioning and Removal of Tooth Single tooth Each additional tooth, same quadrant Removal, Impaction, Requiring Incision of Overlying Soft Tissue, Elevation of a Flap, Removal of Bone AND Sectioning of Tooth for Removal Single tooth Each additional tooth, same quadrant

57 SURGERY Removal, Impaction, Requiring Incision of Overlying Soft Tissue, Elevation of a Flap, Removal of Bone AND/OR Sectioning of Tooth for Removal AND/OR Presents Unusual Difficulties and Circumstances Single tooth Each additional tooth, same quadrant REMOVALS (EXTRACTIONS), RESIDUAL ROOTS Removal, Residual Roots, Erupted First tooth Each additional tooth, same quadrant Removal, Residual Roots, Soft Tissue Coverage First tooth Each additional tooth, same quadrant Removal, Residual Roots, Bone Tissue Coverage First tooth Each additional tooth, same quadrant ALVEOLAR BONE PRESERVATION Alveolar Bone Preservation - Autograft First tooth I.C Each additional tooth I.C. SURGICAL EXPOSURES OF TEETH Surgical Exposure, Unerupted, Uncomplicated, Soft Tissue Coverage (includes operculectomy) Single tooth Each additional tooth, same quadrant Surgical Exposure, Complex, Hard Tissue Coverage Single tooth Each additional tooth, same quadrant Surgical Exposure, Unerupted Tooth, with Orthodontic Attachment Single tooth Each additional tooth, same quadrant ENUCLEATION, SURGICAL Unerupted Tooth and Follicle First tooth Each additional tooth, same quadrant REMODELLING AND RECONTOURING ORAL TISSUES IN PREPARATION FOR REMOVABLE PROSTHESES (To include codes 73111, 73121, , 73161, ) ALVEOLOPLASTY (bone remodelling of ridge with soft tissue revisions) Alveoloplasty, in Conjunction with Extractions Per sextant 70.00

58 SURGERY 47 Alveoloplasty, not in Conjunction with Extractions Per sextant Excision of Bone Torus Palatinus, Excision Torus Mandibularis, Unilateral, Excision Torus Mandibularis, Bilateral, Excision Removal of Bone, Exostosis, Multiple Per quadrant Reduction of Bone, Tuberosity Unilateral, Reduction Bilateral, Reduction GINGIVOPLASTY AND / OR STOMATOPLASTY, ORAL SURGERY Independent Procedure Per sextant Miscellaneous Procedures Excision of Vestibular Hyperplasia, per sextant Surgical Shaving of Papillary Hyperplasia of the Palate Excision of Pericoronal Gingiva (for retained tooth / implant), per tooth / implant Removals, Tissue, Hyperplastic (includes the incision of the mucous membrane, the dissection and removal of hyperplastic tissue, the replacing and adapting of the mucous membrane) Per sextant VESTIBULOPLASTY Vestibuloplasty, Sub-mucous Per sextant SURGICAL EXCISIONS (not in conjunction with tooth removal, including biopsy) SURGICAL EXCISIONS, TUMOURS, BENIGN Tumours, Benign, Scar Tissue, Inflammatory or Congenital Lesions of Soft Tissue of the Oral Cavity cm and under cm Tumours, Benign, Bone Tissue cm and under cm

59 SURGERY SURGICAL EXCISION, CYSTS / GRANULOMAS (based on cyst size) Enucleation of Cyst / Granuloma, Odontogenic and Non-Odontogenic, Requiring Prior Removal of Bony Tissue and Subsequent Suture(s) cm and under cm Excision of Cyst cm and under cm cm SURGICAL INCISIONS SURGICAL INCISION AND DRAINAGE AND / OR EXPLORATION, INTRAORAL Surgical Incision and Drainage and / or Exploration, Intraoral Soft Tissue Intraoral, Surgical Exploration, Soft Tissue Intraoral, Abscess, Soft Tissue Surgical Incision and Drainage and / or Exploration, Intraoral Hard Tissue Intraoral, Abscess, Hard Tissue, Trephination and Drainage lntraoral, Surgical Exploration, Hard Tissue FRACTURES, REDUCTIONS, ALVEOLAR FRACTURES, TREATMENT OF Fracture, Alveolar, Debridement, Teeth Removed cm or less Reduction, Alveolar, Closed, with Teeth (fixation extra) cm or less Reduction, Alveolar, Open, with Teeth (fixation extra) cm and less Replantation, Avulsed Tooth / Teeth (including splinting) Replantation, first tooth Each additional tooth Repositioning of Traumatically Displaced Teeth One unit of time Two units of time Each additional unit over two 77.00

60 SURGERY 49 Repairs, Lacerations, Uncomplicated, Intraoral or Extraoral cm or less cm FRENECTOMY / FRENOPLASTY FRENECTOMY Upper Labial Lower Labial TEMPOROMANDIBULAR JOINT DYSFUNCTIONS, TREATMENT OF TEMPOROMANDIBULAR JOINT, DISLOCATION MANAGEMENT OF TMJ, Dislocation, Closed Reduction, Uncomplicated TMJ, Manipulation, under Anesthesia I.C. ORAL SURGERY PROCEDURES, OTHER POST SURGICAL CARE (required by complications and unusual circumstances, refer to comment under section heading 70000) Post Surgical Care, Subsequent to Initial Post Surgical Treatment, Minor, by Treating Dentist Post Surgical Care, Minor, by Other than Treating Dentist Post Surgical Care, Major, by Other than Treating Dentist IMPLANTOLOGY (includes placement of implant, post-surgical care, uncovering and placement of attachment but not prosthesis) Implants, Osseointegrated, Root Form, More Surgical Installation of Implant with Cover Screw - per implant + E Surgical Installation of Implant with Healing Transmucosal Element per implant + E Surgical Installation of Implant with Final Transmucosal Element I.C. per implant + E Surgical Re-entry, Removal of Healing Screw and Placement of Healing Transmucosal Element per implant + E Surgical Re-entry, Removal of Healing Screw and Placement of Final Standard Transmucosal Element per implant + E Surgical Re-entry, Removal of Healing Screw and Placement of Final Custom Transmucosal Element per implant + E + L Implants, Osseointegrated, Provisional Installation of Provisional Implant, per implant + E I.C Removal of Provisional Implant, per implant + E I.C. Implants, Removal of Uncomplicated, per implant I.C Complicated, per implant I.C.

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62 ORTHODONTICS ORTHO 51 ORTHODONTIC SERVICES, MISCELLANEOUS ORTHODONTIC OBSERVATIONS AND ADJUSTMENTS Orthodontic Observation for Tooth Guidance per Appointment (i.e., tooth position, eruption sequence, serial extraction supervision, etc.) Orthodontic Observation and Adjustment to Orthodontic Appliances and/or the Reduction of Proximal Surfaces of Teeth per Appointment Repairs to Removable or Fixed Appliances (not including removal and recementation) One unit of time + L Two units + L Each additional unit over two + L Alterations to Removable or Fixed Appliances One unit of time + L Two units + L Each additional unit over two + L Recementation of Fixed Appliances One unit of time Each additional unit Separation (except where included in the fabrication of an appliance) One unit of time Removal of Fixed Orthodontic Appliances (by a practitioner other than the original treating Practice or Practitioner) One unit of time Each additional unit APPLIANCES, REMOVABLE APPLIANCES, ACTIVE, FOR TOOTH GUIDANCE OR MINOR TOOTH MOVEMENT Appliances, Removable, Space Regaining Appliance, Maxillary, Bilateral + L Appliance, Mandibular, Bilateral + L Appliances, Removable, Cross-Bite Correction Appliance, Maxillary, Simple + L Appliance, Mandibular, Simple + L Appliances, Removable, Dental Arch Expansion Appliance, Maxillary, Simple + L Appliance, Mandibular, Simple + L

63 ORTHO Appliances, Removable, Closure of Diastemas Appliance, Maxillary, Simple + L Appliance, Mandibular, Simple + L Appliances, Removable, Alignment of Anterior Teeth Appliance, Maxillary, Simple + L Appliance, Mandibular, Simple + L APPLIANCES, FIXED OR CEMENTED Appliances, Fixed, Space Regaining (e.g., lingual or labial arch with molar bands, tubes, locks) Appliance, Maxillary + L Appliance, Mandibular + L Appliances, Fixed, Space Regaining, Unilateral Appliance, Maxillary + L Appliance, Mandibular + L Appliances, Fixed, Cross-Bite Correction - Anterior Appliance, Maxillary + L Appliance, Mandibular + L Appliances, Fixed, Cross-Bite Correction - Posterior Appliance, Maxillary + L Appliance, Mandibular + L Appliance, Two-Molar Band, Hooked and Elastics + L Appliances, Fixed, Dental Arch Expansion Appliance, Maxillary + L Appliance, Mandibular + L Appliance, Maxillary, Rapid Expansion + L Appliance, Headgear + L Appliances, Fixed, Closure of Diastemas Appliance, Maxillary, Simple + L Appliance, Mandibular, Simple + L Appliances, Fixed, Alignment of Incisor Teeth Appliance, Maxillary, Simple + L Appliance, Mandibular, Simple + L Appliances, Fixed, Mechanical Eruption of Tooth / Teeth Appliance, Maxillary Impaction + L Appliance, Mandibular Impaction + L

64 ORTHO 53 APPLIANCES, RETENTION, ORTHODONTIC RETAINING APPLIANCES APPLIANCES, REMOVABLE, RETENTION Appliance, Maxillary + L Appliance, Mandibular + L Appliance, Tooth Positioner + L APPLIANCES, FIXED / CEMENTED, RETENTION Appliance, Maxillary + L Appliance, Mandibular + L COMPREHENSIVE ORTHODONTIC TREATMENT CASE TYPE - Fixed Appliances (includes formal full banded treatment and retention) PERMANENT DENTITION Class I Malocclusion + L I.C Class II Malocclusion + L I.C Class III Malocclusion + L I.C Malocclusion not Requiring Complete Banding + L I.C. MIXED DENTITION Class I Malocclusion + L I.C Class II Malocclusion + L I.C Class III Malocclusion + L I.C. CASE TYPE - Removable Appliances (includes removable appliance therapy and retention; e.g. functional appliances for mixed and primary dentition) PERMANENT DENTITION Class I Malocclusion + L I.C Class II Malocclusion + L I.C Class III Malocclusion + L I.C. MIXED DENTITION Class I Malocclusion + L I.C Class II Malocclusion + L I.C Class III Malocclusion + L I.C. PRIMARY DENTITION Class I Malocclusion + L I.C Class II Malocclusion + L I.C Class III Malocclusion + L I.C.

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66 ADJUNCTIVE GENERAL SERVICES ADJ 55 UNCLASSIFIED TREATMENT, DENTAL PAIN UNCLASSIFIED TREATMENTS Emergency Services not Otherwise Specified in Guide One unit of time Two units Three units Each additional unit over three UNCLASSIFIED TREATMENT, UNUSUAL TIME AND RESPONSIBILITIES Unusual Time and Responsibility Requirement, in Addition to Usual Procedures in Guide One unit of time Two units Three units Each additional unit over three Management of Exceptional Patient One unit of time Two units Three units Four units Each additional unit over four ANESTHESIA ANESTHESIA, LOCAL (not in conjunction with operative or surgical procedures, includes pre-anesthetic evaluation and post-anesthetic evaluation and post-anesthetic follow-up) Regional Block Anesthesia Trigeminal Division Block 39.00

67 ADJ ANESTHESIA, DEEP SEDATION (A controlled state of depressed consciousness accompanied by partial loss of protective reflexes, including inability to respond purposefully to verbal command. This state applies to any technique that has depressed the patient beyond conscious sedation except general anesthesia. Any technique leading to these conditions in a patient including neuroleptanalgesia or anesthesia, regardless of route of administration, would fall within this category of service (includes preanesthetic evaluation and post anesthetic follow-up) One unit of time I.C Two units I.C Three units I.C Four units I.C Five units I.C Six units I.C Seven units I.C Eight units I.C Each additional unit over eight I.C. ANESTHESIA, CONSCIOUS SEDATION (A medically controlled state of depressed consciousness that allows protective reflexes to be maintained, retains the patient's ability to maintain a patent airway independently and continuously and permits appropriate response by the patient to physical stimulation or verbal command, eg. "open your eyes" (includes pre-anesthetic evaluation and post anesthetic followup). Any technique leading to these conditions in a patient would fall within this category of service. Conscious sedation is a varied technique which can require different levels of monitoring, in accordance with the Regulatory Authority Guidelines for the Use of Sedation and General Anesthesia in Dental Practice. The Guidelines should be consulted and observed. Nitrous Oxide (Time is measured from the placement of the inhalation device and terminates with the removal of the inhalation device.) One unit of time Two units Three units Four units Five units Six units Seven units Eight units Each additional unit over eight 28.00

68 ADJ 57 Oral Sedation (sedation sufficient to require monitored care) Time is to be measured from the start of patient monitoring to release from the treatment / recovery room.) One unit of time I.C Two units I.C Three units I.C Four units I.C Five units I.C Six units I.C Seven units I.C Eight units I.C Each additional unit over eight I.C. Nitrous Oxide with Oral Sedation (Time is measured with the administration of nitrous oxide and terminates with the release of the patient from the treatment / recovery room.) One unit of time I.C Two units I.C Three units I.C Four units I.C Five units I.C Six units I.C. Parenteral Conscious Sedation (regardless of method - IM or IV) One unit I.C Two units I.C Three units I.C Four units I.C Five units I.C Six units I.C. NON PHARMACOLOGICAL PAIN CONTROL AND PATIENT MANAGEMENT Hypnosis One unit of time Two units Three units Four units Each additional unit over four Acupuncture One unit of time Two units Three units Four units Each additional unit over four Electronic Dental Anesthesia One unit of time I.C Two units I.C Three units I.C Four units I.C Each additional unit over four I.C.

69 ADJ PROFESSIONAL COMMUNICATIONS PROFESSIONAL SERVICES Consultation with Member of the Profession or other Healthcare Providers, in or out of the office One unit of time + E Two units + E Each additional unit over two + E Dental Legal Letters, Reports and Opinions Dental-legal report - a short factually written or verbal I.C. communication given to any lay person (e.g. lawyer, insurance representative, local, municipal or government agency, etc.) in relation to the patient with prior patient approval Dental-legal report - a comprehensive written report with patient I.C. approval, on symptoms, history and records giving diagnosis, treatment, results and present condition. The report is a factual summary of all information available on the case and could contain prognostic information regarding patient response Dental-legal opinion - a comprehensive written report primarily I.C. in the field of expert opinion. The report may be an opinion regarding the possible course of events (when these cannot be determined factually), with possible long term consequences and complications in the development of the conditions. The report will require expert knowledge and judgement with respect to the facts leading to a detailed prognosis. Consultation and/or Participation During Autopsy (other than forensic) One unit of time + E Two units + E PATIENT FILE MANAGEMENT (not to include predeterminations) Duplication and transfer of patient's dental record at request of the patient + E CLAIM FORMS AND TREATMENT FORMS Completing CDA "Blank" Approved Standard Claim Forms No Fee Upon Request, Providing a Written Treatment Plan / Outline for a No Fee Patient Similar to the Example in the CDA Policy Manual on Claim Form Completion Completing Prepaid Claim Forms which do not Conform with Code 93301

70 ADJ 59 For Extraordinary Time Spent on the Telephone with Third-Party Administrators or their Agents, in Relation to Claim Forms / Treatment Plan Forms, or the Claim Problem of the Patient (plus long distance charges) One unit of time + E Two units + E Each additional unit over two For Extraordinary Time Spent, in Forwarding Predetermination Records, in Predetermination Situations, to Third Parties plus Expenses (i.e. registration, postage, etc.) One unit of time + E Payment for Orthodontic Treatment in Progress I.C. PROFESSIONAL VISITS HOUSE CALLS House Call, Non Emergency Visit (in addition to procedures performed) House Call, Emergency Visit (in addition to procedures performed) - when one must immediately leave home, office or hospital OFFICE OR INSTITUTIONAL VISITS Office or Institutional Visit, Unscheduled, after Regular Scheduled Office Hours (in addition to services performed) Missed or Cancelled Appointment, with Insufficient Notice During Regular Scheduled Office Hours Being a Special Appointment Outside Regularly Scheduled Office Hours Travelling Expenses I.C Professional visits out of the office plus actual services performed I.C. + E (out-of-pocket expense, etc.) COURT APPEARANCES AND / OR PREPARATION Preparation as an Expert Witness One unit of time I.C Two units I.C Three units I.C Four units I.C Each additional unit over four I.C. Court Appearance as an Expert Witness One half day Full day 1,250.00

71 ADJ FORENSIC DENTAL SERVICES FORENSIC SERVICES, MISCELLANEOUS Identification - Opinion as an Expert Assisting in Civil or I.C. Criminal Cases + E Written Odontology Report + E I.C. DRUGS / MEDICATION, DISPENSING PRESCRIPTIONS Prescription, Emergency Dispensing, Non Emergency + E (e.g. fluorides, vitamins, other drugs/medications) INJECTIONS, THERAPEUTIC Intramuscular Drug Injection + E Intravenous Drug Injection + E Intralesional Delivery + E BLEACHING, VITAL Bleaching, Vital, In Office One unit of time Two units Three units Each additional unit over three Bleaching, Vital, Home (includes the fabrication of bleaching trays, dispensing the system and follow-up care) Maxillary Arch + L and/or + E I.C Mandibular Arch + L and/or + E I.C. Micro-Abrasion One unit of time Two units Three units Four units Each additional unit over four 62.00

72 ADJ 61 LABORATORY AND EXPENSE PROCEDURES (This code is used in conjunction with the "+ L" and "+ E" designation following specific codes in the guide. The addition of these codes is to facilitate computer or manual input for third party claims processing, personal records and statistics, providing one description for a specific procedure code). When filling out the third party claim forms, these codes must follow immediately after the corresponding dental procedure code carried out by the dentist, so as to correlate the lab expenses with the correct procedures " + L" Commercial Laboratory Procedures I.C. (A commercial laboratory is defined as an independent business which performs laboratory services and bills the dental practices for these services on a case by case basis) "+ L" In-Office Laboratory Procedures I.C. (An in-office laboratory is defined as a laboratory service(s) performed within the same business entity) "+ E" Additional Expense of Materials I.C. Applicable Taxes G.S.T. I.C P.S.T. I.C.

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74 IMPLANTS IMPLANTS 63 DIAGNOSTIC SERVICES 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 Duplication of each additional film 4.00 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. POSTS RESTORATIVE SERVICES Posts, Prefabricated, with Non-bonded Core for Crown Restoration [including pin(s) where applicable] + E One post, with Non-bonded Composite Core and Pin(s) + E MESOSTRUCTURES (a separate component positioned between the head of an implant and the final restoration, retained by either a cemented post or screw) Mesostructures, Osseo-integrated Implant-supported Indirect, Angulated or Transmucosal Pre-fabricated Abutment, I.C. per implant + L + E Indirect, Custom Laboratory Fabricated, per implant + L + E I.C Direct (with intra-oral preparation), per implant site + E I.C. CROWNS, ACRYLIC / COMPOSITE / COMPOMER / CAST METAL BASE Crowns, Acrylic / Composite / Compomer / Cast Metal Base Implant-supported + L + E I.C. CROWNS, PORCELAIN / CERAMIC / POLYMER GLASS Crown, Porcelain / Ceramic / Polymer Glass, Implant-supported I.C. + L + E Crowns, Porcelain / Ceramic / Polymer Glass Fused to Metal Base Crown, Porcelain / Ceramic Fused to Metal Base, Implant- I.C. supported + L + E

75 IMPLANTS CROWNS, FULL, CAST METAL Crown, Full, Cast Metal, Implant-supported + L + E I.C. RESTORATIVE PROCEDURES, OVERDENTURES OVERDENTURES, DIRECT Implant-supported Prefabricated Attachment as an Overdenture I.C. Retentive Device, Direct + E OVERDENTURES, INDIRECT Coping Crowns, Cast Metal, No Attachments, Indirect No Attachment, Implant-supported, Indirect + L + E I.C. Coping Crowns, Cast Metal, with Attachments, Indirect Implant-supported with Attachment + L + E I.C. RESTORATIVE SERVICES, OTHER RECEMENTATION / REBONDING, INLAYS / ONLAYS / CROWNS VENEERS / POSTS / NATURAL TOOTH FRAGMENTS (single units only) (+ L where laboratory charges are incurred during repair of the unit) Re-Insertion / Recementation Implant-supported Crown One unit of time I.C Two units I.C Three units I.C Four units I.C. Removal, Implant-supported Crowns (single units only) One unit of time I.C Two units I.C Three units I.C Four units I.C. Removal, Mesostructure (to be reseated) One unit of time I.C Two units I.C Three units I.C Four units I.C. Removal of Compromised Mesostructure (to be replaced) One unit of time I.C Two units I.C Three units I.C Four units I.C.

76 IMPLANTS 65 Removal and Replacement of Healing Abutment with a New Healing Abutment (to stimulate improved gingival emergence profile) One unit of time + E I.C Two units + E I.C Three units + E I.C Four units + E I.C. PROSTHODONTICS - REMOVABLE DENTURES, COMPLETE, OVERDENTURES, TISSUE BORNE, SUPPORTED BY NATURAL TEETH OR IMPLANTS WITH OR WITHOUT COPING CROWNS, NO ATTACHMENTS Dentures, Complete, Overdentures, Tissue Borne, Supported by Implants with or without Coping Crowns, No Attachments Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Complete, Overdentures, Tissue Borne, Supported by a Combination of Natural Teeth and Implants with or without Coping Crowns, No Attachments Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. DENTURES, COMPLETE, OVERDENTURES (IMMEDIATE), TISSUE BORNE, SUPPORTED BY NATURAL TEETH OR IMPLANTS, WITH OR WITHOUT COPING CROWNS, NO ATTACHMENTS Dentures, Complete, Overdentures (Immediate), Tissue Borne, Supported by Implants with or without Coping Crowns, No Attachments (includes first tissue conditioner, but not a processed reline) Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Complete, Overdentures (Immediate), Tissue Borne, Supported by a Combination of Natural Teeth and Implants with or without Coping Crowns, No Attachments (includes first tissue conditioner, but not a processed reline) Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. DENTURES, COMPLETE, OVERDENTURES, TISSUE BORNE, SECURED BY ATTACHMENTS TO NATURAL TEETH OR IMPLANTS Dentures, Complete, Overdentures, Tissue Borne, with Independent Attachments Secured to Implants with or without Coping Crowns Maxillary + L Mandibular + L Maxillary plus Mandibular (combined) + L I.C.

77 IMPLANTS Dentures, Complete, Overdentures, Tissue Borne, with Independent Attachments Secured to a Combination of Natural Teeth and Implants with or without Coping Crowns Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Complete, Overdentures, Tissue Borne, with Retention from a Retentive Bar, Secured to Coping Crowns Supported by Natural Teeth Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Complete, Overdentures, Tissue Borne, with Retention from a Retentive Bar, Secured to Coping Crowns Supported by Implants Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Complete, Overdentures, Tissue Borne, with Retention from a Retentive Bar, Secured to Coping Crowns Supported by a Combination of Natural Teeth and Implants (see for Retentive Bar) Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. DENTURES, PARTIAL, OVERDENTURES, ACRYLIC Dentures, Partial, Overdentures, Acrylic, with Cast / Wrought Clasps and/or Rests, Supported by Implants with or without Coping Crowns, No Attachments Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Partial, Overdentures, Acrylic, with Cast / Wrought Clasps and/or Rests, Supported by a Combination of Natural Teeth and Implants with or without Coping Crowns, No Attachments Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Partial, Overdentures (Immediate), Acrylic, with Cast / Wrought Clasps and/or Rests Supported by Implants with or without Coping Crowns, No Attachments (includes first tissue conditioner, but not a processed reline) Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C.

78 IMPLANTS 67 Dentures, Partial, Overdentures (Immediate), Acrylic, with Cast / Wrought Clasps and/or Rests Supported by a Combination of Natural Teeth and Implants, with or without Coping Crowns, No Attachments (includes first tissue conditioner, but not a processed reline) Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Partial, Overdentures, Acrylic, with Cast / Wrought Clasps and/or Rests, with Independent Attachments Secured to Implants with or without Coping Crowns Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Partial, Overdentures, Acrylic, With Cast / Wrought Clasps and/or Rests, with Independent Attachments Secured to a Combination of Natural Teeth and Implants, with or without Coping Crowns [used with (Cast Metal Coping Crowns), with or without Attachments] Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Partial, Overdentures, Acrylic, with Cast / Wrought Clasps and/or Rests, with Retention from a Retentive Bar, Secured to Coping Crowns, Supported by Implants (see for Retentive Bar) Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Partial, Overdentures, Acrylic, with Cast / Wrought Clasps and/or Rests, with Retention from a Retentive Bar, Secured to Coping Crowns Supported by a Combination of Natural Teeth and Implants (see for Retentive Bar) Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. DENTURES, PARTIAL, CAST, OVERDENTURES Dentures, Partial, Casts, Overdentures, Supported by Implants with or without Coping Crowns, No Attachments Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C Altered Cast Impression Technique Done in Conjunction with above I.C. mentioned codes

79 IMPLANTS Dentures, Partial, Casts, Overdentures, Supported by a Combination of Natural Teeth and Implants with or without Coping Crowns, No Attachments Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C Altered Cast Impression Technique Done in Conjunction with above I.C. mentioned codes Dentures, Partial, Cast, Overdentures (Immediate), Supported by Implants, with or without Coping Crowns, No Attachments (includes first tissue conditioner, but not a processed reline) Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C Altered Cast Impression Technique Done in Conjunction with above I.C. mentioned codes Dentures, Partial, Cast, Overdentures (Immediate), Supported by a Combination of Natural Teeth and Implants with or without Coping Crowns, No Attachments (includes first tissue conditioner, but not a processed reline) Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C Altered Cast Impression Technique Done in Conjunction with above I.C. mentioned codes Dentures, Partial, Cast, Overdentures, with Independent Attachments Secured to Implants, with or without Coping Crowns Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Partial, Cast, Overdentures, with Independent Attachments Secured to a Combination of Natural Teeth and Implants, with or without Coping Crowns Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Partial, Cast, Overdentures, with Retention from a Retentive Bar, Secured to Coping Crowns Supported by Implants (see for Retentive Bar) Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C. Dentures, Partial, Cast, Overdentures, with Retention from a Retentive Bar, Secured to Coping Crowns Supported by a Combination of Natural Teeth and Implants (see for Retentive Bar) Maxillary + L I.C Mandibular + L I.C Maxillary plus Mandibular (combined) + L I.C.

80 IMPLANTS 69 DENTURES / IMPLANT RETAINED PROSTHESIS, PROPHYLAXIS AND POLISHING One unit of time + L Each additional unit of time DENTURES, THERAPEUTIC TISSUE CONDITIONING Dentures, Tissue Conditioning, per Appointment, Complete Overdenture, Implant-supported Maxillary I.C Mandibular I.C Maxillary plus Mandibular (combined) I.C. Dentures, Tissue Conditioning, per Appointment, Partial Overdenture, Implant-supported Maxillary I.C Mandibular I.C Maxillary plus Mandibular (combined) I.C. PROSTHODONTICS - FIXED PONTICS, BRIDGE PONTICS, CAST METAL Pontics, Retentive Bar, Pre-fabricated or Custom (Dolder or Hader) I.C. Bar, Attached to Implant-supported Retainer to Retain Removable Prosthesis, Each Bar + L + E REPAIRS, REMOVAL OF EXISTING FIXED BRIDGE / PROSTHESIS Repairs, Removal of Fixed Bridge / Prosthesis, Implant-supported - to be Re-inserted One unit of time I.C Two units I.C Three units I.C Four units I.C Each additional unit over four I.C. Repairs, Removal, Fixed Bridge / Prosthesis, Implant-supported - to be Replaced by New Prosthesis One unit of time I.C Two units I.C Three units I.C Four units I.C Each additional unit over four I.C. Repairs, Reinsertion / Recementation, Implant-supported Bridge / Prosthesis One unit of time + L and/or + E I.C Two units + L and/or + E I.C Three units + L and/or + E I.C Four units + L and/or + E I.C Each additional unit over four + L and/or + E I.C.

81 IMPLANTS Repairs, Fixed Bridge / Prosthesis, Implant-supported, Direct Three units of time + E I.C Four units of time + E I.C. RETAINERS, ACRYLIC / COMPOSITE / COMPOMER, WITH OR WITHOUT CAST OR PREFABRICATED METAL BASES Retainers, Acrylic, Composite / Compomer, Implant-supported, I.C. Indirect + L Retainers, Acrylic, Composite / Compomer (provisional during healing, I.C. done at chairside), Implant-supported, Direct + E Retainers, Composite / Compomer, Resin / Acrylic, Processed to I.C. Metal, Indirect Implant-supported + L + E Retainers, Acrylic / Composite / Compomer, Prefabricated Metal I.C. Base, Provisional, Implant-supported, Direct + E Retainers, Acrylic / Composite / Compomer, Prefabricated Metal I.C. Base, Implant-supported, Provisional, Indirect + L + E RETAINERS, PORCELAIN / CERAMIC / POLYMER GLASS Retainers, Porcelain / Ceramic / Polymer Glass, Full Coverage, I.C. Implant-supported + L + E Retainers, Porcelain / Ceramic / Polymer Glass, Fused to Metal Base, I.C. Implant-supported + L + E RETAINERS, FULL, CAST METAL Retainers, Full, Cast Metal, Implant-supported + L + E I.C Retainers, Metal, Prefabricated or Custom Cast, Implant-supported, I.C. with or without Mesostructure with no Occlusal Component (see for Retentive Bar) + L + E FIXED PROSTHODONTIC FRAMEWORKS, OSSEO-INTEGRATED IMPLANT-SUPPORTED Fixed Prosthodontic Frameworks, Osseo-integrated, Attached with Screws and Incorporating Teeth (denture teeth and acrylic) Maxillary + L I.C Mandibular + L I.C.

82 IMPLANTS 71 ORAL SURGERY PROCEDURES, OTHER POST SURGICAL CARE (required by complications and unusual circumstances, refer to comment under section heading 70000) Post Surgical Care, Subsequent to Initial Post Surgical Treatment, Minor, by Treating Dentist Post Surgical Care, Minor, by Other than Treating Dentist Post Surgical Care, Major, by Other than Treating Dentist IMPLANTOLOGY (includes placement of implant, post-surgical care, uncovering and placement of attachment but not prosthesis) Implants, Osseointegrated, Root Form, More Surgical Installation of Implant with Cover Screw - per implant + E Surgical Installation of Implant with Healing Transmucosal Element - per implant + E Surgical Installation of Implant with Final Transmucosal Element per I.C. implant + E Surgical Re-entry, Removal of Healing Screw and Placement of Healing Transmucosal Element per implant + E Surgical Re-entry, Removal of Healing Screw and Placement of Final Standard Transmucosal Element per implant + E Surgical Re-entry, Removal of Healing Screw and Placement of Final Custom Transmucosal Element per implant + E + L Implants, Osseointegrated, Provisional Installation of Provisional Implant, per implant + E I.C Removal of Provisional Implant, per implant + E I.C. Implants, Removal of Uncomplicated, per implant I.C Complicated, per implant I.C.

83

84 INDEX NOVA SCOTIA DENTAL ASSOCIATION 2008 GUIDE ALPHABETIC INDEX OF CDA CODES AND LIST OF SERVICES 73 -A- "A" Splint, Abscess, Treatment of, , Abutments / Retainers - Fixed Prosthetics, Provisional Coverage, Fixed Prosthetics, Removal and Replacement, (Implant) Sectioning plus Polishing, Acid Etch, Techniques, Acrylics, use with, - Crowns, , 27511, (Implant) Facings, Replacements, Prefabricated Attachable, Partial Dentures, , (Implant) Pontics, Retainers, , (Implant) Space Maintainers, Acupuncture, Additions, Dentures, Adjunctive General Services Section, Adjunctive Services by Classification, - Periodontal, General, Adjustments, - Occlusal, Denture, Orthodontics, Space Maintainers, Allograft, Altered Cast Techniques, 53104, Alveolar Ridge Reconstruction, 73111, Alveoloplasty, Amalgams, - Cores, General, "A' Splints, Amputations, Root, Anesthesia, 78106, Anterior Restorations, Tooth Coloured, , Antimicrobial Agents, , Apical Closure / Apexification, Endodontic, Apical Curettage, Retreatment of, Apically Positioned Flap, , Apicoectomy, Retreatment of,

85 INDEX Appliances, - Active Removable, Adjustments to, Fixed, Cemented, Mouth Guard, Myofacial Pain Syndrome, Oral Habits, , Orthodontic, Periodontal, Retention, Space Maintenance, Temporomandibular Joint, Appointments, Office, Attachments, - Denture type, , (Implant) , , Orthodontic, Surgical Exposure, Overdenture, Precision, , 67218, Autopsy, Consultation or Participation, Avulsion, of Tooth / Teeth, - Replantation, Bands, - for Space Maintainers, for Caries, Pain, Trauma Control, for Isolation, Endodontics, Biopsy, Bitewings, Radiographs, , Bleaching, - Micro Abrasion, Non Vital, Endodontically Treated Teeth, Vital, Home, Vital, Office, Bonding Techniques, , , , Bonded, - Abutments / Retainers, Amalgams, , Pontics, Natural Tooth, Space Maintenance, Bone, - Excision, Fracture Reduction, Reduction, Remodelling, Removal, Bridges, Fixed, Miscellaneous Services, Pontics, , , (Implant) Recementation, , (Implant) Removal, , (Implant) Repairs, , (Implant) Retainers, , , , (Implant) Retentive Pins, Splinting, B-

86 -C INDEX 75 Calls, House, Office, or Institutional, Canadian Dental Association Guidelines, iii-vi Caries, - Control of Trauma, Pain, Susceptibility Test, Case Pattern Section, Orthodontics, Case Presentation, Treatment Planning, Casts, Diagnostic, Cast Partial Dentures, , (Implant) CAT Scan Interpretation, Cephalometric Radiograph, , Chemotherapeutic Agents, Claim Forms, Completion of, Class I-III, Orthodontic Malocclusions, Comprehensive Treatment, Clinical Examination and Diagnosis, Communications, Professional, Commercial Laboratory Procedures, Compomer, - Crowns, Inlays, Pontics, Repair Inlays, Onlays, Crowns, Repair Prostheses, , (Implant) Veneer, Composite Type Restorations, (tooth coloured), Cores, , (Implant) Splints, Connectors, Prefabricated, , (Implant) Conscious Sedation, Consultations, , , Counseling, Nutritional, Court Appearances, Coping Crowns, , 27511, (Implant) Copings, Metal / Plastic, Transfer (Thimble Type), Cores, , , (Implant) Cross-Bites, Treatment of, , Crowns, - Coping, , (Implant) Exploratory Access, Implants, Related to, (Implant) Lengthening, 42341, Open and Drain through, Metal, Partial Veneer, Pontics, Natural Tooth, Porcelain/ Ceramic, Recementing / Rebonding, , (Implant) Recontouring of Existing, Removal, Repairs, Single Units, Curettage, - Apicoectomy / Apical, of Cysts, Retreatment, Cysts, Treatment of,

87 INDEX Cytological, - Tests, Interpretation, Deep Sedation, Dental Records, Duplicate and Transfer, Dentogenic Media, Endodontics, Dentures, - Additions, Adjustments, Complete, Complete, with Implants, Duplication, Equilibrated Overdenture, Implants, Attachments, , (Implant) Overdentures, , , , (Implant) Overdentures, Restorative, Partial, Acrylic, , (Implant) Partial, Cast, , (Implant) Partial, Flexible, Prophylaxis and Polishing of, Provisional, Rebasing, Relining, Remake, Removable, Repairs, Surgical, Tissue Conditioners, , (Implant) Desensitization, Diagnostic Casts, Diagnostic Section, Diastemas, Treatment of, , Restorative Closure of, Disease, Management of Oral, Disking Teeth, Dislocations, - TMJ, Treatment of, Dispensing, Drugs / Medication, - Emergency, Non Emergency, Prescriptions, Therapeutic Injections, Drainage, - Endodontic, Surgical, Dressings, - Periodontal Surgery, Pulpal, Drugs / Medication, Dispensing, Duplication, - Radiographs, , (Implant) Dental Records, and Transfer, Dysfunctions, TMJ, Treatment of, D-

88 INDEX 77 -E- Electronic Dental Anesthesia, Emergency Procedures, - Dispensing of Medications, House Calls, Miscellaneous, Office or Institutional Calls, Open and Drainage, Pulpectomy, Endodontics Section, Endosseous Implants, - Bridge, Attached to, Enucleation, Surgical, , Equilibrated Denture, Equilibration, - Casts, Diagnostic, Occlusal, Occlusal, Dentures, Etch Techniques, Examination and Diagnosis, - Complete, Emergency, Limited, , New Patient, Oral Pathology, Periodontal, Previous Patient (Recall), 01202, 01402, Prosthodontic, Post Mortem, Specific, 01204, Stomatognathic, Excisions, - Bone, Cysts, Granulomas, Hyperplasia, Surgical Incisions, Tumors, Benign, Exerciser, Trismus, TMJ, Expansion, Dental Arch, - Orthodontic Treatment of, , Expenses, Materials, Procedure Codes, Expertise Letters, Exploratory Access, Previously Treated Tooth, Exposure of Tooth, Surgical, Extractions (removals),

89 INDEX -F- Facings, - Prefabricated, Attachable, Repair of, Fibrotomy, Supra Crestal, Finishing Restorations, Fissure Sealants, Fixed Orthodontic Appliances, , , Fixed Prosthodontics, Abutments / Retainers, Implants, Attached to, Miscellaneous and Other Services, Pontics, Provisional Coverage, Recementation, , (Implant) Recontouring, Removal, , (Implant) Repairs, , (Implant) Retainers, , (Implant) Retentive Pins, Splinting, Flap Approach, - Oral Surgery, Periodontal Surgery, Removal of Tooth, Fluoride, Prescription for, Fluoride Treatment, Forensic Dental services, Forms, Completion of, Fractures, Treatment of, Free Soft Tissue Graft, Frenectomy / Frenoplasty, Gingival Curettage, Gingival Fiber Incision, Gingivectomy, Gingivoplasty, 42201, Grafts, - with Periodontal Surgery, Granulomas, Treatment of, Guards, Mouth, Guide, Radiographic, Guidelines, Canadian Dental Association, iii-vii -G -

90 Hand and Wrist Radiographs, Hard Tissue Repair, Induction of, Hemisection, Endodontics, Histological Tests, - Interpretation, Tests, Hospital Calls, House Calls, Hygiene, Instruction, Hyperplasia, Treatment of, Hypnosis, Identifications, Criminal or Civil Cases, Forensics, Immediate Dentures, lmpactions, Implants (see Implant Section) - Abutment, Bridge, Related to, , Crowns, Related to, , Dentures, Related to, Mesostructures, , Osseointegrated, Overdentures, , Pontics, Posts, Removal of, Retainers, Tissue Conditioning, (Implant) Incisions - Biopsy Type, 04312, Surgical Type, Inhalation, Anesthesia, Injections - I.M. or I.V., Therapeutic, Inlays - Recementation / Repairs of, , (Implant) Removal of, Repairs to Plastic, Repairs to Porcelain / Ceramic, Restorations, , as Retainers, Fixed Prosthetics, , , In-Office Laboratory Procedures, Installation of Osseointegrated Implants, Root Form, Installation of Osseointegrated Provisional Implants, Institutional Calls, Instruction, Oral Hygiene, Interpretation, - CAT scans, PET scans, MRIs, Models from Another Source, Radiographs, Intramuscular Injections, , lntraoral Radiographs, Intravenous Injections, , Isolation of Teeth for Endodontics, H- -I INDEX 79

91 INDEX -J - Jacket Crowns, Porcelain / Ceramic, Joint, Temporomandibular, - Appliances, Dislocation of, Dysfunctions, Treatment of, Prosthesis, Splint / Exerciser, Radiographs, Laboratory Examinations and Tests, Laboratory Procedures, Codes, Laboratory Reports, Lacerations, Repair of, Lateral Sliding Flap, Graft, Lengthening of Crown, 42341, Ligation, Periodontal Splinting, Limited Oral Examination, Lingual Arch, , Local Anesthetics, L- -M- Maintenance Appliances, - Space Management, Periodontal, Maintainers, Space, Management of Exceptional Patient, Master Casts, Mesostructure, Osseo-integrated, (Implant) Removal of, (Implant) Metal, - Copings, Crowns, , (Implant) Inlays, Onlays, Pontics, Posts, Cast, Posts, Prefabricated, Prefabricated Restorations, Retainers, , (Implant) Micro-Abrasion, Microbiological Tests, Miscellaneous Services, By Category, - Abutments / Retainers, Adjunctive General Services, Diagnostic, , Endodontic Procedures, Fixed Prosthetic Services, Forensic Services, Oral Habits, Orthodontic Appliance Services, Periodontal Surgical Services, INDEX 81

92 Missed Appointments, Motivation of Patient, re: Oral Habits, Mounted Casts, Diagnostic, Mouth Breathing, Therapy, Mouth Guard, Movement of Teeth, Surgically, MRI, interpretation, Mucosal Disorders, Mucous Membrane, - Replacing and Adapting of, Muscular Disorders, Myofacial Pain Appliance, Myofunctional Therapy, N- Occlusal Radiographs, Occlusion, Treatment of, Odontogenic Cysts, Enucleation Of, Office, Laboratory and Expense Procedure Codes, Office Visits and Extra Time Considerations, , Onlays,- Metal, Composite, Porcelain / Ceramic, Recementation / Rebonding, Removal, Repairs, Restorations, Retainers, Fixed Prosthetics, , 67181, Open and Drain, through Crown, Operculectomy, with Surgical Exposure of Tooth, Oral Disease, Management of, Oral Habits, Oral Hygiene Instruction, Oral Sedation, Oral Surgery Section, Orthodontics Section, Appliances, Casts, Comprehensive Treatment Section, Observations, Retaining Appliances, Surgical Exposure of Tooth with Attachment, Orthodontic Treatments in Progress, Payment for, Osseo-integrated, - Installation of (Implant), Mesostructures (Implant), Removal of (Implant), , Osteotomy / Ostectomy, Flap Approach, 42411, 42431, 42451, Overdentures, , , (Implant) Restorative Procedures, , (Implant) , INDEX Natural Tooth Fragments, Recementaion / Rebonding, etc., Nervous Disorders, Management of, New Patient, Examinations, Nitrous Oxide, , Non-Odontogenic Cysts, Enucleation of, Nutritional Counselling, O- -P-

93 Pain, Caries Control, Pain, Treatment of, Unclassified, Panoramic Radiographs, Partial Dentures, - Acrylic, Additions, Adjustments, Cast with Acrylic, Flexible, Overdenture, Cast, with Precision Attachments, Rebase, Reline, , Remake, Repairs, Tissue, Conditioning, Payment for Orthodontic Treatment in Progress, Periapical Radiographs, Periapical Services, Periodontal Section, Adjunctive Procedures, Appliances, Non-Surgical Section, Root Planing, Scaling, Splinting, Periodontal Surgical Services, Flap Approach, Gingival Curettage, Gingivectomy, Gingivoplasty, Grafts, Miscellaneous Surgery, Proximal Wedge, Periodontal Services, Non-Surgical, Permanent Teeth, Amalgams, PET scan, interpretation, Photographs, Pilot Equilibration, Pins, - Inlays, Onlays, Crowns, Retentive for Amalgams / Tooth Coloured Restorations, Retentive, Fixed Prosthetics, Pit and Fissure Sealants, Planing, Root, Plaque Control Programs, Plastic / Acrylic, - Crowns, , Dentures, Pontics, Retainers, , (Implant) Polishing - Natural Dentition, Cleaning of Dentures,

94 INDEX 83 Pontics, - Acrylic / Plastic, Cast, , (Implant) Natural Tooth, Porcelain / Ceramic, Recontouring, as Space Maintainers, Porcelain / Ceramic / Polymer Glass, - Crowns, , (Implant) Facings, Inlays, Onlays, Pontics, Repairs, , Restorations, , Retainers, , (Implant) Staining, Veneers, Posts, Removal, Post Extraction Bone Preservation, Post Surgical Care, Precision Attachments, - Bridges, , Dentures, Predeterminations, Completion of, Prefabricated, - Attachment, Metal Restorations, Plastic Restorations, Pontics, Posts, Restorations, Full Coverage, Veneers, Tooth Coloured, 23121, Prepaid Claim Forms, Completion of, Prescriptions, Presentations, Case, Preventive Restorative Resin, Prevention Section, Primary Teeth, - Amalgams, Pulpectomy, Pulpotomy, Restorations, Prefabricated, , Restorations, Tooth Coloured, Root Canals, Professional, - Communications, Visits, Prosthodontic, - Examination and Diagnosis, Prosthodontics Section, Removable, adjustments, complete, partial, replication, relining and rebasing dentures,

95 INDEX Prosthodontics Section, Fixed, Abutments/Retainers, Miscellaneous Services, Other Services, Miscellaneous, Provisional Coverage, Retentive Pins, Splinting, Provisional, - Crowns, Single Units, Dentures, Complete, Dentures, Partial, Implants, Installation and Removal, Retainers (Abutments), Fixed Prosthetics, , 67121, (Implant) Provisional Splinting, Periodontal, Proximal Wedge, Psychological Management of Patients, 14301, Pulp Capping, Pulpectomy, Pulpotomy, Puncture Biopsy, 04311, Radiographs, - Cephalometric, Duplication of, , (Implant) Extraoral, Guide, Interpretation, Intraoral, Other Types, Miscellaneous, Panoramic, TMJ, Rebasing, Dentures, Rebonding, Crowns, Inlays, Onlays, Veneers, , (Implant) Recall Examination and Diagnosis, Recementation of, - Fixed Bridges, , (Implant) Inlays, Crowns, Onlays, , (Implant) Space Maintainers, 15601, Orthodontic Appliances, Recontouring of, - Existing Crowns, Oral Tissues, Retainers / Pontics, Soft Tissue, Teeth, Reduction of, - Bone, Fractures, TMJ, Dislocation, Regional Bloc Anesthesia, Relines, - Appliances, Periodontal, Appliances, TMJ, Dentures, Remakes, Dentures, R-

96 INDEX 85 Remodelling, - Alveolar, Bone, Oral Tissues, Removable Orthodontic Appliances, , , Removal of, - Abutment, and Replacement, (Implant) Bone, Crowns, (Implant) Cysts, Fixed Bridge Work, , (Implant) Granulomas, Implants, Inlays, Onlays, Crowns, Veneers, Orthodontic Appliances, Periodontal Splints, Posts, Tissue, Hyperplastic, Removals (extractions), - Erupted Teeth, lmpactions, Residual Roots, Surgical Exposure, Repairs, - Dentures, Fixed Prosthodontics, , (Implant) Inlays, Onlays, Crowns, Partial Dentures, Periodontal Appliances, Porcelain / Plastic, Single Restorative Units Only, Recementation, Fixed Bridges, , (Implant) TMJ Appliances, Replantation of Avulsed Tooth / Teeth, Reports, Laboratory, Reports, Repositioning of Traumatically Displaced Teeth, Restorative Resin, Preventive, Restoration Section, Restorative, - Amalgams, Finishing, Foil, Gold, Inlays / Onlays, , for Overdentures, Porcelain, Partial Denture Clasp, Restoration to Tooth Supporting, Prefabricated Full Coverage, Recementation/Removal of, , (Implant) Resin, Preventive, in Splinting, Tooth Coloured, Veneers, , 27602, Retainers, - Fixed Bridge, Implants, used with, Retention, Appliances, Orthodontics,

97 INDEX Retentive, - Bars, (Implant) , , , Pins, , Pins, Fixed Prosthetics, Posts, Retrofilling, Endodontics, Ridge - Remodelling of, with Alveoloplasty, Root Amputation, Root Canal Therapy, Root Planing, S- Scaling, Periodontal, Sealants, Pit and Fissure, Sectioning, Abutment, Sedation - Conscious, Deep, Oral, Sedative Drugs, Administration of, Separation, Orthodontic, Soft Tissue Impactions, Soft Tissue, Recontouring for Crown Lengthening, Space, - Maintainers, Regaining Appliances, , Retaining Appliances, Specific Examination and Diagnosis, 01204, 01402, Splints, - Fixed Prosthetics, Periodontal, Prosthetic, TMJ, Split Cast Mounting, Diagnostics, Staining, - Porcelain, Chairside, Vital, Sterility, During Endodontics, Isolation of Teeth, Stomatoplasty, Supra Crestal Fibrotomy, Surgery, - Endodontic, Miscellaneous, Enucleation of Tooth/Teeth, Excisions, , Exposure of Tooth/Teeth, Incisions, Oral Surgery Section, Periodontal, Post Surgical Care, , Proximal Wedge, Shaving of Hyperplasia, Stomatoplasty / Gingivoplasty,

98 INDEX 87 Surgical, - Dentures, Template, Susceptibility Test, Caries, Systemic Disease, Oral Manifestations of, Telescoping Crown, , Temporomandibular Joint, - Appliances, Dislocation, Management of, Prosthesis, Splints and Exercisers, Radiographs, Test and Laboratory Examinations, Tests - Cytological, Microbiological, 04101, Pulp Vitality, Therapeutic Apical Closure, Thumb Sucking, Therapy for, Thimble Type Copings, Metal / Plastic, Transfer, Time, - Unusual Requirements for Treatment, Unreasonable, Concerning Third Parties, Tissue Conditioning, , (Implant) Tongue Thrust Therapy, Tooth Borne Partial Dentures, Tooth Coloured Restorations, Veneers, Prefabricated and Non-Prefabricated Types, , Tooth Guidance Appliance, Tooth Guidance Observation, Topical Application, Chlorzoin, Torus, Treatment of, Tracings, Cephalometric Radiographs, Transfer, Copings, Duplication and, of Records, Transitional, - Crowns, Single Units, Dentures, Complete, Dentures, Partial, Retainers (Abutments), Fixed Prosthetics, 62702, Transverse Axis Location, Trauma Control, Traumatic Occlusion, Treatment of, Treatment Planning, Treatment Plans, Completion of, Trephination, - through Artificial Crown, through Hard Tissue, through Soft Tissue, T-

99 INDEX Trigeminal Nerve, - Division, Anesthetic Bloc, Trimmed Models, Trismus Therapy, Exerciser Prosthesis, Tumors, Excision of Benign, Unclassified Treatments, Adjunctive General Services, Unerupted Teeth, Treatment of, - by Surgical Exposure, Enucleation of, Unmounted Casts, Diagnostic, Unreasonable Time, Veneer Applications, - Lab Processed, Rebonding of, Removal of, Tooth Coloured Restorations, Vestibuloplasty, Visits, Office, Professional, Vitality Tests, Pulp, Vital Pulpotomy, Vital Staining, Vitamins, Fluoride, etc., Prescriptions for, Wax-ups, Diagnostic, Wrist and Hand Radiographs, Written Reports, Odontology, X-Rays, (radiographs), U- -V- -W- -X-

100 Nova Scotia Dental Association 2008 ABBREVIATED GUIDE (Refer to complete Guide for items not listed below or for detailed code descriptions.) Code Fee DIAGNOSTIC Standard Oral Examination (or Recall) $24.00 Emergency Oral Examination Specific Oral Examination Complete Oral Exam - primary dentition mixed dentition permanent dentition Radiographs - complete series single film two films three films four films Panoramic Film - single film Diagnostic Casts - Unmounted LAB PREVENTIVE Polishing - one unit of time two units Scaling - one unit of time Topical Fluoride Sealants - single tooth each additional tooth in same quadrant Periodontal Appliances - Maxillary LAB - Mandibular LAB Space Maintainer, Band Type- fixed, unilateral LAB - fixed, bilateral LAB Occlusal Adjustment / Equilibration /U Caries Control - first tooth each additional tooth in same quadrant AMALGAM RESTORATIONS (non bonded) Primary Teeth - one surface two surfaces three surfaces four surfaces five surfaces or maximum surfaces per tooth Permanent Anterior & - one surface Bicuspid Teeth - two surfaces three surfaces four surfaces five surfaces or maximum surfaces per tooth Permanent Molar Teeth - one surface two surfaces three surfaces four surfaces five surfaces or maximum surfaces per tooth Retentive Pins - one pin two pins three pins TOOTH COLOURED RESTORATIONS (bonded technique) Permanent Anteriors - one surface two surfaces (continuous) three surfaces (continuous) four surfaces (continuous) five surfaces (conti., max. surfaces / tooth) Permanent Bicuspids - one surface two surfaces three surfaces

101 - four surfaces five surfaces or maximum surfaces per tooth

102 Code Fee Permanent Molar Teeth - one surface two surfaces three surfaces four surfaces five surfaces or maximum surfaces per tooth TOOTH COLOURED RESTORATIONS, VENEER APPLICATIONS Prefabricated, Direct Chairside - Bonded Non-Prefabricated, Direct Buildup - Bonded CROWNS (single restorations) Porcelain / Ceramic / Polymer Glass Fused to Metal Base LAB Full, Cast Metal LAB 3/4, Cast Metal LAB Prefabricated Metal Crown - primary anterior primary posterior Posts, Cast Metal (including core) as a Separate Procedure, Single Section LAB Posts, Prefabricated Retentive, One Post EXP Posts, Prefabricated, with Non-bonded Core for Crown Restoration - with amalgam core + pins, where applicable EXP - with composite core + pins, where applicable EXP ENDODONTICS Pulpotomy (separate emergency procedure) - permanent anterior and bicuspid teeth, excl. final restoration primary tooth as a separate procedure Root Canals, Permanent Teeth / Retained Primary Teeth (uncomplicated) - one canal two canals three canals four canals or more PERIODONTICS Root Planing /U PROSTHODONTICS - REMOVABLE Dentures, Complete, Standard - Maxillary LAB - Mandibular LAB Partial Dentures - Cast Frame / Connector - Maxillary LAB - Mandibular LAB Minor Denture Adjustments /U+LAB Relining Dentures (complete) - direct reline - Maxillary Mandibular processed reline - Maxillary LAB - Mandibular LAB ORAL SURGERY Surgical Removal of: - Erupted teeth - single tooth, uncomplicated each additional in same quadrant complicated, requiring surgical flap Impacted teeth - soft tissue coverage partial bone coverage complete bone coverage

103