Alberta Blue Cross Usual and Customary dental fees Why Usual and Customary dental fees? In Alberta, individual dental providers set their own prices. As a result, dental offices across the province charge widely varying prices for dental services. Usual and Customary dental fees are based on recent data from actual marketplace billings by Alberta dental offices for over 1,800 procedure codes claimed by Alberta Blue Cross group dental plan members. By using Usual and Customary dental fees as a basis of payment for claims, your plan coverage levels match the fees accepted by most dental offices, most of the time, across Alberta today and this helps to ensure that your plan will remain viable and affordable both today and into the future. Examples of typical Usual and Customary fees Each person has unique dental needs, so your dental treatment may be different from the examples shown here. Please note that some procedures listed here may not be covered by your particular dental plan. Decisions about treatment remain between you and your dental provider. The fees indicated are those of a general practitioner, amounts charged by a specialist or a denturist may be different. Adults Recall and cleaning costs Recall exam - Procedure 01202 $72.50 2 Bitewing Radiographs - Procedure 02142 $49.00 2 Time Units Scaling - Procedure 11112 $144.36 1 Time Unit Polishing - Procedure 11101 $68.00 TOTAL $367.36 Restorations (fillings) 4 surface amalgam (silver) filling permanent molar - Procedure 21224 $234.00 2 pins for filling - Procedure 21402 $46.34 TOTAL $280.34 Children Recall and cleaning costs Recall exam - Procedure 01202 $72.50 2 Bitewing Radiographs - Procedure 02142 $49.00 1 Time Unit Scaling - Procedure 11111 $72.18 1 Time Unit Polishing - Procedure 11101 $68.00 Fluoride - Procedure 12101 $33.50 TOTAL $295.18 Crown Porcelain fused to metal crown - Procedure 27211 $923.00* Post cast metal - Procedure 25721 $194.00* TOTAL $1,117.00* *Dentist s fees only: lab charges may apply Three Unit bridge Retainer, (crown) for fixed bridge - Procedure 67211 Retainer, (crown) for fixed bridge - Procedure 67211 Pontic, for fixed bridge (to replace missing tooth) - Procedure 62501 $938.00* $938.00* $462.00* TOTAL $2,338.00 *Dentist s fees only: lab charges may apply Root canal therapy Three root, root canal therapy - Procedure 33131 $1,187.00 Example denturist fees General prosthodontic exam - Procedure 10010 Complete upper denture - Procedure 31310 Complete lower denture - Procedure 31320 Partial upper denture - Procedure 41114 Complete upper denture repair - Procedure 36110 Complete upper denture reline (processed) - Procedure 32215 *Denturist fees only: lab charges may apply $66.50 $659.70* $659.70* $702.60* $60.00* $198.80* ABC 81304_uc R2016/01 - Page 1
Maximum amounts the Usual & Customary schedule allows for common dental procedures. Some procedures listed on the following pages may not be covered by your particular plan. Please consult your plan contract or benefit booklet for more information. All Alberta dental offices have access to complete copies of the 2016 Usual and Customary Dental Fees. Your dental provider also has quick and easy access to information about your dental coverage through CDAnet or DACnet, a national electronic system. Procedure Procedure Code Maximum allowed Diagnostic New Patient, Complete Exam, Primary Teeth New Patient, Complete Exam, Mixed Teeth New Patient, Complete Exam, Permanent Teeth 01101 $75.00 01102 $106.00 01103 $110.30 Limited Oral Examination, new patient 01201 $75.64 Limited Oral Exam, Recall 01202 $72.50 Specific Exam 01204 $72.66 Emergency Exam 01205 $72.00 Specific Periodontal Exam 01502 $88.00 General Surgical Exam 01601 $150.00 Specific Surgical Exam 01602 $104.00 General Prosthodontic Exam 01701 $107.49 Specific Endodontic Exam 01802 $102.82 General Orthodontic Exam 01901 $400.00* Specific Orthodontic Exam 01902 $86.00 Periapical Radiographs single image 02111 $30.00 Periapical Radiographs two images 02112 $49.00 Periapical Radiographs three images 02113 $67.00 Periapical Radiographs four images 02114 $84.00 Bitewing Radiographs single image 02141 $30.00 Bitewing Radiographs two images 02142 $49.00 Bitewing Radiographs four images 02144 $86.68 Panoramic Radiograph single image 02601 $96.00 Preventive Polishing one unit 11101 $68.00 Polishing one half unit 11107 $34.00 Scaling one unit 11111 $72.18 ABC 81304_uc R2016/01 - Page 2
Scaling two units 11112 $144.36 Scaling three units 11113 $216.54 Scaling four units 11114 $288.72 Scaling five units 11115 $360.90 Scaling one half unit 11117 $36.09 Fluoride 12101 $33.50 Pit and Fissure Sealants first tooth 13401 $35.00 Pit and Fissure Sealants each additional tooth in same quadrant 13409 $18.00 Periodontal appliance 14611 $406.00* Restorative Caries/Trauma/Pain control 20111 $121.28 Amalgam Filling - primary teeth two surfaces Amalgam Filling- permanent anteriors and bicuspids two surfaces one surface two surfaces three surfaces four surfaces 21112 $140.00 21212 $146.40 21221 $112.00 21222 $153.00 21223 $189.04 21224 $234.00 Retentive Pins one pin 21401 $32.00 Retentive Pins two pins 21402 $46.34 Prefabricated Metal Filling primary posterior - permanent anterior one surface - permanent anterior two surfaces 22211 $206.00 23111 $144.00 23112 $168.00 - permanent anterior three surfaces - permanent anterior four surfaces - permanent anterior five surfaces - permanent bicuspids one surface Tooth Coloured Filling - Acid Etch/Bond - permanent bicuspids two surfaces - permanent bicuspids three surfaces 23113 $198.72 23114 $241.50 23115 $299.00 23311 $150.00 23312 $209.15 23313 $246.48 ABC 81304_uc R2016/01 - Page 3
- permanent bicuspids four surfaces - permanent bicuspids five surfaces - permanent molars one surface - Permanent Molars two surfaces - permanent molars three surfaces - permanent molars four surfaces - permanent molars five surfaces - primary posterior one surface - primary posterior two surfaces Tooth Coloured Core/Plastic with Silver fillings, Cores - Tooth Coloured Tooth Coloured Core/Plastic with Silver fillings, Cores - Acid Etch/Bonded 23314 $287.00 23315 $324.00 23321 $158.00 23322 $222.00 23323 $266.00 23324 $302.93 23325 $350.00 23511 $142.50 23512 $197.76 23601 $205.00 23602 $240.00 Cast metal Posts 25721 $194.00* Prefabricated Posts 25731 $155.00* Crowns 27201 $953.00* Crowns 27211 $923.00* Crowns 27301 $932.14* Recementation/ Rebonding 29101 $84.00* Endodontics Pulpotomy - Primary Toothconcurrent with restorations 32232 $82.00 Root Canal - one canal 33111 $696.00 Root Canal - two canals 33121 $1,015.00 Root Canal - three canals 33131 $1,187.00 Periodontics Desensitization one unit 41301 $73.00 Periodontal Surgery gingival curettage, per sextant 42111 $203.00 Root planing one unit 43421 $78.00 Root planing two units 43422 $156.00 Root planing three units 43423 $234.00 Root planing four units 43424 $312.00 ABC 81304_uc R2016/01 - Page 4
Prosthodontics Complete Standard Denture upper 51101 $900.00* Complete Standard Denture lower 51102 $900.00* Partial Denture - lower 53102 $875.00* Denture Adjustment one unit 54201 $71.93* Denture Repair - upper 55101 $77.31* Denture Repair lower 55102 $77.00* Denture Reline upper 56231 $238.00* Denture Reline lower 56232 $238.00* Pontic - porcelain fused to metal 62501 $462.00* Retainer porcelain/ceramic fused to metal 67211 $938.00* Oral Surgery Removal of Erupted Teeth uncomplicated 71101 $140.00 Removal of Erupted Teeth each additional tooth same quadrant Surgical Removal of Single Erupted tooth requiring surgical flap and/or sectioning of tooth Surgical Removal of Impacted tooth partial bone impaction Surgical Removal of Impacted Teeth complete bone impaction Surgical Removal of Impacted Teeth unusual difficulties and circumstances 71109 $130.00 71201 $255.00 72211 $330.00 72221 $400.00 72231 $479.00 Orthodontics Orthodontic Treatment (Braces) Class 1 malocclusion Orthodontic Treatment (Braces) Class 2 malocclusion Orthodontic Treatment (Braces) Malocclusions not requiring complete banding 84101 Variable 84201 Variable 84401 Variable Adjunctive General Services General Anesthesia six units 92216 $582.00 Anesthetic Facilities six units 92226 $582.00 ABC 81304_uc R2016/01 - Page 5