SUGGESTED FEE GUIDE FOR DENTAL SERVICES

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

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 01000-09999 DIAG 1 Preventive Services 10000-19999 PREV 9 Restorative Services 20000-29999 REST 15 Endodontics 30000-39999 ENDO 23 Periodontal Services 40000-49999 PERIO 29 Prosthodontics - Removable 50000-59999 PROS-REM 33 Prosthodontics - Fixed 60000-69999 PROS-FIXED 39 Surgical Services 70000-79999 SURG 45 Orthodontics 80000-89999 ORTHO 51 Other Services 90000-99999 ADJ 55 Implants IMPLANTS 63 Index INDEX 73

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 )

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. 1. 2. 3. 4. 5. 6. 7. 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 )

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 1. 2. 3. 4. 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: 01000-09999 DIAGNOSTIC 10000-19999 PREVENTIVE 20000-29999 RESTORATIVE 30000-39999 ENDODONTICS 40000-49999 PERIODONTICS 50000-59999 PROSTHODONTICS - REMOVABLE 60000-69999 PROSTHODONTICS - FIXED 70000-79999 ORAL SURGERY 80000-89999 ORTHODONTICS 90000-99999 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: 21221 "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 )

6. The UNITS OF TIME and/or the LETTERS following procedures must conform to the following principles: (also see procedure codes 99000 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" 7. 8. 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 )

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 )

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 )

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 18-14 04 designates from 13-23 05 designates from 24-28 06 designates from 38-34 07 designates from 33-43 08 designates from 44-48 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 )

IDENTIFICATION SYSTEM FOR TEETH ARCH QUADRANT SEXTANT 38 37 36 Supernumary Tooth 99 ( viii )

DIAGNOSTIC 01000-09999 2008 - 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 01101 Examination and Diagnosis, Complete, Primary Dentition, to include: 35.00 Extended examination and diagnosis on primary dentition, recording history, charting, treatment planning and case presentation, including above description 01102 Examination and Diagnosis, Complete, Mixed Dentition, to include: 45.00 (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 01103 Examination and Diagnosis, Complete, Permanent Dentition 60.00 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 01201 Examination and Diagnosis, Limited, Oral, New Patient 24.00 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 01101-03 series (may include PSR) 01202 Examination and Diagnosis, Limited Oral, Previous Patient (recall) 24.00 Examination of hard and soft tissues, including checking of occlusion and appliances, but not including specific tests/analysis, as for 01100 01204 Examination and Diagnosis, Specific 39.00 Examination and evaluation of a specific situation 01205 Examination and Diagnosis, Emergency 39.00 Examination and diagnosis for the investigation of discomfort and/or infection in a localized area. 01206 Analysis, Mixed Dentition 21.00

2 2008 - DIAG EXAMINATION AND DIAGNOSIS, STOMATOGNATHIC 01301 Examination and Diagnosis, Stomatognathic, Dysfunctional, 54.00 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 01302 Examination and Diagnosis, Stomatognathic, Dysfunctional, Limited 21.00 EXAMINATION AND DIAGNOSIS, ORAL PATHOLOGY 01401 Examination and Diagnosis, Oral Pathology, General, to include: 54.00 (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 01402 Examination and Diagnosis, Oral Pathology, Specific 21.00 (or repeat examination within 90 days for the same illness) EXAMINATION AND DIAGNOSIS, PERIODONTAL 01501 Examination and Diagnosis, Periodontal, General 37.00 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 01502 Examination and Diagnosis, Periodontal, Limited (previous patient) 26.00 EXAMINATION AND DIAGNOSIS, PROSTHODONTIC 01701 Edentulous, to include: 54.00 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

2008 - DIAG 3 RADIOGRAPHS (Including radiographic examination, diagnosis and interpretation) RADIOGRAPHS, INTRAORAL (where 2-pack films are utilized, it is appropriate to add a +E) 02101 Radiographs, Intraoral, Pedodontic, Complete Series 56.00 (minimum of 12 films including bitewings) 02102 Radiographs, Intraoral, Adult, Complete Series 72.00 (minimum of 16 films including bitewings) Radiographs, Intraoral, Periapical 02111 Single film 12.00 02112 Two films 16.00 02113 Three films 20.00 02114 Four films 23.00 02115 Five films 27.00 02116 Six films 30.00 02117 Seven films 34.00 02118 Eight films 38.00 02119 Nine films 44.00 02120 Ten films 49.00 02121 Eleven films 54.00 02122 Twelve films 58.00 02123 Thirteen films 62.00 02124 Fourteen films 66.00 02125 Fifteen films 69.00 Radiographs, lntraoral, Occlusal 02131 Single film 21.00 02132 Two films 31.00 02133 Three films 33.00 02134 Four films 39.00 Radiographs, Intraoral, Bitewing 02141 Single film 12.00 02142 Two films 16.00 02143 Three films 20.00 02144 Four films 24.00 RADIOGRAPHS, EXTRAORAL 02201 Single film 25.00 02202 Two films 37.00 02203 Three films 51.00 02204 Four films 63.00 RADIOGRAPHS, TEMPOROMANDIBULAR JOINT 02501 Single film 29.00 02502 Two films 41.00 02503 Three films 55.00 02504 Four films (minimum examination and diagnosis, closed and open each side) 66.00 02509 Each additional film over four 13.00

4 2008 - DIAG RADIOGRAPHS, PANORAMIC 02601 Single film 49.00 RADIOGRAPHS, CEPHALOMETRIC 02701 Single film 49.00 02702 Two films 59.00 Radiographs, Cephalometric, Tracing and Interpretation 02751 One unit of time 42.00 02752 Two units 84.00 02759 Each additional unit over two 42.00 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) 02801 One unit of time + E 41.00 02802 Two units + E 82.00 02807 Half unit of time + E 21.00 02809 Each additional unit over two + E 41.00 RADIOGRAPHS, OTHER Radiographs, Duplications 02911 Single film 6.00 02912 Two films 10.00 02913 Three films 14.00 02914 Four films 18.00 02915 Five films 21.00 02916 Six films 25.00 02917 Seven films 29.00 02918 Eight films 32.00 02919 Each additional film over eight 4.00 Duplication of a Complete Series of Radiographs 02921 Duplication of a Complete Series of 12 Radiographs I.C. 02922 Duplication of a Complete Series of 13 or more Radiographs I.C. Radiographs, Hand and Wrist 02941 Radiograph, Hand and Wrist 27.00 (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)] 02951 Maxillary Guide + L + E I.C. 02952 Mandibular Guide + L + E I.C. TEMPLATE, SURGICAL (includes diagnostic wax-up. Also used to locate and orient osseo-integrated implants) 03001 Maxillary Template + L + E I.C. 03002 Mandibular Template + L + E I.C.

2008 - DIAG 5 TESTS / ANALYSIS / LABORATORY PROCEDURES / INTERPRETATION AND/OR REPORTS TEST / ANALYSIS, MICROBIOLOGICAL (technical procedure only) 04101 Microbiological Test / Analysis for the Determination of 33.00 Pathological Agents + L TEST / ANALYSIS, CARIES SUSCEPTIBILITY (technical procedure only) 04201 Bacteriological Test / Analysis for the Determination of 30.00 Dental Caries Susceptibility + L TEST / ANALYSIS, HISTOPATHOLOGICAL (technical procedure only) Soft Tissue 04311 Biopsy, Soft Oral Tissue - by Puncture + L 75.00 04312 Biopsy, Soft Oral Tissue - by Incision + L 75.00 04313 Biopsy, Soft Oral Tissue - by Aspiration + L 75.00 Hard Tissue 04321 Biopsy, Hard Oral Tissue - by Puncture + L 88.00 04322 Biopsy, Hard Oral Tissue - by Incision + L 88.00 04323 Biopsy, Hard Oral Tissue - by Aspiration + L 88.00 TEST / ANALYSIS, CYTOLOGICAL (technical procedure only) 04401 Cytological Smear from the Oral Cavity + L + E 31.00 04402 Vital Staining of Oral Mucosal Tissues + E I.C. TEST / ANALYSIS, PULP VITALITY AND INTERPRETATION 04501 One unit of time 27.00 04509 Each additional unit 27.00 INTERPRETATION AND/OR REPORTS, LABORATORY 04601 Interpretation and/or Report, Microbiological by Oral Microbiologist + L I.C. 04602 Interpretation and/or Report, Histopathological by Oral Pathologist I.C. or Microbiologist + L 04603 Interpretation and/or Report, Cytological by Oral Pathologist + L I.C. 04604 Reports, Other I.C. SUPPLEMENTARY DIAGNOSTIC PROCEDURES (interpretation only) Equilibration, Casts, Diagnostic (pilot equilibration) for Extensive or Complicated Restorative Dentistry 04711 One unit of time + L 41.00 04712 Two units + L 82.00 04713 Three units + L 123.00 04714 Four units + L 164.00

6 2008 - DIAG Wax-up, Diagnostic (to evaluate cosmetic and/or preparation design and/or occlusal considerations) (gnathological wax-up) 04721 One unit of time + L 41.00 04722 Two units + L 82.00 04723 Three units + L 123.00 04724 Four units + L 164.00 Split Cast Mounting, Diagnostic 04731 One unit of time + L 41.00 04732 Two units + L 82.00 Interpretation of Diagnostic Casts 04741 One unit of time 41.00 PHOTOGRAPHS, DIAGNOSTIC (technical procedure only) 04801 Single photograph 13.00 04802 Two photos 19.00 04803 Three photos 26.00 04809 Each additional photo over three 5.00 CASTS, DIAGNOSTIC (technical procedure only) Casts, Diagnostic, Unmounted 04911 Casts, Diagnostic, Unmounted + L 31.00 04912 Casts, Diagnostic, Unmounted, Duplicate + L 13.00 Casts, Diagnostic, Mounted 04921 Casts, Diagnostic, Mounted + L 37.00 04922 Casts, Diagnostic, Mounted, using Face Bow Transfer + L 61.00 04923 Casts, Diagnostic, Mounted, using Face Bow + 91.00 Occlusal Records + L 04924 Casts, Diagnostic, Mounted, using Fully I.C. Adjustable Articulator + L (used with 04941 and 04942) Casts, Diagnostic, Orthodontic 04931 Casts, Diagnostic, Orthodontic 41.00 (unmounted, angle trimmed and soaped) + L Casts, Diagnostic, Miscellaneous Procedures 04941 Transverse Axis Location and Transfer, used in Conjunction with I.C. 04922, 04923, and 04924 + L 04942 Three Dimensional Recordings of Patient's Dynamic Movements I.C. for Programming of Fully Adjustable Articulators

2008 - 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. 05101 One unit of time 36.00 05102 Two units 72.00 CONSULTATION, with patient 05201 One unit of time 36.00 05202 Two units 72.00 05209 Each additional unit over two 36.00

PREVENTION 10000-19999 2008 - 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 11101 One unit of time 24.00 11102 Two units 48.00 11107 One half unit 12.00 11109 Each additional unit over two 24.00 SCALING 11111 One unit of time 34.00 11112 Two units 68.00 11113 Three units 102.00 11114 Four units 136.00 11115 Five units 170.00 11116 Six units 204.00 11117 One half unit 17.00 11119 Each additional unit over six 34.00 FLUORIDE TREATMENTS 12101 Fluoride Treatment, Topical Application 15.00 12102 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 13101 One unit of time 25.00 13102 Two units 50.00 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 13211 One unit of time 15.00 13212 Two units 30.00 13213 Three units 45.00 13217 One half unit of time 8.00 13219 Each additional unit over three 15.00 Re-instruction (within 6 months), Excluding Audio-Visual Time 13231 One unit of time 12.00 13232 Two units 24.00 13237 One half unit of time 6.00

10 2008 - PREV Oral Hygiene Instruction - Audio Visual 13241 One unit of time 11.00 13242 Two units 22.00 13247 One half unit of time 6.00 PIT AND FISSURE SEALANTS (mechanical and/or chemical preparation included) 13401 First tooth 20.00 13409 Each additional tooth same quadrant 14.00 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) 13411 First tooth 42.00 13419 Each additional tooth same quadrant 42.00 TOPICAL APPLICATION TO HARD TISSUE OF AN ANTIMICROBIAL AGENT 13601 One unit of time + E 39.00 13602 Two units + E 78.00 13609 Each additional unit over two + E 39.00 APPLIANCES APPLIANCES, REMOVABLE, CONTROL OF ORAL HABITS 14101 Appliance, Maxillary + L 341.00 14102 Appliance, Mandibular + L 341.00 14103 Appliances, Maxillary plus Mandibular + L 682.00 APPLIANCES, FIXED / CEMENTED, CONTROL OF ORAL HABITS 14201 Appliance, Maxillary + L 390.00 14202 Appliance, Mandibular + L 390.00 CONTROL OF ORAL HABITS, MISCELLANEOUS 14301 Motivation of Patient - Psychological Approach (e.g., thumb sucking, 53.00 lip biting, etc.) - per visit + L Myofunctional Therapy (e.g., to correct mouth breathing, abnormal swallowing, tongue thrust, etc.) 14311 First unit of time per visit + L 53.00 14312 Two units + L 106.00 14319 Each additional unit over two + L 53.00 APPLIANCES, CONTROL OF ORAL HABITS - ADJUSTMENTS, REPAIRS, MAINTENANCE 14401 One unit of time + L 44.00 14402 Two units + L 88.00 APPLIANCES, PROTECTIVE MOUTH GUARDS 14502 Appliance, Protective Mouth Guard, Processed + L 55.00

2008 - PREV 11 APPLIANCES, PERIODONTAL (see separate codes for Control of Oral Habits 14000, Protective Mouth Guards - 14502 and TMJ - 14700) Appliances, Periodontal (including bruxism appliance); includes impression, insertion and insertion adjustment (no post-insertion adjustments) 14611 Maxillary Appliance + L 238.00 14612 Mandibular Appliance + L 238.00 Appliances, Adjustment, Repair 14621 One unit of time + L 50.00 14622 Two units + L 100.00 14623 Three units + L 150.00 14629 Each additional unit over three + L 50.00 Appliances, Reline 14631 Reline, Direct 108.00 14632 Reline, Processed + L 108.00 APPLIANCES, TEMPOROMANDIBULAR JOINT Appliance, TMJ Intraoral Repositioning; includes impression, insertion and insertion adjustment (no post insertion adjustments) 14721 Maxillary Appliance + L 289.00 14722 Mandibular Appliance + L 289.00 Appliance, TMJ, Periodic Maintenance, Adjustment, Repair 14731 One unit of time + L 50.00 14732 Two units + L 100.00 14733 Three units + L 150.00 14739 Each additional unit over three + L 50.00 Appliance, TMJ, Relines 14741 Reline, Direct 108.00 14742 Reline, Indirect + L 108.00 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) 14811 Maxillary Appliance + L 410.00 14812 Mandibular Appliance + L 410.00 Appliance, Myofascial Pain Dysfunction Syndrome, Periodic Maintenance, Adjustment and Repairs 14821 One unit of time + L 50.00 14822 Two units + L 100.00 14823 Three units + L 150.00 14829 Each additional unit over three + L 50.00

12 2008 - PREV SPACE MAINTAINERS (includes the design, separation, fabrication, insertion and where applicable initial cementation and removal) SPACE MAINTAINERS, BAND TYPE 15101 Space Maintainer, Band Type, Fixed, Unilateral + L 125.00 15102 Space Maintainer, Band Type, Fixed, Unilateral with lntra-alveolar 155.00 Attachment + L 15103 Space Maintainer, Band Type, Fixed, Bilateral (soldered lingual 144.00 arch) + L 15104 Space Maintainer, Band Type, Fixed, Bilateral (soldered lingual 176.00 arch) with Teeth Attached + L 15105 Space Maintainer, Band Type, Fixed, Bilateral Tubes and 173.00 Locking Wires + L SPACE MAINTAINERS, STAINLESS STEEL CROWN TYPE 15201 Space Maintainer, Stainless Steel Crown Type, Fixed + L 151.00 SPACE MAINTAINERS, CAST TYPE 15301 Space Maintainer, Cast Type, Fixed + L 247.00 15302 Space Maintainer, Cast Type, Fixed, with Intra Alveolar 280.00 Attachment + L SPACE MAINTAINERS, ACRYLIC, REMOVABLE 15401 Space Maintainer, Acrylic, Removable, Bilateral Clasps, 136.00 Retaining Wires + L 15403 Space Maintainer, Acrylic Removable, No Clasps + L 126.00 SPACE MAINTAINERS, BONDED, PONTIC TYPE 15501 Space Maintainer, Bonded, Pontic Type + L 87.00 SPACE MAINTAINERS, MAINTENANCE OF 15601 Maintenance, Space Maintainer Appliance, to include: adjustment 51.00 and/or recementation after 30 days from insertion 15602 Maintenance, Space Maintainer Appliances, Addition of Clasps 51.00 and/or Activating Wires + L 15603 Repairs, Space Maintainer Appliances (includes recementation) + L 51.00 15604 Removal of Fixed Space Maintainer Appliances by Second Dentist 51.00

2008 - 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) 16101 One unit of time 32.00 16102 Two units 64.00 16103 Three units 96.00 16104 Four units 128.00 16109 Each additional unit over four 32.00 DISKING OF TEETH, Interproximal 16201 One unit of time 52.00 16202 Two units 104.00 16203 Three units 156.00 RECONTOURING OF NATURAL TEETH FOR AESTHETIC REASONS 16301 One unit of time 52.00 16309 Each additional unit of time 52.00 RECONTOURING OF TEETH FOR FUNCTIONAL REASONS (not associated with delivery of a single or multiple prosthesis) 16401 One unit of time 52.00 16409 Each additional unit of time 52.00 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 & 60000 code series) by the same dentist for a period of three months 16511 One unit of time 62.00 16512 Two units 124.00 16513 Three units 186.00 16514 Four units 248.00 16519 Each additional unit over four 62.00

RESTORATION 20000-29999 2008 - 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) 20111 First tooth 75.00 20119 Each additional tooth same quadrant 75.00 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) 20121 First tooth 84.00 20129 Each additional tooth same quadrant 84.00 Trauma Control, Smoothing of Fractured Surfaces, per Tooth 20131 First tooth 30.00 20139 Each additional tooth same quadrant 30.00 RESTORATIONS, AMALGAM RESTORATIONS, AMALGAM, NON-BONDED, PRIMARY TEETH 21111 One surface 65.00 21112 Two surfaces 85.00 21113 Three surfaces 94.00 21114 Four surfaces 104.00 21115 Five surfaces or maximum surfaces per tooth 128.00 RESTORATIONS, AMALGAM, BONDED, PRIMARY TEETH 21121 One surface 68.00 21122 Two surfaces 87.00 21123 Three surfaces 97.00 21124 Four surfaces 114.00 21125 Five surfaces or maximum surfaces per tooth 140.00 RESTORATIONS, AMALGAM, PERMANENT TEETH Restorations, Amalgam, Non-Bonded, Permanent Bicuspids and Anteriors 21211 One surface 79.00 21212 Two surfaces 100.00 21213 Three surfaces 125.00 21214 Four surfaces 143.00 21215 Five surfaces or maximum surfaces per tooth 174.00

16 2008 - REST Restorations, Amalgam, Non-Bonded, Permanent Molars 21221 One surface 87.00 21222 Two surfaces 106.00 21223 Three surfaces 140.00 21224 Four surfaces 174.00 21225 Five surfaces or maximum surfaces per tooth 215.00 Restorations Amalgam, Bonded, Permanent Bicuspids and Anteriors 21231 One surface 94.00 21232 Two surfaces 110.00 21233 Three surfaces 138.00 21234 Four surfaces 156.00 21235 Five surfaces or maximum surfaces per tooth 189.00 Restorations, Amalgam, Bonded, Permanent Molars 21241 One surface 100.00 21242 Two surfaces 117.00 21243 Three surfaces 153.00 21244 Four surfaces 186.00 21245 Five surfaces or maximum surfaces per tooth 227.00 RESTORATIONS, AMALGAM CORES 21301 Restoration, Amalgam Core, Non-Bonded, in Conjunction with Crown 122.00 21302 Restoration, Amalgam Core, Bonded, in Conjunction with Crown 134.00 PINS, RETENTIVE per Restoration (for amalgams and tooth coloured restorations) 21401 One pin 18.00 21402 Two pins 29.00 21403 Three pins 33.00 21404 Four pins 39.00 21405 Five pins or more 47.00 RESTORATIONS MADE TO A TOOTH SUPPORTING AN EXISTING PARTIAL DENTURE CLASP (additional to restoration) 21501 Per restoration 35.00 RESTORATIONS, PREFABRICATED, FULL COVERAGE RESTORATIONS, PREFABRICATED, METAL, PRIMARY TEETH 22201 Primary Anterior 126.00 22211 Primary Posterior 120.00 22212 Primary Posterior - Open Face 131.00 RESTORATIONS, PREFABRICATED, METAL, PERMANENT TEETH 22301 Permanent Anterior 137.00 22311 Permanent Posterior 120.00 RESTORATIONS, PREFABRICATED, PLASTIC, PRIMARY TEETH 22401 Primary Anterior 126.00 22411 Primary Posterior 126.00

2008 - REST 17 RESTORATIONS, PREFABRICATED, PLASTIC, PERMANENT TEETH 22501 Permanent Anterior 126.00 22511 Permanent Posterior 126.00 RESTORATIONS, TOOTH COLOURED / PLASTIC WITH / WITHOUT SILVER FILLINGS RESTORATIONS, PERMANENT ANTERIORS, BONDED TECHNIQUE (not to be used for veneer applications or diastema closures) 23111 One surface 99.00 23112 Two surfaces (continuous) 116.00 23113 Three surfaces (continuous) 143.00 23114 Four surfaces (continuous) 190.00 23115 Five surfaces (continuous, maximum surfaces per tooth) 238.00 RESTORATIONS, TOOTH COLOURED, VENEER APPLICATIONS 23121 Tooth Coloured Veneer Application - Direct Chairside Prefabricated, 213.00 Bonded 23122 Tooth Coloured Veneer Application - Non Prefabricated Direct 214.00 Buildup, Bonded 23123 Tooth Coloured Veneer Application - Diastema Closure, 208.00 Interproximal Only - Bonded RESTORATIONS, TOOTH COLOURED, PERMANENT POSTERIORS, BONDED Permanent Bicuspids 23311 One surface 117.00 23312 Two surfaces 150.00 23313 Three surfaces 199.00 23314 Four surfaces 243.00 23315 Five surfaces or maximum surfaces per tooth 278.00 Permanent Molars 23321 One surface 125.00 23322 Two surfaces 152.00 23323 Three surfaces 202.00 23324 Four surfaces 246.00 23325 Five surfaces or maximum surfaces per tooth 313.00 RESTORATIONS, TOOTH COLOURED, PRIMARY, ANTERIOR, BONDED TECHNIQUE 23411 One surface 83.00 23412 Two surfaces (continuous) 100.00 23413 Three surfaces (continuous) 126.00 23414 Four surfaces (continuous) 138.00 23415 Five surfaces (continuous or maximum surfaces per tooth) 143.00 RESTORATIONS, TOOTH COLOURED, PRIMARY, POSTERIOR, BONDED TECHNIQUE 23511 One surface 85.00 23512 Two surfaces 106.00 23513 Three surfaces 129.00 23514 Four surfaces 145.00 23515 Five surfaces or maximum surfaces per tooth 150.00

18 2008 - REST RESTORATIONS, TOOTH COLOURED / PLASTIC WITH / WITHOUT SILVER FILLINGS, CORES 23602 Restoration, Tooth Coloured, Bonded, Core, in Conjunction with Crown 135.00 RESTORATIONS, FOIL, GOLD RESTORATIONS, FOIL, GOLD, POSTERIORS 24201 Class I 233.00 24203 Class V 433.00 RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS Inlays, Metal 25111 One surface + L 290.00 25112 Two surfaces + L 339.00 25113 Three surfaces + L 385.00 25114 Three surfaces, modified + L 404.00 Inlays, Composite / Compomer, Indirect (Bonded) 25121 One surface + L 324.00 25122 Two surfaces + L 372.00 25123 Three surfaces + L 425.00 25124 Three surfaces, modified + L 436.00 Inlays, Porcelain / Ceramic / Polymer Glass (Bonded) 25141 One surface + L 332.00 25142 Two surfaces + L 395.00 25143 Three surfaces + L 458.00 25144 Three surfaces, modified + L 475.00 RESTORATIONS, ONLAYS (where one or more cusps are restored) Onlays, Cast Metal, Indirect 25511 Onlay, Cast Metal, Indirect + L 454.00 Onlays, Composite / Compomer, Indirect (Bonded) 25521 Onlay, Composite / Compomer, Indirect (Bonded) + L 408.00 Onlays, Porcelain / Ceramic / Polymer Glass (Bonded) 25531 Onlay, Porcelain / Ceramic / Polymer Glass (Bonded) + L 500.00 PINS, RETENTIVE (for inlays, onlays and crowns per tooth) 25601 One pin / tooth + L 26.00 25602 Two pins / tooth + L 38.00 25603 Three pins / tooth + L 52.00 25604 Four pins / tooth + L 69.00 25605 Five or more pins / tooth + L 97.00

2008 - REST 19 POSTS Posts, Cast Metal, (including core) as a Separate Procedure 25711 Single section + L 266.00 25712 Two sections + L 359.00 25713 Three sections + L 398.00 Posts, Cast Metal (including core) Concurrent with Impression for Crown 25721 Single section + L 136.00 25722 Two sections + L 213.00 25723 Three sections + L 262.00 Posts, Prefabricated Retentive 25731 One post + E 124.00 25732 Two posts same tooth + E 207.00 25733 Three posts same tooth + E 258.00 Posts, Prefabricated, with Non-Bonded Core for Crown Restoration [including pin(s) where applicable] 25751 One post, with non-bonded amalgam core + pins + E 185.00 25752 Two posts (same tooth), with non-bonded amalgam core + pins + E 237.00 25753 Three posts (same tooth), with non-bonded amalgam core + pins + E 291.00 25754 One post, with non-bonded composite core + pins + E 208.00 25755 Two posts (same tooth), with non-bonded composite core + pins + E 259.00 25756 Three posts (same tooth), with non-bonded composite core + pins + E 313.00 Posts, Prefabricated, with Bonded Core for Crown Restoration [including pin(s) where applicable] 25761 One post, with bonded amalgam core + pins + E 196.00 25762 Two posts (same tooth), with bonded amalgam core + pins + E 249.00 25763 Three posts (same tooth), with bonded amalgam core + pins + E 302.00 25764 One post, with bonded composite/compomer core + pins + E 220.00 25765 Two posts (same tooth), with bonded composite/compomer 271.00 core + pins + E 25766 Three posts (same tooth), with bonded composite/compomer 325.00 core + pins + E Post Removal 25781 One unit of time 68.00 25782 Two units 136.00 25783 Three units 204.00 25784 Four units 272.00 25789 Each additional unit over four 68.00

20 2008 - REST CROWNS, SINGLE UNITS (only) CROWNS, ACRYLIC / COMPOSITE / COMPOMER (with or without Cast or Prefabricated Metal Bases) Crowns, Acrylic / Composite / Compomer, Indirect 27111 Indirect + L 425.00 27113 Provisional (long term), Indirect (lab fabricated / relined intra-orally) + L 144.00 Crowns, Acrylic / Composite / Compomer, Direct 27121 Direct, Provisional (chairside) + E 133.00 Crowns, Acrylic / Composite / Compomer / Cast Metal Base 27131 Indirect + L 414.00 27135 Implant-supported + L + E I.C. CROWNS, PORCELAIN / CERAMIC / POLYMER GLASS 27201 Crown, Porcelain / Ceramic / Polymer Glass + L 560.00 27205 Crown, Porcelain / Ceramic / Polymer Glass, Implant-supported + L + E I.C. Crowns, Porcelain / Ceramic / Polymer Glass, Fused to Metal Base 27211 Crown, Porcelain / Ceramic / Polymer Glass Fused to Metal Base + L 560.00 27212 Crown, Porcelain / Ceramic / Polymer Glass Fused to Metal Base, I.C. Complicated (restorative, positional and/or aesthetic) + L 27213 Crown, Porcelain / Ceramic / Polymer Glass, Fused to Metal Base, I.C. with Porcelain Margin + L 27215 Crown, Porcelain / Ceramic Fused to Metal Base, Implant-supported + L + E I.C. Crowns, 3/4, Porcelain / Ceramic / Polymer Glass 27221 Crown, 3/4, Porcelain / Ceramic / Polymer Glass + L 595.00 27222 Crown, 3/4, Porcelain / Ceramic / Polymer Glass, Complicated + L I.C. CROWNS, FULL, CAST METAL 27301 Crown, Full, Cast Metal + L 560.00 27302 Crown, Full, Cast Metal, Complicated (restorative, positional) + L I.C. 27305 Crown, Full, Cast Metal, Implant-supported + L + E I.C. Crowns, 3/4, Cast Metal 27311 Crown, 3/4, Cast Metal + L 560.00 27312 Crown, 3/4, Cast Metal, Complicated + L I.C. CROWNS MADE TO AN EXISTING PARTIAL DENTURE CLASP (additional to crown) 27401 One crown 104.00 27409 Each additional crown 104.00 COPINGS, METAL / ACRYLIC, TRANSFER (thimble type) 27511 Coping, Metal / Acrylic, Transfer (thimble) as a Separate 173.00 Procedure + L

2008 - REST 21 VENEERS, LABORATORY PROCESSED 27602 Veneer, Porcelain / Ceramic / Polymer Glass, Bonded + L 414.00 REPAIRS, (single units only, does not include removal and recementation) Repairs, Inlays, Onlays or Crowns, Acrylic / Composite / Compomer (single units) 27711 Direct 70.00 Repairs, Inlays, Onlays or Crowns, Porcelain / Ceramic / Polymer Glass, Porcelain/Ceramic/Polymer Glass/Fused to Metal base 27721 Direct 120.00 27722 Indirect + L 195.00 RECONTOURING OF EXISTING CROWNS, per tooth 27801 One unit of time 67.00 27809 Each additional unit of time 67.00 RESTORATIVE PROCEDURES, OVERDENTURES OVERDENTURES, DIRECT 28101 Natural Tooth Preparation, Placement of Pulp Chamber Restoration 65.00 (amalgam or composite) and Fluoride Application, Endodontically Treated Tooth 28102 Natural Tooth Preparation and Fluoride Application, Vital Tooth 57.00 28103 Prefabricated Attachment, as an Internal / External Overdenture 190.00 Retentive Device, Direct to a Natural Tooth + L and/or + E (used with the appropriate denture code) per tooth 28105 Implant-supported Prefabricated Attachment as an Overdenture I.C. Retentive Device, Direct + L + E OVERDENTURES, INDIRECT Coping Crowns, Cast Metal, No Attachments, Indirect 28211 No Attachment, Indirect + L 191.00 28215 Implant-supported, Indirect + L + E I.C. Coping Crowns, Cast Metal, with Attachments, Indirect 28221 With Attachment, Indirect + L and/or + E 384.00 28225 Implant-supported with Attachment + L + E I.C.

22 2008 - 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) 29101 One unit of time + L + E 66.00 29102 Two units + L + E 132.00 29103 Three units + L + E 198.00 29104 Four units + L + E 264.00 REMOVAL, INLAYS / ONLAYS / CROWNS / VENEERS (single units only) 29301 One unit of time 66.00 29302 Two units 132.00 29303 Three units 198.00 29304 Four units 264.00 STAINING, PORCELAIN (chairside) 29401 One unit of time + L 66.00 29402 Two units + L 132.00 29403 Three units + L 198.00 29404 Four units + L 264.00

ENDODONTICS 30000-39999 2008 - 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) 32221 Anterior and Bicuspid Tooth 87.00 32222 Molar Tooth 104.00 Pulpotomy, Primary Teeth 32231 Primary Tooth as a Separate Procedure 70.00 32232 Primary Tooth, Concurrent with Restorations 72.00 (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 32311 One Canal 119.00 32312 Two Canals 183.00 32313 Three Canals I.C. 32314 Four Canals or more I.C. 32315 Exceptional anatomy / difficult access in addition to 32311-32314 I.C. Pulpectomy, Primary Teeth 32321 Anterior Tooth 73.00 32322 Posterior Tooth 108.00 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.

24 2008 - ENDO ROOT CANALS, PERMANENT TEETH / RETAINED PRIMARY TEETH Includes: clinical procedures with appropriate radiographs, excluding final restoration ONE Canal 33111 One canal 348.00 33112 Difficult access 434.00 33113 Exceptional anatomy 434.00 33114 Calcified canal 434.00 33115 Retreatment of previously completed therapy 434.00 33116 Continuing treatment having been aborted by referring / previous dentist 434.00 TWO Canals 33121 Two canals 497.00 33122 Difficult access 596.00 33123 Exceptional anatomy 596.00 33124 Calcified canals 596.00 33125 Retreatment of previously completed therapy 596.00 33126 Continuing treatment having been aborted by referring / previous dentist 596.00 THREE Canals 33131 Three canals 644.00 33132 Difficult access 772.00 33133 Exceptional anatomy 772.00 33134 Calcified canals 772.00 33135 Retreatment of previously completed therapy 772.00 33136 Continuing treatment having been aborted by referring / previous dentist 772.00 FOUR or More Canals 33141 Four or more canals 782.00 33142 Difficult access 898.00 33143 Exceptional anatomy 898.00 33144 Calcified canals 898.00 33145 Retreatment of previously completed therapy 898.00 33146 Continuing treatment having been aborted by referring / previous dentist 898.00 ROOT CANALS, PRIMARY TEETH 33401 One canal 148.00 33402 More than one canal 198.00 APEXIFICATION / APEXOGENESIS / INDUCTION OF HARD TISSUE REPAIR (to include biomechanical preparation and placement of dentogenic media) 33601 One canal 129.00 33602 Two canals 170.00 33603 Three canals 217.00 33604 Four canals or more 389.00 33605 Difficult access in addition to 33601-33604 I.C.

2008 - ENDO 25 Re-insertion of Dentogenic Media per visit 33611 One canal 55.00 33612 Two canals 55.00 33613 Three canals 55.00 33614 Four canals or more 55.00 APICOECTOMY / APICAL CURETTAGE PERIAPICAL SERVICES Maxillary Anterior 34111 One root 199.00 34112 Two roots 285.00 Maxillary Bicuspid 34121 One root 228.00 34122 Two roots 302.00 34123 Three roots 379.00 Maxillary Molar 34131 One root 252.00 34132 Two roots 334.00 34133 Three roots 422.00 34134 Four or more roots I.C. Mandibular Anterior 34141 One root 196.00 34142 Two or more roots 281.00 Mandibular Bicuspid 34151 One root 224.00 34152 Two roots 297.00 34153 Three or more roots 373.00 Mandibular Molar 34161 One root 278.00 34162 Two roots 367.00 34163 Three roots 462.00 34164 Four or more roots I.C. RETROFILLING Maxillary Anterior 34211 One canal 75.00 34212 Two or more canals 91.00 Maxillary Bicuspid 34221 One canal 90.00 34222 Two canals 112.00 34223 Three canals 123.00 34224 Four or more canals 133.00

26 2008 - ENDO Maxillary Molar 34231 One canal 109.00 34232 Two canals 134.00 34233 Three canals 148.00 34234 Four or more canals 157.00 Mandibular Anterior 34241 One canal 73.00 34242 Two or more canals 89.00 Mandibular Bicuspid 34251 One canal 88.00 34252 Two canals 109.00 34253 Three canals 121.00 34254 Four or more canals 130.00 Mandibular Molar 34261 One canal 109.00 34262 Two canals 134.00 34263 Three canals 148.00 34264 Four or more canals 157.00 RETREATMENT, APICOECTOMY / APICAL CURETTAGE Maxillary Anterior 34311 One root 227.00 34312 Two roots 323.00 Maxillary Bicuspid 34321 One root 257.00 34322 Two roots 340.00 34323 Three roots 429.00 34324 Four or more roots I.C. Maxillary Molar 34331 One root 288.00 34332 Two roots 383.00 34333 Three roots 484.00 34334 Four or more roots I.C. Mandibular Anterior 34341 One root 227.00 34342 Two or more roots 323.00 Mandibular Bicuspid 34351 One root 257.00 34352 Two roots 340.00 34353 Three roots 429.00 34354 Four or more roots I.C.

2008 - ENDO 27 Mandibular Molar 34361 One root 318.00 34362 Two roots 420.00 34363 Three roots 532.00 34364 Four or more roots I.C. AMPUTATIONS, ROOT (includes recontouring tooth and furca) 34411 One root 242.00 34412 Two roots 286.00 HEMISECTION 34421 Maxillary Bicuspid 122.00 34422 Maxillary Molar 159.00 34423 Mandibular Molar 159.00 ENDODONTIC, PROCEDURES, MISCELLANEOUS ISOLATION OF ENDODONTIC TOOTH / TEETH FOR ASEPSIS 39101 Banding and/or Coronal Buildup of Tooth / Teeth and/or Contouring of 89.00 Tissue Surrounding Tooth / Teeth to Maintain Aseptic Operating Field (per tooth) OPEN AND DRAIN (separate emergency procedures) 39201 Anteriors and Bicuspids 65.00 39202 Molars 65.00 Opening Through Artificial Crown (In addition to procedures) 39212 Molars 125.00 BLEACHING, NON VITAL Bleaching Endodontically Treated Tooth / Teeth 39311 One unit of time 66.00 39312 Two units 132.00 39313 Three units 198.00 39319 Each additional unit over three 66.00 EXPLORATORY ACCESS THROUGH CLINICAL CROWN OF PREVIOUSLY TREATED TOOTH Exploratory Access 39411 Anterior 66.00 39412 Bicuspid 131.00 39413 Molar 196.00

PERIODONTICS 40000-49999 2008 - 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. 41211 One unit of time 60.00 41212 Two units 120.00 41213 Three units 180.00 41214 Four units 240.00 41219 Each additional unit over four 60.00 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 41221 One unit of time 52.00 41222 Two units 104.00 41223 Three units 156.00 41224 Four units 208.00 41229 Each additional unit over four 52.00 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). 41231 One unit of time 58.00 41232 Two units 116.00 41233 Three units 174.00 41234 Four units 232.00 41239 Each additional unit over four 58.00 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.) 41301 One unit of time 30.00 41302 Two units 60.00 41309 Each additional unit over two 30.00