1 | DIAGNOSTIC SERVICES | Fee on or after May 1, 1989 |
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01200 | Oral examination | $13.00 |
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01200 | Recall oral examination | $13.00 |
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| A fee for an oral examination will be paid once within a period of twelve consecutive months. A fee for a recall oral examination may be paid once within a period of six consecutive months for children in the care of the Minister under the Family Services Act and social assistance dependent children who have not reached their fourteenth birthday. | |
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01300 | Emergency examination | $13.00 |
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02111 | First film | $10.20 |
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02112 | Each additional film (regardless of type) | $ 3.80 |
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| Radiographs are required for all services listed in Article 5.02 or when requested by the Dental Advisory Committee. | |
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| Only radiographs of proper angulation and exposure will be covered under the Agreement. | |
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| Diagnostic films for a beneficiary are limited to four unless additional films are requested by the Dental Advisory Committee. | |
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02600 | Panorex | $28.50 |
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| The above rate of payment for Panorex shall be paid when the x-rays are | |
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| ( a) submitted by an oral surgeon or orthodontist, | |
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| ( b) requested by the Dental Advisory Committee, or | |
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| ( c) required for prior approval of the Dental Advisory Committee for multiple extractions. | |
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| Where a Panorex x-ray is submitted in cases other than those enumerated above, the rate of payment on or after May 1, 1989 is $17.70. | |
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| Panorex x-rays are not accepted for evaluation of restorative work. | |
85-61; 86-77; 87-138; 88-219; 89-182 |
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2 | SURGICAL SERVICES | Fee on or after May 1, 1989 |
| Removal of erupted teeth - uncomplicated | |
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71101 | Single tooth - initial extraction (bone contouring or treatment of post-surgical complications included) | $ 25.10 |
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71111 | Each additional tooth - same quadrant | $ 12.00 |
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72100 | Impactions - I.C. Maximum | $113.30 |
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72210 | Impactions - I.C. Maximum | $113.30 |
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72220 | Impactions - I.C. Maximum | $118.40 |
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72230 | Impactions - I.C. Maximum | $118.40 |
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| The maximum fee on or after May 1, 1989 for full mouth surgical removal of teeth (twenty-two or more teeth) including alveoloplasty in any one case shall not exceed $186.00. Prior approval by the Dental Advisory Committee is required for | |
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| ( a) all complicated extractions under 72100, 72210, 72220 or 72230, or | |
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| ( b) multiple extractions (four or more teeth) for persons who are eighteen years of age or older. The fee for services performed by oral surgeons shall be negotiated between the oral surgeon and the Department of Social Development. | |
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73133 | Excision of torus palatinus | $164.00 |
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73134 | Excision of torus mandibularis (unilateral) | $ 90.00 |
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73135 | Excision of torus mandibularis (bilateral) | $145.00 |
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| Fees for excisions under 73133, 73134 and 73135 shall be paid only if | |
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| ( a) the excision is a necessary prerequisite for a denture, and | |
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| ( b) prior approval of the Dental Advisory Committee is obtained. | |
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79306 | Closure of oro-antral fistula (oral surgeon only) - I.C. | |
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| The fees on or after May 1, 1989 shall be a minimum of $66.00 and a maximum of $112.00. | |
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79600 | Post surgical treatment - I.C. Maximum | $103.00 |
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| Approval of the fee by the Dental Advisory Committee is required for post surgical treatment. Payment shall be made only when this treatment is done by other than the treating dentist. | |
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79999 | Emergency treatment of accidental trauma to the mouth for persons under eighteen years of age. The request for payment shall be accompanied by an explanation of the circumstances of the accident and a description of the details of treatment. | I.C. |
85-61; 86-77; 87-138; 88-219; 89-182; 94-152; 2000, c.26, s.152; 2008, c.6, s.25 |
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3 | RESTORATIVE SERVICES | Fee on or after May 1, 1989 |
| Amalgam Restorations | |
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| ( a) Primary teeth | |
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21101 | Amalgam, one surface | $23.50 |
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21102 | Amalgam, two surfaces | $31.50 |
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21103 | Amalgam, three surfaces or more | $39.50 |
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| ( b) Permanent bicuspid teeth | |
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21211 | Amalgam, one surface | $24.00 |
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21212 | Amalgam, two surfaces | $39.50 |
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21213 | Amalgam, three surfaces or more | $47.50 |
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| ( c) Permanent molar teeth | |
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21221 | Amalgam, one surface | $32.50 |
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21222 | Amalgam, two surfaces | $45.50 |
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21223 | Amalgam, three surfaces or more | $56.50 |
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| ( d) Retentive pins | |
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21301 | Retentive pin, additional, one pin - per restoration | $ 8.80 |
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21302 | Retentive pin, additional, two pins - per restoration | $19.00 |
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| ( e) Composite restorations | |
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23101 | Class I and V | $30.50 |
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23102 | Class III | $30.50 |
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23103 | Class IV | $51.00 |
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| The maximum per tooth allowance for composite restoration on or after May 1, 1989 will ordinarily be $51.40 except in the case of two Class III restorations where the maximum per tooth allowance on or after May 1, 1989 will be $55.80. | |
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| ( f) Acid etched composite restorations | |
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23111 | Class I and V | $41.00 |
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23112 | Class III | $50.00 |
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23113 | Class IV | $79.80 |
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23114 | Double Class IV | $93.30 |
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| The maximum per tooth allowance on or after May 1, 1989 for two Class III acid etched restorations is $84.50. | |
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| Acid etch on deciduous teeth is not an entitled service. | |
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| Acid etch Class V is an entitled service on permanent anteriors and buccal surfaces of maxillary bicuspids only. | |
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| The maximum per tooth allowance on or after May 1, 1989 for more than one Class IV restoration is $93.30. This fee includes retentive pins if applicable. | |
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| Acid etch Class I is an entitled service on anterior permanent teeth only. | |
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| If a restoration is redone by the same dentist within a period of six months, the second restoration is not an entitled service. | |
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| Restoration on tooth number 51, 52, 61, 62, 71, 72, 81 or 82 is not an entitled service. | |
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| ( g) Crowns | |
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| Prior approval from the Dental Advisory Committee is required in all cases. | |
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22220 | Preformed stainless steel - Primary posterior tooth - per tooth | $68.00 |
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| Payment for preformed stainless steel primary posterior tooth number 54, 64, 74 or 84 is available only for children who are under nine years of age. | |
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22310 | Preformed stainless steel - Permanent anterior tooth | I.C. |
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22320 | Preformed stainless steel - Permanent posterior tooth | $68.00 |
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22410 | Prefabricated restoration on primary cuspid anterior tooth number 53, 63, 73, or 83 | $68.00 |
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22510 | Acrylic or plastic transitional, direct (prefabricated) | I.C. |
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| Fees for filling include any necessary pulp protection. | |
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| When at the same sitting, in order to conserve tooth structure, two separate restorations are performed on the same tooth involving a common surface, the fee will be assessed as one restoration. | |
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| The dental practitioner must include the proper procedure code, international tooth code and the names of the surfaces restored in order to obtain payment for a restoration. | |
85-61; 86-77; 87-138; 88-219; 89-182 |
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4 | PREVENTIVE SERVICES | Fee on or after May 1, 1989 |
| Dental prophylaxis | |
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11100 | Primary dentition | $18.20 |
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11200 | Mixed dentition | $22.00 |
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11300 | Permanent dentition | $35.00 |
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| Dental prophylaxis is available once within a period of six consecutive months for children who are under fourteen years of age. Children who are fourteen years of age and over and under eighteen years of age are entitled to one prophylaxis within a period of twelve consecutive months. Dental prophylaxis will be considered for persons eighteen years of age and over only in cases where minor scaling is necessary in order to fabricate a partial denture. | |
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| Fluoride treatment | |
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12400 | Fluoride topical application | $11.30 |
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| Topical application of fluoride gel or liquid subsequent to prophylaxis is available once within a period of six consecutive months for children who are under fourteen years of age. Children who are fourteen years of age and over and under eighteen years of age are entitled to one topical application within a period of twelve consecutive months. | |
85-61; 86-77; 87-138; 88-219; 89-182 |