?i ,alber?ro dental Guide for Den?rol Fees September 1, 2017 Table of Contents Page Section Code Series Diagnostic...................................................................................................... 01000- 09999 ................ 1 Prevention ..................................................................................................... 10000- 19999 ............... 10 Restoration . .................................................................................................. 20000 - 29999 ...............16 Endodontics....................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30000 - 39999 ...............26 Periodontics................................................................................................. 40000- 49999 ...............32 Prosthodontics-Removable .......................................................................... 50000- 59999 .............. 38 Prosthodontics-Fixed..................................................................................... 60000- 69999 ............. 53 Oral and Maxillofacial Surgery ...................................................................... 70000 - 79999 ............. 59 Orthodontics................................................................................................... 80000- 89999 ............. 80 Adjunctive General Services.......................................................................... 90000- 99999 ............. 84 Appendix .............................................................................................................Guide Structure ..............93 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee DIAGNOSTIC 01000 01010 01100 EXAMINATION AND DIAGNOSIS, CLINICAL ORAL FIRST DENTAL VISIT 01011 Oral assessment for patients up to the age of 3 years inclusive. Assessment to include: Medical history, familial dental history; dietary/feeding practices; oral habits; oral hygiene; fluoride exposure. Anticipatory guidance with parent/guardian EXAMINATIONS, AND DIAGNOSIS COMPLETE ORAL, to include: (a) (b) (c) History, Medical and Dental. Clinical Examination and Diagnosis of Hard and Soft tissues, including the following as necessary: Carious lesions, missing teeth, determination of sulcular depth, gingival contours, mobility of teeth, interproximal tooth contact relationships, occlusion of teeth, TMJ, pulp vitality test/analysis, where necessary and any other pertinent factors; Radiographs extra, as required. 01101 Examination and Diagnosis, Complete, Primary Dentition, to include: (a) Extended examination and diagnosis on primary dentition, recording history, charting, treatment planning and case presentation, including above description as per 01100. 01102 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 as per 01100. (b) Eruption sequence, tooth size - jaw size assessment. 01103 Examination and Diagnosis, Complete, Permanent Dentition, to include: (a) Extended examination on permanent dentition, recording history, charting, treatment planning and case presentation, including above description as per 01100. 01200 74.63 75.04 102.27 106.99 EXAMINATIONS AND DIAGNOSIS, LIMITED ORAL 01201 Examination and Diagnosis, Limited, Oral, New Patient. Examination and diagnosis of hard and soft tissues, including checking of occlusion and appliances, but not including specific test/ analysis as for 01100. (May include PSR) 75.36 01202 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, as for 01100. 70.75 01204 Examination and Diagnosis, Specific Examination and evaluation of a specific situation in a localized area. Not to be used as a substitute for limited exam codes (01201, 01202) 70.81 01205 Examination and Diagnosis, Emergency. Examination and Diagnosis for the investigation of discomfort and/or infection in a localized area. Not to be used as a substitute for limited exam codes (01201, 01202). 70.81 Page 1 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 80.63 01206 Analysis, Mixed Dentition 01300 EXAMINATIONS AND DIAGNOSIS, STOMATOGNATHIC, DYSFUNCTIONAL 01301 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 test/analysis and consultations. 01302 Examination and Diagnosis, Stomatognathic Dysfunctional, Limited 01400 01402 Examination and Diagnosis, Oral Pathology, Specific (or repeat examination within 90 days for the same illness). 164.16 82.08 EXAMINATION AND DIAGNOSIS, PERIODONTAL 01501 Examination and Diagnosis, Periodontal, General Recording History, Charting, Treatment Planning and Case Presentation: (a) History, Medical and Dental (b) 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) 1503 Examination and Diagnosis, Periodontal, Specific 01600 82.08 EXAMINATIONS AND DIAGNOSIS, ORAL PATHOLOGY 01401 Examination and Diagnosis, Oral Pathology, General, to include: (a) Initial consultation with referring dentist or physician, (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. ( c) Clinical examination including in-depth analysis of medical status, (d) Diagnosis, prognosis and formulation of a treatment plan. 01500 270.19 217.28 149.26 186.26 EXAMINATIONS AND DIAGNOSIS, SURGICAL 01601 Examination and Diagnosis, Surgical, General (a) History, Medical and Dental (b) Clinical Examination as above, may include in-depth analysis of medical status, medication, anesthetic and surgical risk, initial consultation with referring dentist or physician, parent or guardian, evaluation of source of chief complaint, evaluation of pulpal vitality, mobility of teeth, occlusal factors, TMJ, or where the patient is to be admitted to hospital for dental procedures. Page 2 164.16 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 01602 Examination and Diagnosis, Surgical, Specific 01700 105.08 EXAMINATIONS AND DIAGNOSIS, PROSTHODONTIC 01701 Examination and Diagnosis, Prosthodontic, Edentulous (a) Extended Examination of the Edentulous Mouth, including detailed Medical and Dental History (incl. prosthetic history), visual and digital examination of the oral structures, head and neck (incl. TMJ), lips, oral mucosa, tongue, oral pharynx, salivary glands and lymph nodes, and including evaluation for implant-supported or retained prosthesis. 111.95 01702 Examination and Diagnosis, Prosthodontic, Specific 75.63 01703 Examination and Diagnosis, Prosthodontic, Fixed Oral Rehabilitation, to include: (a) History, Medical and Dental (b) Clinical Examination 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 test/analysis, where necessary and any other pertinent factors. (c) Evaluation of specific sites for implant-supported or retained prosthesis; (d) Radiographs extra, as required 01800 417.16 EXAMINATION AND DIAGNOSIS, ENDODONTIC 01801 Examination and Diagnosis, Endodontic, Complete Endodontic examination and/or complicated diagnosis. Recording history, charting treatment planning and case history. Includes the following: (a) History, Medical and Dental (b) Clinical Examination and Diagnosis may include vitality test/analysis, thermal test/analysis, cracked tooth test/analysis, occlusal exams, percussion, palpation, transillumination, anesthetic test/analysis and mobility test/analysis. 165.16 01802 Examination and Diagnosis, Endodontic, Specific Endodontic examination and evaluation of a specific situation in a localized area and vitality tests/analysis. 01900 103.08 EXAMINATION AND DIAGNOSIS, ORTHODONTIC 01901 Examination and Diagnosis, Orthodontic, General. To include: (a) Diagnosis models, complete intraoral radiograph series, or panoramic radiographic image, cephalograms, facial and intraoral photographs, consultation and case presentation. (a) Diagnostic models, complete intraoral radiograph series, or panoramic film, cephalograms, facial and intraoral photographs, consultation and case presentation. 01902 Examination and Diagnosis, Orthodontic, Specific 02000 RADIOGRAPHS (including radiographic examination and diagnosis and interpretation) 02100 RADIOGRAPHS, REGIONAL/LOCALIZED 02101 Radiographs, Complete Series (minimum of 12 images incl. bitewings) Page 3 +L 424.10 85.08 198.80 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 02102 Radiographs, Complete Series (minimum of 16 images incl. bitewings) 198.80 02110 RADIOGRAPHS, PERIAPICAL 02111 02112 02113 02114 02115 02116 02117 02118 02119 02120 29.10 58.20 69.54 89.43 109.37 129.19 149.04 168.92 188.74 198.78 Single image Two images Three images Four images Five images Six images Seven images Eight images Nine images Ten images 02130 RADIOGRAPHS, INTRAORAL, OCCLUSAL 02131 02132 02133 02134 49.62 74.51 99.34 124.21 Single film Two films Three films Four films 02140 RADIOGRAPHS, INTRAORAL, BITEWING 02141 02142 02143 02144 02145 02146 02300 29.80 47.53 69.54 82.63 109.37 129.19 Single film Two films Three films Four films Five films Six films RADIOGRAPHS, POSTERO-ANTERIOR AND LATERAL SKULL AND FACIAL BONE 02301 02302 02303 02304 74.49 124.21 173.95 223.66 Single image Two image Three image Sinus Examination and Diagnosis - Minimum four images identified as: 1) Waters 2) Caldwell 3) Lateral Skull 4) Basa 02309 Each additional image over four 02400 49.23 RADIOGRAPHS, SIALOGRAPHY 02401 Single image 02402 Two images 02409 Each additional image over two 74.51 124.21 49.23 02410 RADIOPAQUE DYES, USE OF, TO DEMONSTRATE LESIONS 02411 One unit of time I.C. Page 4 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee I.C. I.C. 02412 Two units of time 02419 Each additional unit over two 02500 RADIOGRAPHS, TEMPOROMANDIBULAR JOINT 02501 02502 02503 02504 02509 74.49 124.21 173.95 223.66 49.23 Single image Two images Three images Four images (minimum examination and diagnosis closed and open each side) Each additional image over four 02510 Arthrography of Temporo-mandibular joint 02511 Performing the Arthrographic Procedure 246.24 02520 Interpretation of the Arthrogram 02521 One unit of time 02529 Each additional unit of time 02600 74.63 74.63 RADIOGRAPHS, PANORAMIC 02601 Single image 02700 93.12 RADIOGRAPHS, CEPHALOMETRIC 02701 02702 02703 02704 02709 118.87 186.38 250.63 310.61 36.96 Single image Two images Three images Four images Each additional image over four 02750 RADIOGRAPHS, CEPHALOMETRIC, TRACING AND INTERPRETATION 02751 One unit of time 02752 Two units 02759 Each additional unit over two 02800 82.08 164.16 82.08 RADIOGRAPHS, COMPUTERIZED AXIAL TOMOGRAMS (CT), POSITION EMISSION TOMOGRAPHY (PET), MAGNETIC RESONANCE IMAGES (MRI) INTERPRETATION (either the radiographs, CT scans, PET scans, MRI scans, or the interpretation must be received from another source) 02801 One unit of time 02802 Two units 02809 Each additional unit over two 02900 +E +E +E RADIOGRAPHS, OTHER (either the radiographs or the interpretation must be received from another source) 02910 RADIOGRAPHS, DUPLICATE Page 5 91.35 182.51 91.35 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 02911 02912 02913 02914 02915 02916 02917 02918 02919 5.66 11.25 16.87 22.49 28.11 33.74 39.38 43.59 5.66 Single image Two images Three images Four images Five images Six images Seven images Eight images Each additional images over eight 02940 RADIOGRAPHS, HAND AND WRIST 02941 Radiographs, Hand and Wrist (as a diagnostic aid for dental treatment) per case 118.87 02930 RADIOGRAPHS, TOMOGRAPHY 02931 02932 02933 02934 02939 02950 118.87 186.44 250.63 310.61 49.23 Single view Two views Three views Four views Each additional view over four 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 02952 Mandibular +L +E I.C. +L +E I.C. 03000 TEMPLATE, SURGICAL (includes diagnostic wax-up. Also used to locate and orient osseo-integrated implants) 03001 Maxillary Template 03002 Mandibular Template 04000 +L +E +L +E 74.63 74.63 +L 70.89 +L 70.89 +L +L 82.08 82.08 TEST/ANALYSIS/LABORATORY PROCEDURES/INTERPRETATION AND/OR REPORTS 04100 TEST/ANALYSIS, MICROBIOLOGICAL (technical procedure only) 04101 Microbiological Test/Analysis for the Determination of Pathological Agents 04200 TEST/ANALYSIS, CARIES SUSCEPTIBILITY (technical procedure only) 04201 Bacteriological Test/Analysis for the Determination of Dental Caries susceptibility 04300 TEST/ANALYSIS, HISTOPATHOLOGICAL (technical procedure only) 04310 Test/Analysis, Histopathological, Soft Tissue 04311 Biopsy, Soft Oral Tissue - by Puncture 04312 Biopsy, Soft Oral Tissue - by Incision Page 6 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 04313 Biopsy, Soft Oral Tissue - by Aspiration +L Average Fee 82.08 +L +L +L I.C. I.C. I.C. 04320 Test/Analysis, Histopathological, Hard Tissue 04321 Biopsy, Hard Oral Tissue - by Puncture 04322 Biopsy, Hard Oral Tissue - by Incision 04323 Biopsy, Hard Oral Tissue - by Aspiration 04400 TEST/ANALYSIS, CYTOLOGICAL(technical procedure only) 04401 Cytological Smear from the Oral Cavity + E 04402 Vital Staining of Oral Mucosal Tissues 04500 +L +E 70.89 70.89 TESTS/ANALYSIS, PULP VITALITY AND INTERPRETATION 04501 One unit of time 04509 Each additional unit 04600 70.89 70.89 INTERPRETATION AND/OR REPORTS, LABORATORY 04601 Interpretation and/or Report, Microbiological by Oral Microbiologist 04602 Interpretation and/or Report, Histopathological by Oral Pathologist or Microbiologist 04603 Interpretation and/or Report, Cytological by Oral Pathologist 04604 Reports, Other 04700 +L to +L to +L 70.89 212.72 82.08 246.24 70.89 I.C. SUPPLEMENTARY DIAGNOSTIC PROCEDURES (INTERPRETATION ONLY) 04710 EQUILIBRATION, CASTS DIAGNOSTIC (PILOT EQUILIBRATION) FOR EXTENSIVE OR COMPLICATED RESTORATIVE DENTISTRY 04711 04712 04713 04714 04719 04720 One unit of time Two units Three units Four units Each additional unit over four +L +L +L +L +L 74.63 149.26 223.91 298.54 74.63 +L +L +L +L +L 74.63 149.26 223.91 298.54 74.63 WAX-UP, DIAGNOSTIC (TO EVALUATE COSMETIC AND/OR PREPARATION DESIGN AND/OR OCCLUSAL CONSIDERATIONS) (GNATHOLOGICAL WAX-UP) 04721 04722 04723 04724 04729 04730 One unit of time Two units Three units Four units Each additional unit over four SPLIT CAST MOUNTING, DIAGNOSTIC Page 7 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 04731 04732 04733 04734 04739 04740 +L +L +L +L +L One unit of time Two units Three units Four units Each additional unit over four Average Fee 74.63 149.26 223.91 298.54 74.63 INTERPRETATION OF DIAGNOSTIC CASTS 04741 One unit of time 04749 Each additional unit over one 04800 71.89 71.89 PHOTOGRAPHS, DIAGNOSTIC (technical procedure only) 04801 04802 04803 04809 04900 18.71 35.45 53.18 32.71 Single photograph Two photos Three photos Each additional photo over three CASTS, DIAGNOSTIC (technical procedure only) 04910 CASTS DIAGNOSTIC, UNMOUNTED 04911 Casts, Diagnostic, Unmounted 04912 Casts, Diagnostic, Unmounted, Duplicate 04913 Cast, Diagnositc, Unmounted, Upper and Lower Combined 04920 Casts, Diagnostic, Mounted Casts, Diagnostic, Mounted, using face bow transfer Casts, Diagnostic, Mounted, using face bow and occlusal records Casts, Diagnostic, Mounted using fully adjustable articulator (used with 04941 and 04942) +L +L +L +L 125.36 166.81 329.42 I.C. CASTS DIAGNOSTIC ORTHODONTIC 04931 Casts, Diagnostic, Orthodontic (unmounted, angle trimmed and soaped) 04940 79.89 35.45 167.81 CASTS DIAGNOSTIC MOUNTED 04921 04922 04923 04924 04930 +L +L +L +L 141.81 CASTS, DIAGNOSTIC, MISCELLANEOUS PROCEDURES 04941 Transverse Axis Location and Transfer, used in conjunction with 04922, 04923, and 04924 +L I.C. 04942 Three Dimensional Recordings of Patient's Dynamic Movements for Programming of Fully Adjustable Articulators 04943 Custom Incisal Guide Table +L I.C. +L I.C. 05000 CASE PRESENTATION/TREATMENT PLANNING 05100 TREATMENT PLANNING Page 8 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee (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 fee and in the radiographic interpretation fee.) 05101 05102 05103 05104 05109 05200 74.63 149.26 223.91 298.54 74.63 One unit of time Two units Three units Four units Each additional unit over four CONSULTATION, with patient 05201 One unit of time 05202 Two units 05209 Each additional unit over two 06100 77.63 155.26 77.63 RADIOGRAPHS, INTRAORAL (technical procedure only) 06101 Radiographs, Intraoral, Pedodontic, Complete Series (minimum of 12 images including bitewings) 06800 07000 RADIOGRAPHS, COMPUTERIZED AXIAL TOMOGRAMS (CT), POSITRON EMISSION TOMOGRAPHY 06810 Radiographs, Computerized Axial Tomograms, Position Emission Tomograms, Magnetic Resonance I.C. 06820 Radiographs, Computerized Axial Tomograms, Positron Emission Tomograms, Magnetic Resonance I.C. 06830 Radiographs, Computerized Axial Tomograms, Positron Emission Tomograms, Magnetic Resonance I.C. RADIOGRAPHS, CONE BEAM COMPUTERIZED TOMOGRAPHY (CBCT) 07010 Radiographs, CBCT, Acquisition 07011 Small field of view (e.g. sextant or part of; isolated temporomandibular joint) 07012 Large field of view (1 arch) 07013 Large field of view (2 arches) 99.34 118.87 186.44 07020 Radiographs, CBCT, Image Processing 07021 07022 07027 07029 I.C. I.C. I.C. I.C. One unit of time Two units of time One half unit of time Each additional unit over two 07030 Radiographs, CBCT, Interpretation 07031 One unit of time 07032 Two units of time 07037 One half unit of time 82.08 164.16 41.03 Page 9 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 82.08 07039 Each additional unit over two 07040 Radiographs, CBCT, Acquisition, Processing and Interpretation 07041 Small field of view (sextant or part of; isolated temporomandibular joint) 07042 Large field of view (1 arch) 07043 Large field of view (2 arches) 181.42 200.95 268.52 PREVENTION 11100 POLISHING 11101 One Unit of Time 11102 Two Units of Time 11107 1/2 Unit of Time 65.96 141.81 32.98 11110 SCALING 11111 One Unit of Time 11112 Two Units of Time 11113 Three Units of Time 11114 Four Units of Time 11115 Five Units of Time 11116 Six Units of Time 11117 1/2 Unit of Time 11119 Each Additional Unit over Six 12100 70.81 141.62 212.43 283.24 373.17 447.82 35.41 70.81 FLUORIDE TREATMENTS 12101 Fluoride Treatment, Topical Application 12102 Fluoride Treatment, Supervised, Self-Administered Brush-In 12600 FLUORIDE, CUSTOM APPLIANCES, (home application) 12601 Fluoride, Custom Appliance - Maxillary Arch 12602 Fluoride, Custom Appliance - Mandibular Arch 12700 31.95 35.45 +L +L 70.89 70.89 +L +L 70.89 70.89 MEDICATION, CUSTOM APPLIANCE 12701 Medication, Custom Appliance - Maxillary Arch 12702 Medication, Custom Appliance - Mandibular Arch 13000 PREVENTIVE SERVICES, OTHER 13100 NUTRITIONAL COUNSELING Including: recording and analysis of up to seven day dietary intake and consultation 13101 13102 13103 13104 13109 70.89 141.81 212.72 283.64 70.89 One unit of time Two units Three units Four units Each additional unit over four Page 10 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 13200 ORAL HYGIENE INSTRUCTION/PLAQUE CONTROL To include: brushing and/or flossing and/or embrasure cleaning. 13210 INDIVIDUAL INSTRUCTION (ONE INSTRUCTOR TO ONE PATIENT) - EXCLUDING AUDIO-VISUAL TIME 13211 13212 13213 13214 13217 13219 13220 GROUP INSTRUCTION - EXCLUDING AUDIO-VISUAL TIME 13221 13222 13223 13224 13229 13230 70.89 141.81 212.72 283.64 35.45 70.89 One unit of time Two units Three units Four units 1/2 Unit of Time Each additional unit over four 70.89 141.81 212.72 283.64 70.89 One unit of time Two units Three units Four units Each additional unit over four RE-INSTRUCTION (WITHIN 6 MONTHS) - EXCLUDING AUDIO-VISUAL TIME 13231 One unit of time 13232 Two units 13239 Each additional unit of two 13240 70.89 141.81 70.89 ORAL HYGIENE INSTRUCTION - AUDIO-VISUAL 13241 One unit of time 13242 Two units 13249 Each additional unit over two 13400 70.89 141.81 70.89 SEALANTS, PIT AND FISSURE (Mechanical and/or chemical preparation included) 13401 First tooth 13409 Each additional tooth same quadrant 13410 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 13419 Each additional tooth same quadrant 13600 35.97 18.71 72.56 68.56 TOPICAL APPLICATION TO HARD TISSUE LESION(S) OF AN ANTIMICROBIAL OR REMINERALIZATION AGENT 13601 One unit of time 13602 Two units of time 13609 Each additional unit over two +E +E Page 11 70.89 141.81 70.89 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 14000 APPLIANCES 14100 APPLIANCES, REMOVABLE, CONTROL OF ORAL HABITS 14101 Appliance, Maxillary 14102 Appliance, Mandibular 14103 Appliances, Maxillary plus Mandibular 14200 14310 +L 82.08 +L +L +L 82.08 164.16 82.08 +L +L +L +L 82.08 164.16 246.24 82.08 +L 84.89 92.89 +L +L 418.61 420.61 +L +L 76.12 152.25 APPLIANCES, CONTROL OF ORAL HABITS ADJUSTMENTS, REPAIRS MAINTENANCE 14401 14402 14403 14409 One unit of time Two units of time Three units of time Each additional unit over three APPLIANCES, PROTECTIVE MOUTH GUARDS 14501 Appliance, Protected Mouth Guards, Preformed 14502 Appliance, Protective Mouth Guards, Processed 14600 574.57 574.57 MYOFUNCTIONAL THERAPY (e.g. to correct mouth breathing, abnormal swallowing, tongue thrust, etc.) 14311 First unit of time per visit 14312 Two units 14319 Each additional unit over two 14500 +L +L CONTROL OF ORAL HABITS, MISCELLANEOUS 14301 Motivation of Patient - Psychological Approach (e.g. thumb sucking, lip biting, etc.) - per visit 14400 523.49 727.49 738.75 APPLIANCES, FIXED/CEMENTED, CONTROL OF ORAL HABITS 14201 Appliance, Maxillary 14202 Appliance, Mandibular 14300 +L +L +L APPLIANCES, PERIODONTAL (see separate code for control of Oral Habits 14100, Protective Mouth Guards 14500, TMJ 14700 and TMJ appliances 14800) 14610 APPLIANCES, PERIODONTAL (including bruxism appliance); INCLUDES IMPRESSION, INSERTION AND INSERTION ADJUSTMENT (no post-insertion adjustments) 14611 Maxillary Appliance 14612 Mandibular Appliance 14620 APPLIANCES, ADJUSTMENTS, REPAIRS 14621 One unit of time 14622 Two units Page 12 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 14623 Three units 14629 Each additional unit over three +L +L Average Fee 228.37 76.12 +L 228.37 228.37 +L +L 616.27 616.27 +L +L 616.27 726.16 +L +L +L +L 79.92 159.84 239.78 79.92 +L 228.37 228.37 +L +L 695.50 695.50 +L +L +L +L 79.92 159.84 239.78 79.92 14630 APPLIANCES, RELINE 14631 Reline, Direct 14632 Reline, Processed 14700 APPLIANCES, TEMPOROMANDIBULAR JOINT 14710 Appliance, TMJ, Diagnostic and/or Therapeutic, includes impression, insertion and insertion adjustment (no post-insertion adjustments) 14711 Maxillary Appliance 14712 Mandibular Appliance 14720 Appliance, TMJ Intraoral Repositioning; includes impression, insertion and insertion adjustment (no post-insertion adjustments) 14721 Maxillary Appliance 14722 Mandibular Appliance 14730 APPLIANCE, TMJ, PERIODIC MAINTENANCE, ADJUSTMENTS, REPAIRS 14731 14732 14733 14739 14740 One unit of time Two units Three units Each additional unit over three APPLIANCE, TMJ, RELINE 14741 Reline, Direct 14742 Reline, Indirect 14800 APPLIANCES, MYOFACIAL PAIN DYSFUNCTION SYNDROME (conditions that originate outside the temporomandibular joint) 14810 Appliance, Myofascial Pain Dysfunction Syndrome, (to include: models, gnathological determinants) Appliance Construction only, and insertion adjustment (no post-insertion adjustments) 14811 Maxillary Appliance 14812 Mandibular Appliance 14820 14821 14822 14823 14829 APPLIANCE, MYOFACIAL PAIN DYSFUNCTION SYNDROME, PERIODIC MAINTENANCE, ADJUSTMENT AND REPAIRS One unit of time Two units Three units Each additional unit over three Page 13 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 14900 APPLIANCES, INTRAORAL, TO TREAT MEDICALLY DIAGNOSED OBSTRUCTIVE SLEEP APNEA, SNORING, UPPER AIRWAY RESISTANCE SYNDROM (UARS) WITH OR WITHOUT APNEA (Includes models, gnathological determinants, appliance construction and insertion adjustment (no postinsertion adjustments)) 14901 Appliance, Intraoral, For the Treatment of Obstructive Airway Disorders, Ridge or Tooth Supported 14902 Appliance, Tongue Retaining Device, for the Treatment of Obstructive Airway Disorders +L 738.75 +E 418.61 +L +L +L 82.08 164.16 82.08 14910 Appliance, Intraoral, For the Treatment of Obstructive Airway Disorders, Periodic Maintenance, 14911 One unit of time 14912 Two units 14919 Each additional unit over two 14920 Appliance, Intraoral, For the Treatment of Obstructive Airway Disorders, Monitoring To include patient to 14921 One unit of time 14922 Two units 14929 Each additional unit over two 74.63 149.26 74.63 15000 SPACE MAINTAINERS (Includes the design, separation, fabrication, insertion, and where applicable initial cementation and removal) 15100 SPACE MAINTAINERS, BAND TYPE 15101 15102 15103 15104 Space Space Space Space Maintainer, Band Type, Fixed, Unilateral Maintainer, Band Type, Fixed, Unilateral w/ Intra-alveolar attachment Maintainer, Band Type, Fixed, Bilateral (soldered lingual arch) Maintainer, Band Type, Fixed, Bilateral (soldered lingual arch), with Teeth Attached 15105 Space Maintainer, Band Type, Fixed, Bilateral Tubes and Locking Wire 15200 246.24 246.24 328.33 328.33 +L 328.33 +L +L 260.24 246.24 SPACE MAINTAINERS, STAINLESS STEEL CROWN TYPE 15201 Space Maintainer, Stainless Steel Crown Type, Fixed 15202 Space Maintainer, Stainless Steel Crown Type, Fixed, with intra Alveolar Attachment 15300 +L +L +L +L SPACE MAINTAINERS, CAST TYPE 15301 Space Maintainer, Cast Type, Fixed 15302 Space Maintainer, Cast Type, Fixed, with Intra Alveolar Attachment 15400 I.C. I.C. SPACE MAINTAINERS, ACRYLIC, REMOVABLE 15401 Space Maintainer, Acrylic, Removable, Bilateral Clasps, Retaining Wires 15402 Space Maintainer, Acrylic, Removable, Bilateral Clasps, Retaining Wires with Teeth 15403 Space Maintainer, Acrylic Removable, No Clasps Page 14 +L +L +L 325.24 246.24 246.24 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 15500 SPACE MAINTAINERS, BONDED, PONTIC TYPE 15501 Space Maintainer, Bonded, Pontic Type + L 15600 16100 +L 246.24 15601 Maintenance, Space Maintainer Appliances, to include: adjustment and/or recementation after 30 days from insertion 15602 Maintenance, Space Maintainer Appliances, addition of clasps and/or activating wires +L 15603 Repairs, Space Maintainer Appliances (including recementation) +L 15604 Removal of Fixed Space Maintainer Appliances by Second Dentist 82.08 SPACE MAINTAINERS, MAINTENANCE OF 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 16102 16103 16104 16109 16200 74.63 149.26 223.91 298.54 74.63 One unit of time Two units Three units Four units Each additional unit over four DISKING OF TEETH, Interproximal 16201 16202 16203 16209 16300 70.89 141.81 212.72 70.89 One unit of time Two units Three units Each additional unit over three RECONTOURING OF NATURAL TEETH FOR AESTHETIC REASONS 16301 One unit of time 16309 Each additional unit over three 16400 78.35 78.35 RECONTOURING OF TEETH FOR FUNCTIONAL REASONS (Not associated with delivery of a single or multiple prosthesis) 16401 One unit of time 16409 Each additional unit of time 16500 164.16 164.16 78.35 78.35 78.35 OCCLUSION 16510 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 period of three months. Page 15 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 16511 16512 16513 16514 16519 87.51 175.04 262.56 350.07 87.51 One unit of time Two units Three units Four units Each additional unit over four RESTORATION 20100 Note 1: Note 2: Treatment of dental caries includes pulp protection and local anaesthesia. Where, at the same appointment, in order to conserve tooth structure, two separate restorations are performed on the same tooth involving a common surface, when one restoration might have been done; this should be considered as one restoration in assessing the fee. Note 3: Finishing restorations is a separate procedure done at a separate appointment> (See 16100) CARIES, TRAUMA AND PAIN CONTROL 20110 Caries/Trauma/Pain Control (removal of carious lesions or existing restorations or gingivally attached tooth fragments and placement of sedative/protective dressings, includes pulp caps when necessary, as a separate procedure). 20111 First tooth to 20119 Each additional tooth same quadrant to 79.92 159.84 79.92 159.84 20120 Caries/Trauma/Pain Control (removal of carious lesions or existing restorations or gingivally attached tooth fragments and placement of sedative/protective-protective dressings, includes pulp caps when necessary and the use of a band for retention and support, as a separate procedure) 20121 First tooth to 20129 Each additional tooth same quadrant to 119.89 199.81 119.89 199.81 20130 TRAUMA CONTROL, SMOOTHING OF FRACTURED SURFACES PER TOOTH 20131 First tooth 20139 Each additional tooth same quadrant 21000 RESTORATIONS, AMALGAM 21100 RESTORATION, AMALGAM, PRIMARY TEETH 21110 43.06 39.06 RESTORATIONS, AMALGAM, NON-BONDED, PRIMARY TEETH 21111 One surface 21112 Two surfaces Page 16 97.29 135.80 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 21113 Three surfaces 21114 Four surfaces 21115 Five surfaces or maximum surfaces per tooth 21120 21121 21122 21123 21124 21125 21200 127.95 169.71 203.89 240.08 278.66 RESTORATIONS, AMALGAM, PERMANENT TEETH 21210 RESTORATIONS, AMALGAM, NON-BONDED, PERMANENT BICUSPIDS AND ANTERIORS 21211 21212 21213 21214 21215 21220 One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth 107.29 148.11 188.29 231.48 252.08 RESTORATIONS, AMALGAM, NON-BONDED, PERMANENT MOLARS 21221 21222 21223 21224 21225 21230 One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth 113.29 148.41 192.29 242.48 271.08 RESTORATIONS, AMALGAM, BONDED, PERMANENT BICUSPIDS AND ANTERIORS 21231 21232 21233 21234 21235 21240 One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth 135.95 168.71 209.89 251.08 281.66 RESTORATIONS, AMALGAM, BONDED, PERMANENT MOLARS 21241 21242 21243 21244 21245 21300 RESTORATIONS, AMALGAM, BONDED, PRIMARY TEETH One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth Average Fee 176.29 215.48 257.08 One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth 146.95 181.71 216.89 258.08 311.66 RESTORATIONS, AMALGAM CORES 21301 Restoration, Amalgam Core, Non-Bonded, in Conjunction with Crown or Fixed Bridge Retainer Page 17 197.89 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 221.48 21302 Restoration, Amalgam Core, Bonded, in Conjunction with Crown or Fixed Bridge Retainer 21400 PINS, RETENTIVE per restoration (for amalgams and tooth coloured restorations) 21401 21402 21403 21404 21405 21500 32.92 47.39 61.86 77.33 86.78 One pin Two pins Three pins Four pins Five pins or more RESTORATIONS MADE TO A TOOTH SUPPORTING AN EXISTING PARTIAL DENURE CLASP (ADDITIONAL TO RESTORATION) 21501 Per restoration 74.33 22000 RESTORATIONS, PREFABRICATED, FULL COVERAGE 22200 RESTORATIONS, PREFABRICATED, METAL, PRIMARY TEETH 22201 22202 22211 22212 22300 Permanent Permanent Permanent Permanent Anterior Anterior - open face Posterior Posterior - open face RESTORATIONS PREFABRICATED, PLASTIC, PRIMARY TEETH 174.84 174.84 RESTORATIONS PREFABRICATED, PLASTIC, PERMANENT TEETH 22501 Permanent Anterior 22511 Permanent Posterior 22600 207.29 255.48 229.52 309.48 300.24 235.08 274.24 22401 Primary Anterior 22411 Primary Posterior 22500 +L RESTORATIONS PREFABRICATED, METAL, PERMANENT TEETH 22301 22302 22311 22312 22400 Primary Anterior Primary Anterior - open face/acrylic veneer Primary Posterior Primary Posterior - open face 233.08 233.08 RESTORATIONS, PREFABRICATED, PORCELAIN/CERAMIC/POLYMER GLASS, PRIMARY TEETH 22601 Primary Anterior 22602 Primary Posterior 23000 RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT SILVER FILINGS 23100 RESTORATIONS, TOOTH COLOURED, PERMANENT ANTERIORS, NON BONDED TECHNIQUE Page 18 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 23101 23102 23103 23104 23105 23110 112.89 127.89 179.86 195.83 233.78 RESTORATIONS, PERMANENT ANTERIORS, BONDED TECHNIQUE (not to be used for Veneer Applications or Diastema Closures) 23111 23112 23113 23114 23115 23120 23200 One surface Two surfaces (continuous) Three surfaces (continuous) Four surfaces (continuous) Five surfaces (continuous, or maximum surfaces per tooth) One surface Two surfaces (continuous) Three surfaces (continuous) Four surfaces (continuous) Five surfaces (continuous, or maximum surfaces per tooth) 139.38 166.84 192.40 245.48 301.66 RESTORATIONS, TOOTH COLOURED, VENEER APPLICATIONS 23122 Tooth Colored Veneer Application - Non Prefabricated Direct Buildup - Bonded 333.02 23123 Tooth Colored Veneer Application - Diastema Closure, Interproximal only, Bonded 266.66 RESTORATIONS, TOOTH COLORED/PLASTIC WITH/WITHOUT SILVER FILLINGS, PERMANENT POSTERIORS NON BONDED 23210 PERMANENT BICUSPIDS 23211 23212 23213 23214 23215 23220 109.89 139.86 175.84 211.83 222.81 PERMANENT MOLARS 23221 23222 23223 23224 23225 23300 One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surface per tooth One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surface per tooth 119.89 156.86 183.84 213.83 268.81 RESTORATIONS, TOOTH COLORED, PERMANENT POSTERIORS - BONDED 23310 PERMANENT BICUSPIDS 23311 23312 23313 23314 146.13 203.57 238.42 288.24 One surface Two surfaces Three surfaces Four surfaces Page 19 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 23315 Five surfaces or maximum surface per tooth 23320 PERMANENT MOLARS 23321 23322 23323 23324 23325 23400 One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surface per tooth 152.75 215.34 254.95 306.24 354.42 RESTORATIONS, TOOTH COLORED, PRIMARY, ANTERIOR, NON BONDED 23401 23402 23403 23404 23405 23410 One surface Two surfaces (continuous) Three surfaces (continuous) Four surfaces (continuous) Five surfaces (continuous, or maximum surfaces per tooth) 107.89 155.89 155.86 196.83 239.78 RESTORATIONS, TOOTH COLORED, PRIMARY, ANTERIOR, BONDED TECHNIQUE 23411 23412 23413 23414 23415 23500 Average Fee 327.42 One surface Two surfaces (continuous) Three surfaces (continuous) Four surfaces (continuous) Five surfaces (continuous, or maximum surfaces per tooth) 137.11 160.71 176.29 215.48 281.66 RESTORATIONS, TOOTH COLORED/PLASTIC WITH/WITHOUT SILVER FILLINGS, PRIMARY, POSTERIOR, NON BONDED 23501 23502 23503 23504 23505 23510 109.89 143.86 165.84 178.83 218.81 RESTORATIONS, TOOTH COLORED, PRIMARY, POSTERIOR, BONDED TECHNIQUE 23511 23512 23513 23514 23515 23600 One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surface per tooth One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surface per tooth 144.11 192.06 235.08 274.24 313.42 RESTORATIONS, TOOTH COLORED/PLASTIC WITH/WITHOUT SILVER FILLINGS, CORES 23601 Restoration, Tooth Colored, Non-Bonded Core, in Conjunction with Crown or Fixed Bridge Retainer Page 20 209.89 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 242.08 23602 Restoration, Tooth Colored, Bonded Core, in Conjunction with Crown or Fixed Bridge Retainer 23700 RESIN INFILTRATION (Placement of an infiltrating resin restoration for the purpose of filling the sub- surface porosity of an incipient, non-cavitated lesion for the purpose of strengthening, stabilizing and/or limiting the progression of the lesion.) 23701 One surface 23709 Each addition surface over one 24000 RESTORATIONS, FOIL, GOLD 24100 RESTORATIONS, FOIL, GOLD, ANTERIORS 24101 24102 24103 24104 24200 I.C. I.C. 523.55 698.41 479.55 823.52 Class l Class lll Class V Class lV RESTORATIONS, FOIL, GOLD, POSTERIORS 24201 Class l 24202 Class ll 24203 Class V 523.55 698.41 523.41 25000 RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS 25100 RESTORATIONS INLAYS 25110 INLAYS, METAL 25111 25112 25113 25114 25120 One surface Two surface Three surface Three surface, modified +L +L +L +L 455.63 705.55 651.42 786.93 +L +L +L +L 470.97 549.34 641.68 987.65 +L +L +L +L 436.63 489.55 839.47 691.93 Inlays, Composite/Compomer, Indirect (Bonded) 25121 25122 25123 25124 25130 One surface Two surface Three surface Three surface, modified Inlays, Porcelain/Ceramic/Polymer Glass 25131 25132 25133 25134 One surface Two surface Three surface Three surface, modified Page 21 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 25140 Inlays, Porcelain/Ceramic/Polymer Glass (Bonded) 25141 25142 25143 25144 25500 One surface Two surface Three surface Three surface, modified +L 886.47 +L 1133.68 +L 896.68 +L +L +L +L +L 46.60 85.21 135.99 165.34 199.70 +L +L +L 332.70 399.63 524.55 +L +L +L 189.84 255.78 319.70 Onlays, Cast Metal, Indirect 25511 Onlay, Cast Metal, Indirect 25520 Onlays, Composite/Compomer, Processed (Bonded) 25521 Onlays, Composite/Compomer, Indirect (Bonded) 25530 Onlays, Porcelain/Ceramic/ Polymer glass (Bonded) 25531 Onlays, Porcelain/Ceramic/Polymer Glass (Bonded) PINS, RETENTIVE (for inlays, onlays and crowns per tooth) 25601 25602 25603 25604 25605 25700 466.97 655.34 864.68 1107.65 RESTORATIONS, ONLAYS (where one or more cusps are restored) 25510 25600 +L +L +L +L One pin/tooth Two pins/tooth Three pins/tooth Four pins/tooth Five or more pins/tooth POSTS 25710 POSTS, CAST METAL, (including core) AS A SEPARATE PROCEDURE 25711 Single section 25712 Two sections 25713 Three sections 25720 Posts, Cast Metal (including core) Concurrent with Impression for Crown 25721 Single section 25722 Two sections 25723 Three sections 25730 POST, PREFABRICATED RETENTIVE 25731 One post 25732 Two posts same tooth 25733 Three posts same tooth 25740 +E +E +E POSTS, PREFABRICATED, RETENTIVE AND CAST CORE Page 22 158.89 263.78 359.66 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 25741 One post and cast core 25742 Two posts (same tooth) and cast core 25743 Three posts (same tooth) and cast core 25770 Average Fee 276.78 349.70 436.63 +L +E and/or Posts, Provisional 25771 Per post 25780 86.92 POST REMOVAL 25781 25782 25783 25784 25789 26000 +L +E +L +E +L +E 106.91 213.45 320.16 427.89 106.71 One unit of time Two units of time Three units of time Four units of time Each additional unit over four MESOSTRUCTURES (a separate component positioned between the head of an implant and the final restoration, retained by either a cemented post or screw) 26100 Mesostructures, Osseo-integrated Implant Supported 26101 Indirect, Angulated or transmucosal pre-fabricated abutment, per implant 26102 Indirect, Custom laboratory fabricated, per implant 26103 Direct, (with intra-oral preparation), per implant site 27000 CROWNS, SINGLE UNITS ONLY (includes temporary protection and local anesthetic, caries removal, and uncomplicated restoration prior to crown preparation). Extensive restoration requiring pins or dowels extra. 27100 CROWNS, ACRYLIC/COMPOSITE/ COMPOMER, (with or without Cast or Prefabricated Metal Bases) 27110 Crowns, Acrylic/Composite/Compomer, Indirect 27111 Crown, Acrylic/Composite/Compomer, Indirect 27112 Crown, Acrylic/Composite/Compomer, Indirect, Complicated (restorative, positional and/or esthetic) 27113 Crown, Acrylic/Composite/Compomer, Provisional [Long Term], Indirect (lab fabricated/relined intra-orally) 27120 +L 654.41 +L 874.27 +L 255.78 +E +E 197.89 518.89 CROWNS, PLASTIC, DIRECT 27121 Crowns, Acrylic/Composite/Compomer, Direct, Provisional (chairside) 27125 Crowns, Acrylic/Composite/Compomer, Direct, Provisional Implant-supported 27130 +L +E I.C. +L +E I.C. +E I.C. Crown, Acrylic/Composite/Compomer/ Cast Metal Base, Indirect Page 23 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 27131 Crown, Acrylic/Composite/Compomer/Cast Metal Base, Indirect 27135 Crown, Acrylic/Composite/Compomer Cast Metal Base, Implant-supported 27136 Crown, Acrylic/Composite/Compomer/Cast Metal Base with Cast Post Retention 27200 27210 Crown, Porcelain/Ceramic/Polymer Glass Crown, Porcelain/Ceramic/Polymer Glass, Complicated Crown, Porcelain/Ceramic/Polymer Glass, Implant-supported Crown, Porcelain/Ceramic/Polymer Glass, with Cast Ceramic Post Retention +L +L +L +E +L 969.87 1098.68 1098.87 1099.68 +L +L 909.86 1095.68 +L +E +L 1095.87 1099.68 +L +L 1050.87 1137.68 +L +L +L +E +L +L +E +L +E 949.87 1241.68 1091.87 1100.68 184.67 456.59 +L +L +L 998.87 1100.68 1049.96 Crown, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base 27211 Crown, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base 27212 Crown, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base, Complicated (restorative, positional and/or aesthetic) 27215 Crown, Porcelain/Ceramic Fused to Metal Base, Implant-supported 27216 Crown, Porcelain/Ceramic Fused to Metal Base with Cast Metal Post Retention 27220 Crown, ¾, Porcelain/Ceramic/Polymer Glass 27221 Crown, ¾, Porcelain/Ceramic/Polymer Glass 27222 Crown, ¾, Porcelain/Ceramic/Polymer Glass, Complicated CROWNS, CAST METAL 27301 27302 27305 27306 27307 27308 27310 Crown, Cast Metal Crown, Cast Metal, Complicated (restorative, positional) Crown, Cast Metal, Implant-supported Crown, Cast Metal, with Cast Metal Post Retention Semi-precision Rest (Interlock) (in addition to Cast Medal Crown) Semi-precision or Precision Attachment RPD Retainer (in addition to Cast Medal Crown) Crowns, ¾, Cast Metal 27311 Crowns, ¾, Cast Metal 27312 Crowns, Metal ¾ Cast Metal, Complicated 27313 Crowns, ¾, Cast Metal, with Direct Tooth Colored Corner 27400 Average Fee 697.41 697.41 874.27 CROWNS, PORCELAIN/CERAMIC/POLYMER GLASS 27201 27202 27205 27206 27300 +L +L +E +L CROWNS MADE TO AN EXISTING PARTIAL DENTURE CLASP (additional to crown) 27401 One crown 27409 Each additional crown 27500 119.33 78.33 COPINGS, METAL/PLASTIC, TRANSFER (thimble type) 27510 Coping, Metal/Acrylic, Transfer (thimble), as a separate procedure 27511 Coping, Metal/Acrylic, Transfer (thimble) as a Separate Procedure 27520 Posts, Cast Metal (including core) Concurrent with Impression for Crown Page 24 +L 348.70 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 27521 Coping, Metal/Acrylic, Transfer (thimble) Concurrent with Impression for Crown 27600 86.92 +L +L 721.41 849.41 to 79.92 239.78 VENEERS, LABORATORY PROCESSED 27601 Veneers, Acrylic/Composite/Compomer, Bonded 27602 Veneers, Porcelain/Ceramic/Polymer Glass, Bonded 27700 +L REPAIRS, (single units only, does not include removal and recementation) 27710 Repairs, Inlays, Onlays or Crowns, Acrylic/Composite/Compomer (single units) 27711 Repairs, Acrylic/Composite/Compomer, Direct 27720 Repairs, Inlays, Onlays or Crowns, Porcelain/Ceramic/Polymer Glass Porcelain/Ceramic/Polymer/Fused to Metal Base (single units) 27721 Repairs, Inlays, Onlays or Crowns, Porcelain/Ceramic/Polymer Glass, Porcelain/Ceramic/Polymer Glass/Fused to Metal Base, Direct 27722 Repairs, Inlays Onlays or Crowns, Porcelain/Ceramic/Polymer Glass, Porcelain/Ceramic/Polymer Glass Fused to Metal Base, Indirect + L 27800 79.92 to +L RECONTOURING OF EXISTING CROWNS per tooth 27801 One unit of time 27809 Each additional unit of time 84.92 84.92 28000 RESTORATIVE PROCEDURES, OVERDENTURES 28100 RESTORATIVE PROCEDURES, OVERDENTURES, DIRECT 28101 Natural Tooth Preparation, Placement of Pulp Chamber Restoration (amalgam or composite) and Fluoride Application Endodontically Treated Tooth 28102 Natural Tooth Preparation and Fluoride Application, Vital Tooth 28103 Pre-fabricated Attachment, as an Internal/External Overdenture Retentive Device, Direct to a Natural Tooth (used with the appropriate denture code) per tooth 28105 Implant-supported Prefabricated Attachment as an Overdenture Retentive Device, Direct 28200 239.78 156.92 218.81 +L +E 261.78 261.78 +E 130.89 +L +L +E +L +E 349.70 349.70 524.55 RESTORATIVE PROCEDURES, OVERDENTURES, INDIRECT 28210 Coping Crowns, Cast Metal, No Attachments, Indirect 28211 Coping Crown, Cast Metal, No Attachments, Indirect 28215 Coping Crown, Cast Metal, No Attachments, Implant-supported, Indirect 28216 Coping Crown, Cast Metal with Cast Metal Retentive Post, No Attachments 28220 Coping Crown, Cast Metal, with Attachments, Indirect Page 25 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 28221 Coping Crown, Metal Cast, with Attachment, Indirect 28225 Coping Crown, Cast Metal, Implant-supported with Attachment 28226 Coping Crown, Cast Metal with Cast Metal Retentive Post, with Attachment 29000 RESTORATIVE SERVICES, OTHER 29100 RECEMENTATION/REBONDING, INLAYS/ONLAYS/ CROWNS/VENEERS/POSTS/ NATURAL TOOTH +L +E +L +E +L +E Average Fee 436.63 436.63 642.68 FRAGMENTS (single units only) (+ L where laboratory charges are incurred during repair of the unit) 29101 29102 29103 29104 29300 85.92 171.84 257.78 343.70 REMOVAL, INLAYS/ONLAYS, CROWNS, VENEERS (single units only) 29301 29302 29303 29304 29400 +L +L +L +L One unit of time Two units Three units Four units 84.92 169.84 254.78 339.70 One unit of time Two units Three units Four units STAINING PORCELAIN (chairside) 29401 29402 29403 29404 +L +L +L +L One unit of time Two units Three units Four units 86.92 74.84 261.78 349.70 ENDODONTICS General Endodontic Procedures There are certain Endodontic cases, which, as a result of a previous treatment, tooth position, anatomy and/or stage of development, require additional time and care. Such situations could merit an additional fee. Conservative root canal therapy includes treatment plan, clinical procedures with appropriate follow up care. Excludes final restoration. Note: If Endodontic therapy is not completed it would be deemed reasonable to charge a portion of the suggested fee in relation to time expended in the procedure. 31100 PULP CAPPING (refer to code 20100) 32000 PULP CHAMBER, TREATMENT OF, (excluding final restoration) 32200 PULPOTOMY 32220 PULPOTOMY, PERMANENT TEETH (as a separate Emergency Procedure) 32221 Anterior and Bicuspid Teeth 32222 Molar Teeth 159.84 159.84 Page 26 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 32230 PULPOTOMY, PRIMARY TEETH 32231 Primary Tooth, as a Separate Procedure 32232 Primary Tooth, Concurrent with Restoration (but excluding final restoration) 32300 152.25 80.51 PULPECTOMY (An emergency procedure and/or as a pre-emptive phase to the preparation) (An emergency procedure and/or as a pre-emptive phase to the preparation of the root canal system for obturation) 32310 PULPECTOMY, PERMANENT TEETH/RETAINED PRIMARY TEETH 32311 32312 32313 32314 32320 144.89 185.84 250.81 274.78 One Canal Two Canals Three Canals Four Canals or more PULPECTOMY, PRIMARY TEETH 32321 Anterior Tooth 32322 Posterior Tooth 122.89 221.81 33000 ROOT CANAL THERAPY To include: treatment plan, clinical procedures (ie. pulpectomy, biomechanical preparation, chemotherapeutic treatment and obturation), with appropriate radiographs, excluding final restoration. 33100 ROOT CANALS, PERMANENT TEETH/RETAINED PRIMARY TEETH (Includes: Clinical procedures with appropriate radiographs, excluding final restoration.) Definitions: Uncomplicated - Virtually straight canal penetrated by size #15 file Difficult Access - Limited jaw opening, unfavourable tooth inclination, through complex restorations eg. Post/core buildups. Exceptional Anatomy - Canal size same as uncomplicated, but made complicated by dens-indente 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 33110 ROOT CANALS, PERMANENT TEETH/RETAINED PRIMARY TEETH, ONE CANAL 33111 33112 33113 33114 33115 33120 One canal Difficult Access Exceptional Anatomy Calcified Canal Retreatment of Previously Completed Therapy ROOT CANALS, PERMANENT TEETH/RETAINED PRIMARY TEETH, TWO CANALS Page 27 676.09 879.11 899.11 924.11 894.75 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 33121 33122 33123 33124 33125 33130 33140 Three canals Difficult Access Exceptional Anatomy Calcified Canal Retreatment of Previously Completed Therapy 1151.39 1399.39 1465.45 1390.45 1380.45 ROOT CANALS, PERMANENT TEETH/RETAINED PRIMARY TEETH, FOUR OR MORE CANALS 33141 33142 33143 33144 33145 Four or more canals Difficult Access Exceptional Anatomy Calcified Canal Retreatment of Previously Completed Therapy 1423.30 1632.63 1632.63 1632.63 1708.63 PULPAL REVASCULARIZATION 33501 One canal 33502 Two canals 33503 Three canals or more 33600 984.55 1234.94 1234.94 1234.94 1268.94 ROOT CANALS, PERMANENT TEETH/RETAINED PRIMARY TEETH, THREE CANALS 33131 33132 33133 33134 33135 33500 Two canals Difficult Access Exceptional Anatomy Calcified Canal Retreatment of Previously Completed Therapy 251.16 376.75 502.34 APEXIFICATION/APEXOGENESIS/ INDUCTION OF HARD TISSUE REPAIR (to include biomechanical preparation and placement of dentogenic media) 33601 33602 33603 33604 33610 261.16 376.75 502.34 669.79 One canal Two canals Three canals Four canals or more RE-INSERTION OF DENTOGENIC MEDIA PER VISIT 33611 33612 33613 33614 125.57 170.45 255.45 341.89 One canal Two canals Three canals Four canals or more 34000 PERIAPICAL SERVICES 34100 APICOECTOMY/APICAL CURETTAGE Page 28 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 34110 MAXILLARY ANTERIOR 34111 One root 34112 Two roots 34120 528.60 652.23 MAXILLARY BICUSPID 34121 One root 34122 Two roots 34123 Three roots 34130 651.91 758.56 932.18 MAXILLARY MOLAR 34131 One root 34132 Two roots 34133 Three roots 34140 633.91 742.56 1119.82 MANDIBULAR ANTERIOR 34141 One root 34142 Two or more roots 34150 549.13 745.56 MANDIBULAR BICUSPID 34151 One root 34152 Two roots 34153 Three or more roots 34160 809.23 839.88 1025.50 MANDIBULAR MOLAR 34161 One root 34162 Two roots 34163 Three roots 34200 650.23 821.88 1119.82 RETROFILLING 34210 MAXILLARY ANTERIOR 34211 One canal 34212 Two or more canals 34220 146.51 177.04 MAXILLARY BICUSPID 34221 34222 34223 34224 99.51 256.04 267.56 356.07 One canal Two canals Three canals Four or more canals Page 29 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 34230 MAXILLARY MOLAR 34231 34232 34233 34234 34240 110.51 177.04 267.56 356.07 One canal Two canals Three canals Four or more canals MANDIBULAR ANTERIOR 34241 One canal 34242 Two or more canals 34250 MANDIBULAR BICUSPID 34251 34252 34253 34254 34260 88.51 177.04 267.56 356.07 One canal Two canals Three canals Four or more canals MANDIBULAR MOLAR 34261 34262 34263 34264 34300 112.51 177.04 88.51 177.04 267.56 356.07 One canal Two canals Three canals Four or more canals RETREATMENT, APICOECTOMY/APICAL CURETTAGE 34310 34320 34330 34340 34350 Maxillary Anterior 34311 one root 34312 two roots 535.13 745.56 Maxillary Bicuspid 34321 one root 34322 two roots 34323 three roots 652.23 885.53 1119.82 Maxillary Molar 34331 one root 34332 two roots 34333 three roots 652.23 885.53 1305.47 Mandibular Anterior 34341 one root 34342 Two or more roots 670.42 932.18 Manibular Bicuspid 34351 one root 34352 two roots 34353 three roots 745.56 1025.50 1212.14 Page 30 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 34360 34400 Mandibular Molar 34361 one root 34362 two roots 34363 three roots 745.56 979.56 1305.47 SURGICAL SERVICES, MISCELLANEOUS 34410 AMPUTATIONS, ROOT (includes recontouring tooth and furca) 34411 One root 34412 Two roots 34420 366.56 446.60 HEMISECTION 34421 Maxillary Bicuspid 34422 Maxillary Molar 34423 Mandibular Molar 34430 267.56 261.56 261.56 DECOMPRESSION, PERIO-RADICULAR LESION 34431 First visit 34432 Each Additional visit 34440 356.07 177.04 SURGERY, ENDODONTIC, EXPLORATORY 34441 34442 34443 34444 34445 34446 34450 267.56 356.07 446.60 267.56 356.07 446.60 Maxillary Anterior Maxillary Bicuspid Maxillary Molar Mandibular Anterior Mandibular Bicuspid Mandibular Molar REMOVAL, INTENTIONAL, OF TOOTH, APICAL FILLING AND REPLANTATION (splinting additional) 34451 Single rooted tooth 34452 Two rooted tooth 34453 Three rooted tooth or more 34500 372.27 559.91 745.56 PERFORATIONS 34510 PERFORATION/RESORPTIVE DEFECT(S), PULP CHAMBER REPAIR, OR ROOT REPAIR, NONSURGICAL 34511 per tooth 34520 80.92 PERFORATION/RESORPTIVE DEFECT(S), PULP CHAMBER REPAIR, OR ROOT REPAIR, SURGICAL Page 31 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 88.51 177.51 265.56 34521 Anterior Tooth 34522 Bicuspid Tooth 34523 Molar Tooth 34600 ENLARGEMENT, CANAL AND/OR PULP CHAMBER (Preparation of Post Space) 34601 In Previously Filled Tooth when Root Canal Treatment Done by Another Practitioner 34602 In Calcified Canals 39000 ENDODONTIC, PROCEDURES, MISCELLANEOUS 39100 ISOLATION OF ENDODONTIC TOOTH/TEETH FOR ASEPSIS 39101 Banding and/or Coronal Buildup of Tooth/Teeth and/or Contouring of Tissue Surrounding Tooth/Teeth to Maintain Aseptic Operating Field (per tooth) 39200 39210 85.33 92.33 OPENING THROUGH ARTIFICIAL CROWN (In addition to Procedures) 39211 Anteriors and Bicuspids 39212 Molars 139.92 138.92 BLEACHING, NON VITAL 39310 BLEACHING ENDODONTICALLY TREATED TOOTH/TEETH 39311 39312 39313 39319 39400 159.84 OPEN AND DRAIN (Separate Emergency Procedures) 39201 Anteriors and Bicuspids 39202 Molars 39300 84.71 255.16 80.92 162.84 244.78 80.92 One unit of time Two units Three units Each additional unit over three EXPLORATORY ACCESS THROUGH CLINICAL CROWN OF PREVIOUSLY TREATED TOOTH 39410 EXPLORATORY ACCESS 39411 Anterior 39412 Bicuspid 39413 Molar 94.33 72.33 151.92 PERIODONTICS Page 32 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee In the treatment of periodontal diseases, variables such as the severity of the patient's periodontal condition and the distribution (i.e. extent) of the condition may require a relatively wide selection of therapeutic procedures and involve considerable variation in time and expense. In most instances the time required to perform a certain procedure could, and usually does, vary from one quadrant to another and therefore the amounts of time as outlined in the following guide could vary in the management of a particular case. 41000 PERIODONTAL SERVICES, NON SURGICAL 41200 ORAL INFECTIONS, Management of 41210 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 41212 41213 41214 41219 41220 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 41222 41223 41224 41229 41230 89.92 179.84 269.78 319.70 89.92 One unit of time Two units Three units Four units Each additional unit over four Oral Manifestations of Systemic Disease 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 leukemia, diabetes and bleeding disorders (e.g. haemophilia) 41231 41232 41233 41234 41239 41300 79.92 159.84 239.78 319.70 79.92 One unit of time Two units Three units Four units Each additional unit over four 79.92 159.84 239.78 319.70 79.92 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.) 41301 One unit of time 79.92 Page 33 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 159.84 79.92 41302 Two units 41309 Each additional unit over two 42000 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 group of teeth or in some cases a single tooth.) 42100 PERIODONTAL SURGERY, GINGIVAL CURETTAGE 42110 SURGICAL CURETTAGE, TO INCLUDE DEFINITIVE ROOT PLANING 42111 Per sextant 42200 209.30 PERIODONTAL SURGERY, GINGIVOPLASTY (Does not include limited re-contouring to facilitate restorative services) 42201 Per sextant 42300 251.16 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; does not include limited re-contouring to facilitate restorative services). 42310 GINGIVECTOMY, UNCOMPLICATED 42311 Per sextant 42320 285.35 GINGIVECTOMY, WITH CURETTAGE 42321 Per sextant 42330 421.47 GINGIVAL FIBER INCISION (supra crestal fibrotomy) 42331 First tooth 42339 Each additional tooth 42400 81.33 72.33 PERIODONTAL SURGERY, FLAP APPROACH 42410 FLAP APPROACH, WITH OSTEOPLASTY/OSTECTOMY 42411 Per sextant 42420 1093.84 FLAP APPROACH, WITH CURETTAGE OF OSSEOUS DEFECT 42421 Per sextant 42430 680.26 FLAP APPROACH, WITH CURETTAGE OF OSSEOUS DEFECT AND OSTEOPLASTY 42431 Per sextant 969.16 Page 34 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 42440 FLAP APPROACH, EXPLORATORY (for diagnosis) 42441 Per site 42500 523.14 PERIODONTAL SURGERY, GRAFTS, SOFT TISSUE 42510 GRAFTS, SOFT TISSUE, PEDICLE (including apically or lateral sliding and rotated flaps.) 42511 Per site 42512 Periostial stimulation in addition to 42511 42520 639.06 76.12 GRAFTS, SOFT TISSUE, PEDICLE (Coronally Positioned) 42521 Per site 42522 Periostial stimulation in addition to 42521 42530 639.06 76.12 GRAFTS FREE SOFT TISSUE 42531 Per site 42540 965.06 GRAFTS, SOFT TISSUE, PEDICLE, WITH FREE GRAFT PLACED IN PEDICLE DONOR SITE 42541 Per site 42550 1166.56 GRAFTS, FREE CONNECTIVE TISSUE (For root or implant coverage) 42551 Autograft (free connective tissue), for root coverage, includes harvesting from donor site - Per site 42552 Allograft, for root coverage – per site 42557 Allograft, adjacent to an implant – per site 42560 +E +E I.C. I.C. +E I.C. GRAFTS, FOR RIDGE AUGMENTATION 42561 Autograft (free connective tissue), includes harvesting from donor site – per site. 42562 Allograft – per site 42570 916.56 1130.32 GRAFTS, CONNECTIVE TISSUE, PEDICLE WITH FREE GRAFT FOR ROOT COVERAGE 42571 Per site 42580 875.08 GRAFTS, GINGIVAL ONLAY (for ridge augmentation) 42581 Per site 42590 905.32 Grafts, Dermal, Onlay, for Ridge Augmenation 42591 Autograft – per site 42592 Allograft – per site +E Page 35 905.32 905.32 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 42600 PERIODONTAL SURGERY, FLAPS, GRAFTS, OSSEOUS TISSUE 42610 GRAFTS, OSSEOUS, AUTOGRAFT (Including flap entry, closure and donor site) 42611 Per site 42620 1065.09 GRAFTS, OSSEOUS, ALLOGRAFT (Including flap entry and closure) 42621 Per site 42630 +E 1065.09 +E +E +E 1616.98 1616.98 1616.98 GUIDED TISSUE REGENERATION 42701 Guided Tissue Regeneration – Non-resorbable Membrane – per site 42702 Guided Tissue Regeneration – Resorbable Membrane 42703 Guided Tissue Regeneration – Non-resorbable Membrane, Surgical Re-entry for Removal 42720 Biological materials to aid in soft and osseous tissue regeneration (not including surgical entry and closure) 42721 Per site 42800 1065.09 Grafts, Osseous, Zenograft (Including Flap Entry and Closure) 42631 Per Site 42700 +E +E I.C. PERIODONTAL SURGERY, MISCELLANEOUS PROCEDURES 42810 PROXIMAL WEDGE PROCEDURE (as a separate procedure) 42811 With Flap Curettage, per site 42819 With Flap Curettage and Osectomy/Osteoplasty, per site 42820 POST SURGICAL PERIODONTAL TREATMENT VISIT PER DRESSING CHANGE (by dentist other than operating dentist) 42821 42822 42823 42829 42830 76.12 152.25 228.37 76.12 One unit of time Two units Three units Each additional unit over three PERIODONTAL ABSCESS OR PERICORONITIS, MAY INCLUDE ANY OF THE FOLLOWING PROCEDURES: LANCING, SCALING, CURETTAGE, SURGERY OR MEDICATION 42831 42832 42833 42834 42839 42840 485.11 585.80 79.92 159.84 239.78 319.70 79.92 One unit of time Two units Three units Four units Each additional unit over four Flap Approach for Creation of Interdental Papillae Page 36 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee I.C. 42841 Per Site 43000 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) 43100 PERIODONTAL SPLINTING OR LIGATION, PROVISIONAL, INTRA CORONAL Periodontal Splint or ligation, provisional, intra coronal. Note: This procedure is in addition to the usual code for the tooth restoration of either side. 43110 "A" SPLINT (acrylic, composite or amalgam, plus knurled wire) 43111 Per joint 43200 +E PERIODONTAL SPLINTING OR LIGATION, PROVISIONAL, EXTRA CORONAL 43220 Bonded, Interproximal Enamel Splint 43221 Per joint 43230 76.12 WIRE LIGATION 43231 Per joint 43240 76.12 WIRE LIGATION, ACRYLIC COVERED 43241 Wire ligation, Restorative Material Covered 43260 83.12 ORTHODONTIC BAND SPLINT 43261 Per band 43270 +E 80.12 Cast/Soldered/Ceramic/Polymer Glass, Splint Bonded 43271 Per abutment ` REMOVAL OF FIXED PERIODONTAL SPLINTS 43280 43281 One unit of time 43289 Each additional unit of time 43400 154.25 +L 79.92 76.12 76.12 ROOT PLANING, PERIODONTAL 43420 Root Planing 43421 43422 43423 43424 76.63 153.26 232.43 336.26 One unit of time Two units of time Three units of time Four units of time Page 37 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 43425 43426 43427 43429 43500 Average Fee 445.66 479.55 39.96 79.92 Five units of time Six units of time 1/2 unit of time Each additional unit over six CHEMOTHERAPEUTIC and/or ANTIMICROBIAL AGENTS, TOPICAL APPLICATION 43510 CHEMOTHERAPEUTIC and/or ANTIMICROBIAL AGENTS, TOPICAL APPLICATION 43511 One unit of time 43519 Each additional unit of time 43520 76.12 76.12 Chemotherapeutic and/or antimicrobial therapy, intra-sulcular application 43521 One unit of time 43529 Each additional unit of time +E +E 49000 PERIODONTAL SERVICES, MISCELLANEOUS 49100 PERIODONTAL RE-EVALUATION/EVALUATION This follow-up service applies to the evaluation of ongoing periodontal treatment or to a postsurgical re-evaluation performed more than one (1) month after surgery, or if performed by another practitioner 79.92 79.92 49101 One unit of time 49102 Two units 49109 Each additional unit over two 49300 76.12 152.25 76.12 SOFT TISSUE PROSTHESIS 49301 Gingival Mask +L (Removable appliance to mask unaesthetic embrasures Note: For extensive gingival prostheses required after maxilla facial surgery see sub-classification 57300 Prosthesis Maxillofacial, other, code 57372 Gingival Prosthesis) PROSTHODONTICS - REMOVABLE Special Aesthetic and anatomical considerations involving additional chair time and/or responsibility may require an increase over the basic fee. Special aesthetic and functional laboratory costs beyond normal laboratory charges will require an increase over the basic fee. EXAMINATION, DIAGNOSIS AND TREATMENT PLAN - Refer to Diagnostic Services, separate fee. 51000 DENTURE COMPLETE (includes: impressions, initial and final jaw relation records, try-in evaluation and check records, insertion and adjustments, including three month post insertion care) Page 38 I.C. Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 51100 DENTURE COMPLETE, STANDARD 51101 Maxillary 51102 Mandibular 51104 Liners, Processed, Resilient, in addition to above 51200 +L +L LAB +L +L 931.27 979.27 +L +L 1380.41 1380.41 DENTURES, COMPLETE, GNATHOLOGICAL (CAST BASE AND METAL OCCLUSALS) 51501 Maxillary 51502 Mandibular 51600 I.C. I.C. DENTURES, COMPLETE, PROVISIONAL 51601 Maxillary 51602 Mandibular 51700 1731.77 1724.77 DENTURES, SURGICAL, COMPLEX (IMMEDIATE) includes first tissue conditioner, but not a processed reline 51401 Maxillary 51402 Mandibular 51500 LAB DENTURES, SURGICAL, STANDARD, (IMMEDIATE) includes first tissue conditioner, but not a processed reline 51301 Maxillary 51302 Mandibular 51400 873.00 873.00 DENTURES, COMPLETE, COMPLEX 51201 Maxillary 51202 Mandibular 51204 Liners, Processed, Resilient in addition to above 51300 +L +L +L +L 575.89 575.89 +L +L 1724.70 1187.70 +L +L 1088.70 2252.70 DENTURES, COMPLETE, OVERDENTURES, TISSUE BORNE, SUPPORTED BY NATURAL TEETH OR IMPLANTS WITH OR WITHOUT COPING CROWNS, NO ATTACHMENTS 51710 Dentures, Complete, Overdentures, Tissue Borne, Supported by Natural Teeth with or without Coping Crowns, no Attachments 51711 Maxillary 51712 Mandibular 51720 Dentures, Complete, Overdentures, Tissue Borne, Supported by Implants with or without Coping Crowns, no Attachments 51721 Maxillary 51722 Mandibular Page 39 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 51730 Dentures, Complete, Overdentures Tissue Borne, Supported by a Combination of Natural Teeth and Implants with or without Coping Crowns, no Attachments +L +L 51731 Maxillary 51732 Mandibular 51800 1088.70 1088.70 DENTURES, COMPLETE, OVERDENTURES, (IMMEDIATE), TISSUE BORNE, SUPPORTED BY NATURAL TEETH OR IMPLANTS WITH OR WITHOUT COPING CROWNS, NO ATTACHMENTS 51810 Dentures, Complete, Overdentures (Immediate), Tissue Borne, Supported by Natural Teeth with or without Implants with or without Coping Crowns, no Attachments (includes first tissue conditioner, but not a processed reline) 51811 Maxillary 51812 Mandibular 51900 +L +L 1039.13 1039.13 DENTURES, COMPLETE, OVERDENTURES, TISSUE BORNE, SECURED BY ATTACHMENTS TO NATURAL TEETH OR IMPLANTS 51910 Dentures, Complete, Overdentures, Tissue Borne, with Independent Attachments Secured to Natural Teeth with or without Coping Crowns 51911 Maxillary 51912 Mandibular 51920 +L +L Dentures, Complete, Overdentures, Tissue Borne, with Independent Attachments Secured to Implants with or without Coping Crowns 51921 Maxillary 51922 Mandibular 51930 I.C. I.C. +L +L I.C. I.C. +L +L I.C. I.C. +L +L I.C. I.C. Dentures, Complete, Overdentures, Tissue Borne, with Retention from a Retentive Bar, Secured to Coping Crowns Supported by Implants 51951 Maxillary 51952 Mandibular 51960 +L +L Dentures, Complete, Overdentures, Tissue Borne, with Independent Attachments Secured to a Combination of Natural Teeth and Implants with or without Coping Crowns 51931 Maxillary 51932 Mandibular 51950 959.13 959.13 Dentures, Complete, Overdentures, Tissue Borne, with Retention from a Retentive Bar, Secured to Coping Crowns Supported by a Combination of a Natural Teeth and Implants (see 62105 for Retentive Bar) 51961 Maxillary 51962 Mandibular Page 40 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 52000 DENTURES, PARTIAL, ACRYLIC 52100 DENTURES, PARTIAL, ACRYLIC BASE (PROVISIONAL) (With or Without Clasps) 52101 Maxillary 52102 Mandibular 52110 52210 270.37 230.37 +L +L 241.37 309.37 +L +L 299.37 522.37 +L +L 795.28 790.28 +L +L 843.28 789.28 Dentures, Partial, Acrylic, Resilient Retainer, (Immediate) (includes first tissue conditioner, but not a processed reline) 52211 Maxillary 52212 Mandibular DENTURES, PARTIAL, ACRYLIC, WITH METAL WROUGHT/CAST CLASPS AND/OR RESTS 52301 Maxillary 52302 Mandibular 52310 Dentures, Partial, Acrylic, with Metal Wrought/Cast Clasps and/or Rests, (Immediate) (includes first tissue conditioner, but not a processed reline) 52311 Maxillary 52312 Mandibular 52400 +L +L DENTURES, PARTIAL, ACRYLIC, RESILIENT RETAINER 52201 Maxillary 52202 Mandibular 52300 269.37 267.37 Dentures, Partial, Acrylic Base (Immediate) (includes first tissue conditioner, but not a processed reline) 52111 Maxillary 52112 Mandibular 52200 +L +L DENTURES, PARTIAL, ACRYLIC, WITH METAL/WROUGHT PALATAL/LINGUAL BAR AND CLASPS AND/OR RESTS 52401 Maxillary 52402 Mandibular 52410 +L +L 768.28 768.28 +L +L 761.28 1009.28 Dentures, Partial, Acrylic, with Metal Wrought Palatal/Lingual Bar and Clasps and/or Rests, (Immediate) (includes first tissue conditioner, but not a processed reline) 52411 Maxillary 52412 Mandibular 52500 52510 Dentures, Partial (Flexible, Non Metal, Non Acrylic) Page 41 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 52511 Maxillary 52512 Mandibular 52513 Maxillary plus Mandibular 52700 +L +L +L Average Fee 579.39 766.39 481.79 +L +L 989.56 1438.56 +L +L 989.56 989.56 +L +L 989.56 989.56 DENTURES, PARTIAL, OVERDENTURES, ACRYLIC, WITH CAST/WROUGHT CLASPS AND/OR RESTS SUPPORTED BY NATURAL TEETH OR IMPLANTS WITH OR WITHOUT COPING CROWNS, NO ATTACHMENTS 52710 Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps and/or Rests supported by Natural Teeth with or without Coping Crowns, no attachments 52711 Maxillary 52712 Mandibular 52720 Dentures, Partial, Overdentures, Acrylic, with Cast/ Wrought Clasps and/or Rests, Supported by Implants with or without Coping Crowns, No Attachments 52721 Maxillary 52722 Mandibular 52730 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 52731 Maxillary 52732 Mandibular 52800 DENTURES, PARTIAL, OVERDENTURES (IMMEDIATE), ACRYLIC, WITH CAST/WROUGHT CLASPS AND/OR RESTS SUPPORTED BY NATURAL TEETH OR OR IMPLANTS WITH OR WITHOUT COPING CROWNS, NO ATTACHMENTS 52810 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) 52811 Maxillary 52812 Mandibular 52820 989.56 989.56 +L +L 989.56 989.56 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) 52821 Maxillary 52822 Mandibular 52830 +L +L Dentures, Partial, Overdentures (Immediate), Acrylic with Cast/Wrought Clasps and/or Rests Secured by a Combination of Natural Teeth and Implants with or without Coping Crowns, No Attachments (includes first tissue conditioner, but not a processed reline) Page 42 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 52831 Maxillary 52832 Mandibular 52900 +L +L 989.56 989.56 Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps and/or Rests Secured by Natural Teeth or Implants 52910 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 52911 Maxillary 52912 Mandibular 52920 989.56 989.56 +L +L 989.56 989.56 +L +L 989.56 989.56 +L +L 989.56 989.56 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 or Implants (see 62105 for Retentive Bar) 52961 Maxillary 52962 Mandibular 53000 +L +L 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 62105 for Retentive Bar) 52951 Maxillary 52952 Mandibular 52960 989.56 989.56 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 62105 for Retentive Bar) 52941 Maxillary 52942 Mandibular 52950 +L +L 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 26101, 26103 (Mesostructures); or 28221, 28225, 28226 (Cast Metal Coping Crowns) with or without Attachments] 52931 Maxillary 52932 Mandibular 52940 989.56 989.56 Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps and/or Rests, with Independent Attachments Secured to Implants with or without Coping Crowns 52921 Maxillary 52922 Mandibular 52930 +L +L DENTURES, PARTIAL, CAST WITH ACRYLIC BASE Page 43 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 53100 DENTURES, PARTIAL, FREE END, CAST FRAME/CONNECTOR, CLASPS AND RESTS 53101 Maxillary 53102 Mandibular 53104 Altered Cast Impression technique in conjunction with 53101, & 53102 53110 +L +L +L 872.03 872.03 85.92 +L +L 959.13 971.13 +L +L 1004.70 1004.70 +L +L 1925.66 1925.66 +L +L +L 959.13 959.13 559.47 +L +L +L 959.13 968.13 605.47 +L +L 2010.66 1925.66 Dentures, Partial, Free End, Cast Frame/Connector, Clasps and Rests, (Immediate) (includes first tissue conditioner, but not a processed reline) 53111 Maxillary 53112 Mandibular 53120 DENTURES, PARTIAL FREE END, SWING LOCK/CONNECTOR 53121 Maxillary 53122 Mandibular 53130 DENTURES, PARTIAL, FREE END, CAST FRAME/CONNECTOR, CLASPS AND RESTS (EQUILIBRATED) 53131 Maxillary 53132 Mandibular 53200 DENTURES, PARTIAL, TOOTH-BORNE, CAST FRAME/CONNECTOR, CLASPS AND RESTS 53201 Maxillary 53202 Mandibular 53205 Unilateral, one piece casting, clasps and pontics 53210 Dentures, Partial, Tooth Borne, Cast Frame/Connector, Clasps and Rests, (Immediate) (includes first tissue conditioner, but not a processed reline) 53211 Maxillary 53212 Mandibular 53215 Unilateral, one piece casting, clasps and pontics 53220 DENTURES, PARTIAL, TOOTH BORNE, CAST FRAME/CONNECTOR, CLASPS AND RESTS (EQUILIBRATED) 53221 Maxillary 53222 Mandibular 53400 DENTURES, PARTIAL, CAST, PRECISION ATTACHMENTS 53401 Maxillary 53402 Mandibular 53404 Altered Cast Impression Technique done in conjunction with the above mentioned codes 53500 DENTURES, PARTIAL, CAST, SEMI-PRECISION ATTACHMENTS Page 44 I.C. I.C. I.C. Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee I.C. I.C. I.C. 53501 Maxillary 53502 Mandibular 53504 Altered Cast Impression Technique done in conjunction with the above mentioned codes 53600 DENTURES, PARTIAL, CAST, STRESS BREAKER ATTACHMENTS 53610 Denture, Cast Partial, Maxillary, Stress Breaker Attachments 53611 53612 53613 53614 53620 +L +L +L 959.13 959.13 959.13 85.93 +L +L +L 959.13 959.13 959.13 85.92 Dentures, Cast Partial, Mandibualar, Stress Breaker Attachments 53621 53622 53623 53624 53700 Maxillary (resilient) Maxillary (one hinge) Maxillary (two hinges) Altered Cast Impression Technique done in conjunction with the above mentioned codes Mandibular (resilient) Mandibular (one hinge) Mandibular (two hinges) Altered Cast Impression Technique done in conjunction with the above mentioned codes DENTURES, PARTIAL, CAST, OVERDENTURES, SUPPORTED BY NATURAL TEETH OR IMPLANTS WITH OR WITHOUT COPING CROWNS, NO ATTACHMENTS 53710 Dentures, Partial, Cast, Overdentures, Supported by Natural Teeth with or without Coping Crowns, no Attachments 53711 Maxillary 53712 Mandibular 53714 Altered Cast Impression technique done in conjunction with the above mentioned codes 53720 DENTURES, PARTIAL, CAST, OVERDENTURES (IMMEDIATE), SUPPORTED BY NATURAL TEETH OR IMPLANTS WITH OR WITHOUT COPING CROWNS, NO ATTACHMENTS 53810 +L +L 1039.13 1039.13 85.92 +L +L 1039.13 1039.13 85.92 Dentures, Partial, Casts, Overdentures, Supported by a Combination of Natural Teeth and Implants with or without Coping Crowns, No Attachments 53731 Maxillary 53732 Mandibular 53734 Altered Cast Impression technique done in conjunction with the above mentioned codes 53800 959.13 959.13 85.92 Dentures, Partial, Casts, Overdentures, Supported by Implants with or without Coping Crowns, No Attachments 53721 Maxillary 53722 Mandibular 53724 Altered Cast Impression technique done in conjunction with the above mentioned codes 53730 +L +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) Page 45 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 53811 Maxillary 53812 Mandibular 53814 Altered Cast Impression technique done in conjunction with the above mentioned codes 53820 1039.13 1039.13 85.92 +L +L 1039.13 1039.13 85.92 +L +L 1039.13 1039.13 85.92 +L +L 1039.13 1039.13 85.92 +L +L 1039.13 1039.13 85.92 +L +L 1039.13 1039.13 85.92 +L +L 1039.13 1039.13 Dentures, Partial, Cast, Overdentures (Immediate), Supported by Implants with or without Coping Crowns, No Attachments (includes first tissue conditioner, but not a processed reline) 53821 Maxillary 53822 Mandibular 53824 Altered Cast Impression technique done in conjunction with the above mentioned codes 53830 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) 53831 Maxillary 53832 Mandibular 53834 Altered Cast Impression technique done in conjunction with the above mentioned codes 53900 +L +L DENTURES, PARTIAL, CAST, OVERDENTURES, SECURED BY ATTACHMENTS TO NATURAL TEETH OR IMPLANTS 53910 Dentures, Partial, Cast, Overdentures, with Independent Attachments Secured to Natural Teeth, with or without Coping Crowns 53911 Maxillary 53912 Mandibular 53914 Altered Cast Impression technique done in conjunction with the above mentioned codes 53920 Dentures, Partial, Cast, Overdentures, with Independent Attachments Secured to Implants, with or without Coping Crowns 53921 Maxillary 53922 Mandibular 53924 Altered Cast Impression technique done in conjunction with the above mentioned codes 53930 Dentures, Partial, Cast, Overdentures, with Independent Attachments Secured to a Combination of Natural Teeth and Implants, with or without Coping Crowns 53931 Maxillary 53932 Mandibular 53934 Altered Cast Impression technique done in conjunction with the above mentioned codes 53940 Dentures, Partial, Cast, Overdentures, with Retention from a Retentive Bar, Secured to Coping Crowns Supported by Natural Teeth (see 62105 for Retentive Bar) 53941 Maxillary 53942 Mandibular Page 46 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 53950 Dentures, Partial, Cast, Overdentures, with Retention from a Retentive Bar, Secured to Coping Crowns Supported by Implants (see 62105 for Retentive Bar) 53951 Maxillary 53952 Mandibular 53954 Altered Cast Impression technique done in conjunction with the above mentioned codes 53960 1039.13 1039.13 85.92 +L +L 1039.13 1039.13 85.92 +L +L 73.59 144.66 72.33 +L +L 692.41 692.41 Dentures, Partial, Cast, Overdentures, with Retention from a Retentive Bar, Secured to Coping Crowns Supported by a Combination of Natural Teeth and Implants (see 62105 for Retentive Bar) 53961 Maxillary 53962 Mandibular 53964 Altered Cast Impression technique done in conjunction with the above mentioned codes 54000 DENTURES, ADJUSTMENT (after three month's insertion or by other than the dentist providing prosthesis) 54200 DENTURE ADJUSTMENTS, PARTIAL OR COMPLETE DENTURE, MINOR 54201 One unit of time 54202 Two units 54209 Each additional unit over two 54300 +L +L DENTURE ADJUSTMENTS, PARTIAL, OR COMPLETE DENTURE, REMOUNT AND OCCLUSAL EQUILIBRATION 54301 Maxillary 54302 Mandibular 54400 DENTURE ADJUSTMENTS, COMPLETE DENTURE, WITH CAST METAL OCCLUSAL SURFACES, REMOUNT AND OCCLUSAL EQUILIBRATION 54401 Maxillary 54402 Mandibular 54500 +L +L 692.41 692.41 DENTURE, ADJUSTMENT, PARTIAL DENTURE, WITH CAST METAL OCCLUSAL SURFACES, REMOUNT AND OCCLUSAL EQUILIBRATION 54501 Maxillary 54502 Mandibular 55000 DENTURES, REPAIRS/ADDITIONS 55100 DENTURE, REPAIR, COMPLETE DENTURE, NO IMPRESSION REQUIRED 55101 Maxillary 55102 Mandibular Page 47 +L +L 692.41 692.41 +L +L 77.12 80.12 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 55200 DENTURE, REPAIR, COMPLETE DENTURE, IMPRESSION REQUIRED 55201 Maxillary 55202 Mandibular 55300 +L +L DENTURE, REPAIRS/ADDITIONS, PARTIAL DENTURE, NO IMPRESSION REQUIRED 55301 Maxillary 55302 Mandibular 55400 79.12 81.12 +L +L 156.25 156.25 DENTURES/IMPLANT RETAINED PROSTHESIS PROPHYLAXIS AND POLISHING 55501 One unit of time 55509 Each additional unit of time 55600 +L +L DENTURE, REPAIRS/ADDITIONS, PARTIAL DENTURE, IMPRESSION REQUIRED 55401 Maxillary 55402 Mandibular 55500 +L 79.92 79.92 DENTURES, CUSTOM STAINED (PIGMENTED) DENTURE BASES (DIRECT CHAIRSIDE) 55701 One unit of time 55709 Each addition unit of time 85.92 85.92 56000 DENTURES, REPLICATION, RELINING AND REBASING 56100 DENTURES, REPLICATION, PROVISIONAL 56110 Dentures, Replication, Complete Denture, Provisional (No Intra-oral Impression Required) 56111 Maxillary 56112 Mandibular 56120 +L +L 164.25 164.25 +L +L 164.25 164.25 Dentures, Replication, Partial Denture (Provisional) (No Intra-oral Impression Required) 56121 Maxillary 56122 Mandibular 56200 78.33 78.33 DENTURES, REBUILDING WORN ACRYLIC DENTURE TEETH (DIRECT CHAIRSIDE) WITH TOOTH COLOURED 55601 One unit of time 55609 Each addition unit of time 55700 148.73 168.25 DENTURES, RELINING (Does not include Remount - see 54000 series) 56210 DENTURE, RELINE, DIRECT COMPLETE DENTURE 56211 Maxillary 56212 Mandibular 222.13 234.37 Page 48 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 56220 DENTURE, RELINE, DIRECT, PARTIAL DENTURE 56221 Maxillary 56222 Mandibular 56230 228.37 229.37 DENTURE, RELINE, PROCESSED, COMPLETE DENTURE 56231 Maxillary 56232 Mandibular 56240 229.37 231.37 +L +L 380.64 416.64 +L +L 389.64 473.64 +L +L 237.37 243.37 +L +L 273.37 246.37 +L +L 411.64 411.64 +L +L 411.64 411.64 DENTURE, RELINE, PROCESSED, FUNCTION IMPRESSION REQUIRING THREE APPOINTMENTS, PARTIAL DENTURE 56261 Maxillary 56262 Mandibular 56300 +L +L DENTURE, RELINE, PROCESSED, FUNCTION IMPRESSION REQUIRING THREE APPOINTMENTS, COMPLETE DENTURE 56251 Maxillary 56252 Mandibular 56260 245.37 249.37 DENTURE, RELINE, PROCESSED, PARTIAL DENTURE 56241 Maxillary 56242 Mandibular 56250 +L +L DENTURES, REBASING (Where the vestibular tissue-contacting surfaces are modified) 56310 DENTURE, REBASE COMPLETE DENTURE 56311 Maxillary 56312 Mandibular 56320 DENTURE, REBASE PARTIAL DENTURE 56321 Maxillary 56322 Mandibular 56330 DENTURE, REBASE, COMPLETE DENTURE, PROCESSED, FUNCTIONAL IMPRESSION REQUIRING THREE APPOINTMENT 56331 Maxillary 56332 Mandibular 56340 DENTURE, REBASE, PARTIAL DENTURE, PROCESSED, FUNCTIONAL IMPRESSION, REQUIRING THREE APPOINTMENTS 56341 Maxillary 56342 Mandibular Page 49 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 56400 DENTURES, REMAKE 56410 Dentures, Remake, Using Existing Framework, Partial Denture (equilibration)) 56411 Maxillary +L to +L to 56412 Mandibular 56500 304.52 495.37 304.52 495.37 DENTURES, THERAPEUTIC TISSUE CONDITIONING 56510 Denture, Therapeutic Tissue Conditioning, per appointment, Complete Denture 56511 Maxillary 56512 Mandibular 56520 152.25 152.25 Denture, Therapeutic Tissue Conditioning, per appointment, Partial Denture 56521 Maxillary 56522 Mandibular 56530 152.25 152.25 Dentures, Tissue Conditioning, per appointment, Complete Overdenture, Supported by Natural Teeth 56531 Maxillary 56532 Mandibular 56540 164.25 164.25 Dentures, Tissue Conditioning, per appointment, Complete Overdenture, Implant Supported 56541 Maxillary 56542 Mandibular 56550 164.25 164.25 Dentures, Tissue Conditioning, per appointment, Partial Overdenture, Supported by Natural Teeth 56551 Maxillary 56552 Mandibular 56560 164.25 164.25 Dentures, Tissue Conditioning, per appointment, Partial Overdenture, Implant Supported 56561 Maxillary 56562 Mandibular 56600 164.25 164.25 DENTURES, MISCELLANEOUS SERVICES 56601 Resilient Liner, in Relined or Rebased Denture (in addition to reline or rebase of denture) 56602 Resetting of Teeth (not including reline or rebase of denture) 56603 Cast occlusal surfaces (includes remount and equilibration) Page 50 LAB +L +L 319.70 692.41 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 57000 PROSTHESIS, MAXILLOFACIAL 57100 PROSTHESIS, FACIAL 57101 Orbital +L to +L to +L to +L +L to 57102 Nose 57103 Ear 57104 Patch 57105 Facial, Complex 57106 57107 57108 57109 57200 Facial Moulage Impression, Complete Facial Moulage Impression, Sectional Ocular Conformer Prosthesis (temporary post-surgical) Ocular Prosthesis +L to +L to +L to +L to +L to +L to +L to +L to +L to 102.71 444.84 102.71 444.84 102.71 1112.11 102.71 1112.11 102.71 1112.11 102.71 1112.11 410.84 1335.54 410.84 778.98 718.98 1446.25 +L to +L to +L +L +L to 102.71 1112.11 102.71 1112.11 667.27 332.14 102.71 668.31 PROSTHESIS, MAXILLOFACIAL, OBTURATORS 57201 Obturator, Cleft Palate (prosthesis extra) 57202 Obturator, Palatal (prosthesis extra) 57203 Obturator, Post-Maxillectomy (prosthesis extra) 57204 Obturator, Temporary Palatal (prosthesis extra) 57205 Obturator, Resilient (prosthesis extra) 57206 Obturator, Hollow Bulb (prosthesis extra) 57207 Obturator, Inflatable (prosthesis extra) 57208 Obturator Prosthesis, Modification (relines or repairs) 57209 Speech Aid Prosthesis 57300 +L +L to 2362.38 5565.61 1848.81 3784.21 1848.81 3784.21 555.55 2362.38 4563.19 362.89 272.16 555.55 718.98 3004.22 PROSTHESIS, MAXILLOFACIAL, OTHER 57301 Velar Bulb (prosthesis and obturator extra) 57302 Velar Lift Button, Mechanical (prosthesis and obturator extra) 57303 Retention, Spiral Spring (prosthesis extra) 57304 Retention, Magnetic (prosthesis extra) 57305 Guide Plane, Condylar (prosthesis extra) 57306 Implant, Silastic Chin I.C. Page 51 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 57307 57308 57309 57311 Mesh Prosthesis, Chrome Cobalt Mandibular Mesh Skull Plate, Customized Akerman, Pseudotemporomandibular Joint (prosthesis extra) Feeding Appliance (for infants with cleft palate) 57321 Lingual Prosthesis 57341 Mandibular Resection Prosthesis with Guide Flange 57342 Mandibular Resection Prosthesis without Guide Flange 57351 Prosthesis, Maxillofacial, Fixed 57361 Palatal Augmentation Prosthesis 57371 Palatal Life Prosthesis, Modification (relines or repairs) 57372 Gingival Prosthesis Note: For removable appliance used to mask unaesthetic embrasures see sub-classification 49300soft tissue prosthesis, code 49301 Gingival Mask 57400 57402 Splint, Permanent Cast Occlusal 821.68 1334.54 2054.24 3339.35 +L +L +L +L +L +L +L to 989.18 1385.47 1385.47 1385.47 1385.47 1385.47 308.14 1447.25 +L +L +L +L 989.18 989.18 989.18 989.18 +L to +L 913.18 2969.58 989.18 PROSTHESIS, SPLINTS 57501 57502 57503 57504 57505 57506 57508 57600 +L to +L to +L to +L to +L to +L to PROSTHESIS, TEMPOROMANDIBULAR JOINT 57401 Exerciser, Trismus, Therapy 57500 +L to +L to +L Average Fee I.C. I.C. I.C. 513.55 1112.11 1643.38 3339.35 1027.11 1781.38 616.27 1334.54 I.C. 718.98 1669.68 205.41 778.98 362.89 Stout Cast Capped Gunning (upper and lower) Bar Splint, Cast, Labial and Lingual Scaffolding, Rhinoplastic Cast, Adjustable Commisure Splint PROSTHESIS, STENTS 57601 57602 57603 57604 57650 Ridge Extension Palatal Skin Grafts Mucous Membrane Grafts PROSTHESIS, RADIATION APPLIANCES 57651 Radiation Vehicle Carrier 57652 Radiation Protection Shield (extraoral) Page 52 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 +L +L to Average Fee 989.18 308.14 1781.38 +L +L 989.18 593.91 +L to +L to 513.55 1112.11 616.27 1334.54 62101 Pontics, Cast Metal 62102 Pontics, Cast Metal Framework with Separate Porcelain/Ceramic/Polymer Glass Jacket Pontic +L +L 440.94 437.94 62103 Pontics, Prefabricated Attachable Facing 62104 Pontics, Retentive Bar, Pre-fabricated or Custom (Dolder or Hader) Bar Attached to Retainer +L +E 340.62 437.94 62105 Pontics, Retentive Bar, Pre-fabricated or Custom (Dolder or Hader) Bar, Attached to Implantsupported Retainer to Retain Removable Prosthesis, Each Bar +L +E I.C. 57653 Radiation Protection Shield (intraoral) 57654 Radiation Cone Locator 57660 PROSTHESIS, STENTS, DECOMPRESSION 57661 Decompression Stent, Localized 57662 Decompression Stent, (prosthesis extra) 57700 PROSTHESIS, ORTHOPEDIC 57701 Orthopedic Prosthesis (extraoral) 57702 Orthopedic Prosthesis (intraoral) PROSTHODONTICS - FIXED Initial description: Fixed prosthodontic therapy requires the use of a variety of technical and therapeutic procedures depending on the nature of the problems presented in each individual case. The range of these procedures extends into many areas of treatment in order to provide comprehensive therapy for the patient. Many of the procedures used vary considerably in their difficulty, time, involvement and expense. The amount of time involved in a procedure may vary considerably from those outlined in the following guide. Fixed Bridges (each abutment, each retainer and each pontic, constitutes a separate unit in the bridge, with a separate code number) 62000 PONTICS, BRIDGE 62100 PONTICS, CAST METAL 62500 PONTICS, PORCELAIN/CERAMIC/POLYMER GLASS 62501 Pontics, Porcelain/Ceramic/Polymer Glass, Fused to Metal 62502 Pontics, Porcelain/Ceramic/Polymer Glass, Aluminous 62700 +L +L 448.14 509.94 +L +L 341.62 100.51 PONTICS, ACRYLIC/COMPOSITE /COMPOMER 62701 Pontics, Acrylic/Composite/Compomer, Processed to Metal 62702 Pontics, Acrylic/Composite/Compomer, Indirect (Provisional) Page 53 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 62703 Pontics, Acrylic/Composite/Compomer, Bonded to adjacent Teeth Direct (Provisional) 62704 Pontics, Acyrilic/Composite/Compomer 62800 +E +L Average Fee 100.51 100.51 PONTICS, NATURAL TOOTH 62801 Pontics, Natural Tooth Crown, Direct, Bonded to Adjacent Teeth (Provisional) 63000 169.84 RECONTOURING OF RETAINER/PONTICS, (of existing bridgework) 63001 One unit of time 63009 Each additional unit of time 79.92 79.92 64000 MASTER CAST TECHNIQUES 64100 MASTER CAST, TECHNIQUES, MAXILLO-MANDIBULAR REGISTRATIONS 64120 Master Cast Techniques, True Hinge Axis Registration and Transfer 64121 One unit of time 64129 Each additional unit of time 64130 +L +L I.C. I.C. Master Cast Mounting with Arbitrary Facebow Transfer 64221 One unit of time 64229 Each additional unit of time 64230 +L +L 76.33 76.33 Master Cast Mounting with Kinematic Facebow Transfer 64231 One unit of time 64239 Each additional unit of time +L +L I.C. I.C. +L +L I.C. I.C. Master Cast Gnathological Wax-Up 64301 One unit of time 64309 Each additional unit of time 66000 76.33 76.33 MASTER CAST MOUNTING TECHNIQUES 64220 64300 +L +L Master Cast Techniques, Three Dimensional Recordings of Mandibular Movement (Pantograph or Stereograph) 64141 One unit of time 64149 Each additional unit of time 64200 76.33 76.33 Master Cast Techniques, Centric Registration Recording 64131 One unit of time 64139 Each additional unit of time 64140 +L +L REPAIRS Page 54 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 66100 REPAIRS, REPLACEMENT REPLACE BROKEN PREFABRICATED ATTACHABLE FACINGS 66110 66111 66112 66113 66114 66119 66200 79.92 159.84 239.78 319.71 79.92 +L +L +L +L +L 88.51 177.04 266.56 355.09 88.51 Repairs, Removal, Fixed Bridge/Prosthesis - To be re-cemented 66211 66212 66213 66214 66219 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 66220 66221 66222 66223 66224 66229 84.92 169.84 254.78 339.71 84.92 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) 66301 66302 66303 66304 66309 66700 +L +L +L +L REPAIRS, REMOVAL OF EXISTING FIXED BRIDGE/PROSTHESIS 66210 66300 One unit of time Two units Three units Four units Each additional unit over four +L +L +L +L +L One unit of time Two units Three units Four units Each additional unit over four 81.92 163.84 245.78 327.71 81.92 REPAIRS, FIXED BRIDGE/PROSTHESIS 66710 Repairs, Fixed Bridge/Prosthesis, Porcelain/Ceramic/Polymer Glass/Acrylic/Composite/Compomer, Direct 66711 First tooth 66719 Each additional tooth 66720 167.45 167.45 REPAIRS, SOLDER INDEXING TO REPAIR BROKEN SOLDER JOINT 66721 One unit of time 66729 Each additional unit of time +L Page 55 84.92 84.92 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 66730 REPAIR FRACTURED PORCELAIN/METAL PONTIC WITH TELESCOPING TYPE CROWN (pontic prepared, impression made and processed crown seated over metal) 66731 First pontic 66739 Each additional pontic +L 447.94 437.94 +L +L +L 921.50 840.70 279.57 +L 653.66 67121 Retainers, Acrylic, Composite/Compomer, Direct(provisional during healing, done at chair-side +E ) 67125 Retainers, Acrylic, Composite/Compomer, (provisional during healing,done at chair-side), +E Implant-supported, Direct 184.04 67000 FIXED BRIDGE RETAINERS It is appropriate to use Fixed Bridge Retainer codes, rather than codes for single tooth restorations, where two, or more single tooth inlays/onlays or crowns are joined (Splinted) together and do not support a pontic 67100 RETAINERS, ACRYLIC/COMPOSITE/ COMPOMER WITH, OR WITHOUT CAST OR PREFABRICATED METAL BASES 67110 Retainers, Acrylic, Composite/Compomer, Indirect 67111 Retainers, Acrylic, Composite/Compomer, Indirect 67112 Retainers, Acrylic, Composite/Compomer, Complicated, Indirect 67113 Retainers, Acrylic, Composite/Compomer, Provisional, Indirect (lab fabricated/relined intraorally) 67115 Retainers, Acrylic, Composite/Compomer, Implant-supported Indirect 67120 67130 67200 Retainers, Acrylic, Composite/Compomer, Direct (provisional during healing, done at chair-side) 185.04 RETAINERS, Acrylic, Composite/Compomer, Cast Metal Base, Indirect 67131 Retainer, Compomer/Composite Resin/Acrylic, Processed to Cast Metal, Indirect 67135 Retainer, Compomer/Composite Resin/Acrylic, Processed to Metal, Indirect, Implant-supported +L +L +E 639.24 681.24 67160 Retainers, Acrylic/Composite/Compomer, Two surface Inlay, indirect bonded +L 593.58 67161 Retainers, Acrylic/Composite/Compomer, Two surface Inlay, Indirect +L 584.92 67170 Retainers, Acrylic/Composite/Compomer, Three surface Inlay, Indirect, bonded +L 730.56 67171 Retainers, Acrylic/Composite/Compomer, Three surface Inlay, Indirect +L 730.90 67180 Retainers, Acrylic/Composite/Compomer, Onlay, Indirect, bonded +L 867.54 67181 Retainers, Acrylic/Composite/Compomer, Onlay, Indirect +L 876.88 +L +L 987.88 1004.52 RETAINER, PORCELAIN/CERAMIC/POLYMER GLASS 67201 Retainer, Porcelain/Ceramic/Polymer Glass 67202 Retainer, Porcelain/Ceramic/Polymer Glass, Complicated Page 56 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 67205 Retainer, Porcelain/Ceramic/Polymer Glass, Implant-supported 67210 Average Fee 1123.88 +L +L +L +E 921.50 1004.52 1077.88 Retainers, Porcelain/Ceramic/Polymer Glass, Fused To Metal Base 67211 Retainers, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base 67212 Retainers, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base, Complicated 67215 Retainers, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base, Implant-supported 67220 +L +E Retainers, Porcelain/Ceramic/Polymer Glass, Partial Coverage, Bonded (External Retentione.g. “Maryland Bridge”) 67221 Retainer, Porcelain/Ceramic/Polymer Glass, Partial Coverage, Bonded (External Retention- e.g. +L “Maryland Bridge”) 67230 Retainers, Porcelain/Ceramic/Polymer Glass, Two surface Inlay, Bonded 67231 Retainers, Porcelain/Ceramic/Polymer Glass, Two surface Inlay, Bonded 67240 632.58 +L 779.56 +L 925.54 +L +L +E 942.00 1004.52 821.88 +L +L 1175.47 1004.52 +L +L 680.91 900.88 +L 945.88 Retainers, Porcelain/Ceramic/Polymer Glass, Onlay, Bonded (where one or more cusps are restored) 67251 Retainers, Porcelain/Ceramic/Polymer Glass, Onlay, Bonded 67300 +L Retainers, Porcelain/Ceramic/Polymer Glass, Three surface Inlay, Bonded 67241 Retainers, Porcelain/Ceramic/Polymer Glass, Three surface Inlay, Bonded 67250 1075.92 RETAINERS, CAST METAL 67301 Retainers, Cast Metal 67302 Retainers, Cast Metal, Complicated 67305 Retainers, Cast Metal, Implant-Supported 67310 Retainer, ¾ Cast Metal 67311 Retainers, ¾, Cast Metal 67312 Retainers, 3/4, Cast Metal, Complicated 67320 RETAINERS, METAL INLAY (used with broken stress technique) 67321 Retainer, Metal Inlay, Two Surfaces 67322 Retainer, Metal Inlay, Three or More Surfaces 67330 Retainers, Cast Metal Onlay (internal retention type) 67331 Retainers, Cast Metal, Onlay 67340 Retainers, Cast Metal, Onlay (bonded external retention/partial coverage - - e.g. Maryland Bridge) 67341 Retainer, Cast Metal, Onlay, with or without Perforations, Bonded to Abutment Page 57 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 +L Tooth, (Pontic extra) 67400 Average Fee 456.60 RETAINERS, OVERDENTURES, CUSTOM CAST OR PRE-FABRICATED WITH NO OCCLUSAL COMPONENT 67415 Retainer, Metal, Pre-fabricated or Custom Cast, Implant-supported, with or without Mesostructure +L +E I.C. with no Occlusal Component (see 62105 for retentive bar) 67500 FIXED PROSTHETICS, ABUTMENTS/RETAINERS, MISCELLANEOUS SERVICES 67501 Abutment Preparation Under Existing Partial Denture Clasp, in addition to retainer codes 67502 Telescoping Crown Unit 69000 FIXED PROSTHETICS, OTHER SERVICES 69100 FIXED PROSTHETICS, MISCELLANEOUS SERVICES 69101 Fixed Prosthesis, Porcelain, to Replace a Substantial Portion of the Alveolar Process (in addition to retainer and pontics) 69200 +L +L 76.33 340.70 +L 1037.60 FIXED PROSTHETICS, SPLINTING 69201 Splinting, for Extensive or Complicated Restorative Dentistry (per tooth) 69300 FIXED PROSTHETICS, RETENTIVE PINS (for retainers in addition to restoration) 69301 69302 69303 69304 69305 69700 +L +L +L +L +L One pin/restoration Two pins/restoration Three pins/restoration Four pins/restoration Five pins or more/restoration 44.60 90.21 134.99 168.34 194.70 FIXED PROSTHETICS, PROVISIONAL COVERAGE (in extensive or complicated restorative dentistry) 69701 Abutment Tooth 69702 Pontic 69800 I.C. +L +L 279.56 92.51 FIXED PROSTHODONTIC FRAMEWORKS, OSSEO-INTEGRATED IMPLANT-SUPPORTED 69810 Fixed Prosthodontic Frameworks, Osseo-Integrated, Attached with Screws and Incorporating Teeth (denture teeth and acrylic) 69811 Maxillary 69812 Mandibular 69820 I.C. I.C. Fixed Prosthodontic Framework, Osseo-Integrated, Attached with Screws Or Cement and Incorporating Teeth (Porcelain/Ceramic/Polymer Glass Bonded to Metal, Acrylic/Composite/Compomer Processed to Metal or Full Metal Crowns) Page 58 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee I.C. I.C. 69821 Maxillary 69822 Mandibular ORAL AND MAXILLOFACIAL SURGERY 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 teeth or in some cases a single tooth. 71000 REMOVALS, (EXTRACTIONS), ERUPTED TEETH 71100 REMOVALS, ERUPTED TEETH, UNCOMPLICATED 71101 Single tooth, Uncomplicated 71109 Each additional tooth, same quadrant, same appointment 71200 REMOVALS, ERUPTED TEETH, COMPLICATED 71201 Odontectomy, (extraction), Erupted Tooth, Surgical Approach, Requiring Surgical Flap and/or Sectioning of Tooth 71209 Each additional tooth, same quadrant 71210 Requiring elevation of a Flap, Removal of Bone and may include Sectioning of Tooth for Removal of Tooth 71211 Single Tooth 71219 Each Additional tooth, same quadrant 72000 REMOVALS, (EXTRACTIONS), SURGICAL 72100 REMOVALS, IMPACTIONS, SOFT TISSUE COVERAGE 72110 247.45 247.35 264.13 309.13 264.13 REMOVALS, IMPACTION, REQUIRING INCISION OF OVERLYING SOFT TISSUE AND REMOVAL OF THE TOOTH 72111 Single tooth 72119 Each additional tooth, same quadrant 72200 137.16 137.16 270.50 298.50 REMOVALS, IMPACTIONS, INVOLVING TISSUE AND/OR BONE COVERAGE 72210 REMOVALS, IMPACTION, REQUIRING INCISION OF OVERLYING SOFT TISSUE, ELEVATION OF A FLAP AND EITHER REMOVAL OF BONE AND TOOTH OR SECTIONING AND REMOVAL OF TOOTH (Partial Bone Impaction) 72211 Single tooth 72219 Each additional tooth, same quadrant 72220 359.23 359.23 REMOVALS, IMPACTION, REQUIRING INCISION OF OVERLYING SOFT TISSUE, ELEVATION OF A FLAP, REMOVAL OF BONE AND/OR SECTIONING OF TOOTH FOR REMOVAL (Complete Bone Impaction) Page 59 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 479.00 479.00 72221 Single tooth 72229 Each additional tooth, same quadrant 72230 REMOVALS, IMPACTION, REQUIRING INCISION OF OVERLYING SOFT TISSUE, ELEVATION OF A FLAP, REMOVAL OF BONE, AND/OR SECTIONING OF THE TOOTH FOR REMOVAL AND/OR PRESENTS UNUSUAL DIFFICULTIES AND CIRCUMSTANCES 72231 Single tooth 72239 Each additional tooth, same quadrant 72240 653.06 653.06 CORONECTOMY (DELIBERATE VITAL ROOT RETENTION) 72241 Coronectomy (Deliberate Vital Root Retention of Unerupted Mandibular Molar) 72242 Coronectomy (Deliberate Vital Root Retention to prevent Complications Associated with Extraction) 72300 I.C. I.C. REMOVALS, (EXTRACTIONS), RESIDUAL ROOTS 72310 REMOVALS, RESIDUAL ROOTS, ERUPTED 72311 First tooth 72319 Each additional tooth, same quadrant 72320 110.88 116.88 REMOVALS, RESIDUAL ROOTS, SOFT TISSUE COVERAGE 72321 First tooth 72329 Each additional tooth, same quadrant 72330 163.32 163.32 REMOVALS, RESIDUAL ROOTS, BONE TISSUE COVERAGE 72331 First tooth 72339 Each additional tooth, same quadrant 72400 ALVEOLAR BONE PRESERVATION 72410 72420 72430 72500 239.50 239.50 Alveolar Bone Preservation – Autograft 72411 First tooth 72419 Each additional tooth +E +E 304.68 304.68 Alveolar Bone Preservation - Allograft 72421 First tooth 72429 Each additional tooth +E +E 304.68 304.68 Alveolar Bone Presevation – Zenograft 72431 First tooth 72439 Each additional tooth +E +E 304.68 304.68 SURGICAL EXPOSURE OF TEETH Page 60 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 72510 SURGICAL EXPOSURE, UNERUPTED, UNCOMPLICATED, SOFT TISSUE COVERAGE (includes operculectomy) 72511 Single tooth 72519 Each additional tooth, same quadrant 72520 217.76 217.76 SURGICAL EXPOSURE, COMPLEX, HARD TISSUE COVERAGE 72521 Single tooth 72529 Each additional tooth, same quadrant 72530 391.82 391.82 SURGICAL EXPOSURE, UNERUPTED TOOTH, WITH ORTHODONTIC ATTACHMENT 72531 Single tooth 72539 Each additional tooth, same quadrant 72540 +E +E SURGICAL EXPOSURE, UNERUPTED TOOTH, SOFT TISSUE COVERAGE WITH POSITIONING OF ATTACHED GINGIVAE 72541 Single tooth 72550 326.64 SURGICAL EXPOSURE, UNERUPTED TOOTH, HARD TISSUE COVERAGE WITH POSITIONING OF ATTACHED GINGIVAE 72551 Single tooth 72600 435.55 SURGICAL MOVEMENT OF TEETH 72610 TRANSPLANTATION OF ERUPTED TOOTH 72611 First tooth 72619 Each additional tooth, same quadrant 72620 653.06 653.06 TRANSPLANTATION OF UNERUPTED TOOTH 72621 First tooth 72629 Each additional tooth, same quadrant 72630 783.68 783.68 REPOSITIONING, SURGICAL 72631 First tooth 72639 Each additional tooth, same quadrant 72700 522.44 522.44 479.00 479.00 ENUCLEATION, SURGICAL 72710 UNERUPTED TOOTH FOLLICLE 72711 First tooth 72719 Each additional tooth, same quadrant 479.00 479.00 Page 61 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 72800 REMOVAL OF FRACTURED CUSP AS A SEPARATE PROCEDURE, NOT IN CONJUCTION WITH SURGICAL OR RESTORATIVE PROCEDURE ON THE SAME TOOTH 72801 First tooth 72802 Each Additional Tooth 83.73 80.73 73000 REMODELING AND RECONTOURING ORAL TISSUES 73100 ALVEOLOPLASTY (Bone remodeling of ridge with sift tissue revisions) 73110 ALVEOLOPLASTY, IN CONJUNCTION WITH EXTRACTIONS 73111 Per sextant 73120 111.88 ALVEOLOPLASTY, NOT IN CONJUNCTION WITH EXTRACTIONS 73121 Per sextant 73140 217.76 REMODELING OF BONE 73141 Mylohyoid Ridge Remodeling 73142 Genial Tubercle Remodeling 73150 EXCISION OF BONE 73151 73152 73153 73154 73160 424.42 408.13 408.13 479.00 359.23 598.73 Nasal Spine, Excision Torus Palatinus, Excision Torus Mandibularis, Unilateral, Excision Torus Mandibularis, Bilateral, Excision REMOVAL OF BONE, EXOSTOSIS, MULTIPLE 73161 Per quadrant to 73170 REDUCTION OF BONE, TUBEROSITY 73171 Unilateral, Reduction 73172 Bilateral, Reduction 73180 217.76 435.55 AUGMENTATION OF BONE 73181 Unilateral, Pterygomaxillary Tuberosity, Augmentation 73182 Bilateral, Pterygomaxillary Tuberosity, Augmentation 73183 Unilateral, Mandibular Ridge, Augmentation 73184 Bilateral, Mandibular Ridge, Augmentation 73200 359.23 718.49 GINGIVOPLASTY AND/OR STOMATOPLASTY, ORAL SURGERY Page 62 +E +E +E to +E to 424.42 848.86 522.19 696.25 1044.38 1392.53 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 73210 INDEPENDENT PROCEDURE 73211 Per sextant 73220 MISCELLANEOUS PROCEDURES 73221 73222 73223 73224 73230 239.50 Gingivoplasty, in Conjunction with Tooth Removal 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) 73231 Per sextant 73240 239.50 REMOVAL, MUCOSA, EXCESS (complete removal without dissection) 73241 Per sextant 73300 239.50 REMODELING, FLOOR OF THE MOUTH 73301 Full Arch Lowering of the Floor of the Mouth 73302 Partial Arch Lowering of the Floor of the Mouth 73303 Reinsertion of the Mylohyoid Muscle 73400 239.50 239.50 424.42 119.73 2088.78 1044.38 870.31 VESTIBULOPLASTY 73410 VESTIBULOPLASTY, SUB-MUCOUS 73411 Per sextant 73420 228.56 SULCUS DEEPENING AND RIDGE RECONSTRUCTION 73421 Per sextant 73430 183.62 VESTIBULOPLASTY, WITH SECONDARY EPITHELIZATION 73431 Per sextant 73440 282.94 VESTIBULOPLASTY, WITH LABIAL INVERTED FLAP 73441 Per sextant 73450 424.42 VESTIBULOPLASTY, WITH SKIN GRAFT 73451 Per sextant 73460 522.19 VESTIBULOPLASTY, WITH MUCOSAL GRAFT Page 63 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 73461 Per sextant 73470 73480 73490 73500 522.19 Vestibuloplasty – with Dermal Graft - Autograft 73471 Per Sextant 183.62 Vestibuloplasty – with Dermal Graft - Allograft 73481 Per Sextant 183.62 Vestibuloplasty – with Connective Tissue for Ridge Augmentation 73491 Per sextant 183.62 RECONSTRUCTION, ALVEOLAR RIDGE 73510 RECONSTRUCTION, ALVEOLAR RIDGE, WITH AUTOGENOUS BONE 73511 Per sextant 73520 +E 696.25 +E 696.25 RECONSTRUCTION, ALVEOLAR RIDGE, WITH ALLOPLASTIC MATERIAL 73521 Per sextant 73600 +E EXTENSIONS, MUCOUS FOLDS 73610 EXTENSIONS, MUCOUS FOLDS WITH SECONDARY EPITHELIZATION 73611 Per sextant 73620 505.88 EXTENSIONS, MUCOUS FOLDS, WITH SKIN GRAFTS 73621 Per sextant 73630 505.88 EXTENSIONS, MUCOUS FOLDS, WITH MUCOUS GRAFT 73631 Per sextant 505.88 74000 SURGICAL EXCISION (not in conjunction with tooth removal, including biopsy) 74100 SURGICAL EXCISION, TUMORS, BENIGN 74110 TUMORS, BENIGN, SCAR TISSUE, INFLAMMATORY OR CONGENITAL LESIONS OF SOFT TISSUE OF THE ORAL CAVITY 74111 74112 74113 74114 74115 74116 74117 74118 326.53 424.42 514.17 587.62 709.97 788.85 897.62 1011.79 1 cm. and under 1-2 cm. 2-3 cm. 3-4 cm. 4-6 cm. 6-9 cm. 9-15 cm. 15 cm. and over Page 64 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 74120 TUMORS, BENIGN, BONE TISSUE 74121 74122 74123 74124 74125 74126 74127 74128 74200 391.82 544.18 707.39 881.45 1028.35 1218.72 1371.05 1577.70 1 cm. and under 1-2 cm. 2-3 cm. 3-4 cm. 4-6 cm. 6-9 cm. 9-15 cm. 15 cm. and over SURGICAL EXCISION, TUMORS, MALIGNANT 74210 TUMORS, MALIGNANT, SOFT TISSUE, ORAL CAVITY 74211 74212 74213 74214 74215 74216 74217 74218 74220 304.68 457.01 631.07 788.85 979.19 1142.40 1349.06 1517.69 1 cm. and under 1-2 cm. 2-3 cm. 3-4 cm. 4-6 cm. 6-9 cm. 9-15 cm. 15 cm. and over TUMORS, MALIGNANT BONE TISSUE 74221 74222 74223 74224 74225 74226 74227 74228 457.01 609.36 788.85 946.63 1142.40 1305.61 1517.69 1740.66 1 cm. and under 1-2 cm. 2-3 cm. 3-4 cm. 4-6 cm. 6-9 cm. 9-15 cm. 15 cm. and over 74230 Selective neck dissection 74231 Unilateral 74232 Bilateral I.C. I.C. 74240 Radical neck dissection 74241 Unilateral 74242 Bilateral 74300 I.C. I.C. CHEILOPLASTY (LIP SHAVE) 74301 Cheiloplasty, Partial 74302 Cheiloplasty, Total to Page 65 609.36 914.04 1218.72 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 74400 HARD TISSUE GRAFTS TO THE JAW 74401 Autograft – per site – Maxilla or Mandible 74402 Allograft – per site – Maxilla or Mandible 74403 Xenograft – per site – Maxilla or Mandible 74500 696.25 696.25 696.25 AUGMENTATIONS, PROSTHETIC, OF THE JAW 74520 AUGMENTATION, SYNTHETIC, OF THE JAW 74521 Augmentation, of the Chin 74600 +E +E +E I.C. SURGICAL EXCISION, CYSTS/GRANULOMAS (Based on Cyst Size) 74610 ENUCLEATION OF CYST/GRANULOMA, ODONTOGENIC AND NON-ODONTOGENIC, REQUIRING PRIOR REMOVAL OF BONY TISSUE AND SUBSEQUENT SUTURE(S) 74611 74612 74613 74614 74615 74616 74617 74618 74620 375.54 522.44 680.22 848.86 1028.35 1218.72 1419.95 1632.03 1 cm. and under 1-2 cm. 2-3 cm. 3-4 cm. 4-6 cm. 6-9 cm. 9-15 cm. 15 cm. and over MARSUPIALIZATION 74621 Cyst, Marsupialization 74630 479.00 EXCISION OF CYST 74631 74632 74633 74634 74635 74636 74637 74638 375.54 522.44 680.22 848.86 1028.35 1218.72 1419.95 1632.03 1 cm. and under 1-2 cm. 2-3 cm. 3-4 cm. 4-6 cm. 6-9 cm. 9-15 cm. 15 cm. and over 75000 SURGICAL INCISIONS 75100 SURGICAL INCISION AND DRAINAGE AND/OR EXPLORATION, INTRAORAL 75110 SURGICAL INCISION AND DRAINAGE AND/OR EXPLORATION, INTRAORAL SOFT TISSUE 75111 Intraoral, Surgical Exploration, Soft Tissue Page 66 239.50 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 239.50 408.13 75112 Intraoral, Abscess, Soft Tissue 75113 Intraoral, Abscess, In Major Anatomical area with Drain 75120 SURGICAL INCISION AND DRAINAGE AND/OR EXPLORATION, INTRAORAL HARD TISSUE 75121 Intraoral, Abscess, Hard Tissue, Trephination and Drainage 75122 Intraoral, Surgical Exploration, Hard Tissue 75123 Intraoral, Abscess, Hard Tissue, Trephination and Drainage in a Major Anatomical Area 75200 250.35 391.82 544.18 SURGICAL INCISION AND DRAINAGE AND/OR EXPLORATION, EXTRAORAL 75210 SURGICAL INCISION AND DRAINAGE AND/OR EXPLORATION, EXTRAORAL, SOFT TISSUE 75211 Extraoral, Abscess, Superficial 75212 Extraoral, Abscess, Deep 75220 565.89 707.39 SURGICAL INCISION AND DRAINAGE AND/OR EXPLORATION, EXTRAORAL HARD TISSUE 75221 Extraoral, Surgical Exploration, Hard Tissue 75300 565.89 SURGICAL INCISION FOR REMOVAL OF FOREIGN BODIES 75301 Removal, from Skin or Subcutaneous Alveolar Tissue to 75302 Removal, of Reaction Producing Foreign Bodies to 75303 Removal, of Needle from Musculo-skeletal System to 75400 SEQUESTRECTOMY (FOR OSTEOMYELITIS) 75401 Intraoral Sequestrectomy 75402 Saucerization 75403 Osteomyelitis, Non Surgical Treatment of 75410 522.44 914.04 195.91 EXTRAORAL SEQUESTRECTOMY 75411 75412 75413 75414 75415 75500 761.69 1523.40 761.69 1523.40 761.69 1523.40 522.44 653.06 816.27 952.31 1131.80 3 cm. and less 3-4 cm. 4-6 cm. 6-9 cm. 9 cm. and over MANDIBULECTOMY 75510 MANDIBULECTOMY 75511 3 cm. or less 457.01 Page 67 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 75512 75513 75514 75515 75516 75517 75518 75600 to Average Fee 609.36 788.85 979.19 1180.42 1392.53 1566.59 1914.72 2480.44 to 761.69 914.04 1104.38 1305.61 1517.69 1740.66 2001.75 2219.34 2959.12 3-4 cm. 4-6 cm. 6-9 cm. 9-12 cm. 12-15 cm. 15 cm. and over Total Mandibulectomy MAXILLECTOMY 75610 MAXILLECTOMY 75611 75612 75613 75614 75615 75616 75617 75618 3 cm. or less 3-4 cm. 4-6 cm. 6-9 cm. 9-12 cm. 12-15 cm. 15 cm. and over Total Maxillectomy 76000 FRACTURES, TREATMENT OF 76100 INTERMAXILLARY FIXATION (WIRING) 76110 SPLINTS PER ARCH, ONE OR MORE PER JAW 76111 76112 76113 76114 76115 76116 76120 130.59 130.59 565.89 565.89 914.04 Nasal Spine Wiring Piriform Apertures Suspension Frontal Suspension Orbital Rim Suspension, Bilateral Head Frame Suspension CIRCUMMANDIBULAR WIRING 76131 Wiring, one 76132 Wiring, two 76133 Wiring, three or over 76140 391.82 391.82 130.59 130.59 130.59 391.82 INTRA MAXILLARY SUSPENSION (Wiring) 76121 76122 76123 76124 76125 76130 Wiring of Dentures or Arch Bar Acrylic Prosthesis or Cap Splint Circumzygomatic Wiring Unilateral Perialveolar or Transpalatal Wiring Intra or Periosseous Splinting for Pericranial Suspension Intermaxillary Fixation 130.59 261.21 391.82 SPLINTS/WIRES, REMOVAL OF, Page 68 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 76141 76142 76143 76144 217.76 217.76 522.44 522.44 Removal of Wire Removal of Arch Splint (one or more per jaw) Removal of Interosseous Ligature or Bone Plate Removal of Intra or Peri Osseous Rod or Wire for Pericranial Suspension and/or Pericranial Apparatus 76145 Removal of Acrylic Prosthesis or Cap Splint, Attached to Maxilla or to Teeth (one or more per jaw) 76146 Removal of Wire Plate or Screw used in Osteosynthesis (one or more at the same site) 76200 408.13 522.44 FRACTURES, REDUCTIONS, MANDIBULAR 76201 Reduction, Mandibular, Closed to 76202 Reduction, Mandibular, Open, Single 76203 Reduction, Mandibular, Open, Double 76204 Reduction, Mandibular, Open, Multiple 76300 FRACTURES, REDUCTIONS, MAXILLARY, HORIZONTAL LE FORT'S l 76301 76302 76303 76304 Reduction, Maxillary, Closed Reduction, Maxillary, Open, Single Reduction, Maxillary, Open, Double Reduction, Maxillary, Open, Multiple to 76305 Reduction, Compound Fracture of Maxilla (requiring reduction and soft tissue repair) to 76400 1218.72 1218.72 1828.08 FRACTURES, REDUCTIONS, NASO-ORBITAL 76501 76502 76503 76504 76505 76506 76507 76600 1044.91 1523.40 1828.08 2088.78 2785.06 2959.12 3698.90 FRACTURES, REDUCTIONS, MAXILLA, PYRAMIDAL LE FORT'S ll 76401 Reduction, Maxillary, Closed 76402 Reduction, Maxillary, Open, Unilateral 76403 Reduction, Maxillary, Open, Bilateral 76500 1044.91 1306.12 1523.40 1828.08 2023.60 Reduction, Closed Unilateral Reduction. Closed Bilateral Reduction, Naso-orbital, Open, External Approach Reduction, Naso-orbital, Open, Sinusal Approach Reduction, Naso-orbital, Open, Orbital Approach with Insertion of Subperiosteal Implant Exploration, of Orbital Blowout Fracture Exploration, of Orbital Blowout Fracture and Reconstruction with Insertion of a Subperiosteal Implant 946.63 1893.26 1686.33 1686.33 1854.96 1218.72 2023.60 FRACTURES, REDUCTION, MALAR BONE 76601 Reduction, Malar Bone, Closed 76602 Reduction, Malar Bone, Open, by Simple Elevation Page 69 522.44 783.68 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 1392.53 1142.40 1142.40 76603 Reduction, Malar Bone, Open, by Osteosynthesis 76604 Reduction, Malar Bone, Open, by Sinus Approach 76605 Reduction, Malar Bone, Simple Fracture, (open reduction with antrostomy and packing) 76700 FRACTURES, REDUCTION, ZYGOMATIC ARCH 76701 76702 76703 76704 76800 522.44 1218.72 783.68 1523.40 Reduction, Zygomatic Arch, IntraOral Approach Reduction, Zygomatic Arch, Temporal Approach Reduction, Zygomatico-Maxillary Fracture Dislocation,Complex,Closed Reduction Reduction, Zygomatico-Maxillary Fracture Dislocation, Open Reduction FRACTURES, REDUCTIONS, CRANIOFACIAL DISJUNCTION, LE FORT'S lll TRANSVERSE (specify type of procedure according to previous code used for fracture) 76801 Reduction, Craniofacial Disjunction, Closed 76802 Reduction, Craniofacial Disjunction, Open 76900 2088.78 2959.12 FRACTURES, REDUCTIONS, ALVEOLAR 76910 FRACTURE, ALVEOLAR, DEBRIDEMENT, TEETH REMOVED 76911 3 cm. or less to 653.06 1306.12 653.06 1306.12 680.22 1360.45 +E to +E to +E to +E to 653.06 1306.12 653.06 1306.12 680.22 1360.45 680.22 1360.45 +E to +E to +E to +E to 653.06 1306.12 653.06 1306.12 680.22 1360.45 707.39 1414.77 to 76912 3-6 cm. to 76913 6 cm. and over 76920 REDUCTION, ALVEOLAR, CLOSED, WITH TEETH 76921 3 cm. and less 76922 3-6 cm. 76923 6-9 cm. 76924 9 cm. and over 76930 REDUCTION, ALVEOLAR, OPEN WITH TEETH 76931 3 cm. and less 76932 3-6 cm. 76933 6-9 cm. 76934 9 cm. and over Page 70 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 76940 REPLANATION, AVULSED TOOTH/TEETH (including splinting) 76941 Replanation, first tooth 76949 Each additional tooth 76950 408.13 408.13 REPOSITIONING OF TRAUMATICALLY DISPLACED TEETH 76951 One unit of time 76952 Two units of time 76959 Each additional unit over two 76960 125.16 250.35 125.16 REPAIRS, LACERATIONS, UNCOMPLICATED, INTRAORAL OR EXTRAORAL 76961 76962 76963 76964 76965 76966 76967 76968 76969 76970 261.21 293.88 326.53 359.18 408.13 442.13 476.16 530.54 565.89 2 cm. or less 2-4 cm. 4-6 cm. 6-9 cm. 9-12 cm. 12-16 cm. 16-20 cm. 20-25 cm. 25 cm. and over REPAIRS, LACERATIONS, THROUGH AND THROUGH 76971 76972 76973 76974 76975 76976 76977 76978 76979 76980 282.94 318.32 353.69 389.04 440.72 477.45 514.17 571.26 609.36 2 cm. or less 2-4 cm. 4-6 cm. 6-9 cm. 9-12 cm. 12-16 cm. 16-20 cm. 20-25 cm. 25 cm. and over REPAIRS, LACERATIONS, COMPLICATED (local tissue shifts) 76981 76982 76983 76984 76985 76986 76987 76988 76989 304.68 342.75 380.83 418.93 473.32 512.74 552.19 612.00 652.81 2 cm. or less 2-4 cm. 4-6 cm. 6-9 cm. 9-12 cm. 12-16 cm. 16-20 cm. 20-25 cm. 25 cm. and over 77000 MAXILLOFACIAL DEFORMITIES, TREATMENT OF 77100 OSTEOTOMY/OSTECTOMY, RAMUS OF THE MANDIBLE Page 71 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 77101 77102 77103 77104 77105 77106 77107 77108 77200 4351.65 4351.65 4351.65 4351.65 4351.65 4351.65 4351.65 4351.65 4351.65 Osteotomy, Oblique with Bone Graft Osteotomy, Inverted "L" Osteotomy, "C" Osteotomy of the Ramus of the Madible for Distraction Osteogenesis – Unilateral Osteotomy of the Ramus of the Madible for Distraction Osteogenesis – Bilateral Activation of Distraction Device - Unilateral Activation of Distraction Device - Bilateral Removal of Distraction Device - Unilateral Removal of Distraction Device - Bilateral OSTEOTOMY, MAXILLA 77301 77302 77303 77304 77305 77306 77307 77308 77309 77311 77312 77313 77314 77315 77316 77317 77318 77319 77400 Average Fee 4656.28 4656.28 4656.28 4656.28 4656.28 2219.34 2219.34 4656.28 OSTEOTOMY, MISCELLANEOUS 77201 77202 77203 77204 77205 77206 77207 77208 77209 77300 Osteotomy, Subcondylar, Closed Osteotomy, Subcondylar, Open Osteotomy, Ramus of the Mandible, Oblique, Extraoral Osteotomy, Ramus of the Mandible, Oblique, Intraoral Osteotomy/Ostectomy, Body of the Mandible Osteotomy, Coronoidectomy Osteotomy, Condylar Neck Osteotomy, Sagittal Split Osteotomy, Maxilla, Le Fort l Osteotomy, Maxilla, Le Fort ll Osteotomy, Maxilla, Le Fort lll Additional to the Above Osteotomy Requiring Two Segments Additional to the Above Osteotomy Requiring Three Segments Additional to the Above Osteotomy Requiring Four Segments Additional to the Above Osteotomy Requiring a Cranial Flap Closure of Cleft Fistula (Alveolar) Closure of Cleft Fistula (Palatal) Pharyngoplasty Submuccous Resection Osteotomy, Maxillary, Le Fort I – for Distraction Osteogenesis Osteotomy, Maxillary, Le Fort II – for Distraction Osteogenesis Osteogenesis, Maxillary, Le Fort III – for Distraction Osteogenesis Activation of Distraction Device – Le Fort I Level Activation of Distraction Device – Le Fort II Level Activation of Distraction Device – Le Fort III Level Removal of Maxillary Distraction Device 4656.28 4917.37 5874.75 609.22 783.28 1000.88 783.28 739.78 739.78 1174.94 739.78 I.C. I.C. I.C. I.C. I.C. I.C. I.C. OSTEOTOMY, MAXILLARY/MANDIBULAR, SEGMENTAL 77410 OSTEOTOMY, SEGMENTAL, MAXILLA 77411 77412 77413 77414 77415 Osteotomy, Segmental, Anterior Osteotomy, Segmental, Posterior Osteotomy, Midpalatal Split, Anterior Osteotomy, Midpalatal Split, Complete Osteotomy, Segmental, Anterior – for Distraction Osteogenesis Page 72 2088.78 2088.78 1392.53 2088.78 I.C. Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee I.C. I.C. I.C. 77416 Osteotomy, Segmental, Posterior – for Distraction Osteogenesis 77417 Activation of Distraction Device 77418 Removal of Segmentation Maxillary Distraction 77420 OSTEOTOMY, SEGMENTAL, MANDIBLE 77421 77422 77423 77424 77425 77426 77427 77428 77429 77430 77440 522.19 489.60 522.19 +E 348.13 326.39 348.13 GENIOPLASTY 77501 77502 77503 77504 2088.78 2088.78 2088.78 522.44 Genioplasty, Sliding, Reduction or Augmentation Genioplasty, Reduction (vertical) Genioplasty, Augmentation with Graft (see grafting codes) Myotomy, Suprahyoid MISCELLANEOUS TREATMENT OF MAXILLOFACIAL DEFORMITIES 77601 77602 77603 77604 77605 77700 +E OSTEOTOMY WHEN "ONLAY GRAFT" IS REQUIRED FOR OSTEOTOMY, TRAUMA OR RECONSTRUCTIVE PROCEDURES 77441 Using Bone 77442 Using Alloplast 77443 Using Cartilage 77600 I.C. I.C. I.C. I.C. OSTEOTOMY WHEN "INTERPOSITIONAL GRAFT" IS REQUIRED 77431 Using Bone 77432 Using Alloplast 77433 Using Cartilage 77500 2088.78 2088.78 1893.26 2088.78 4351.65 Osteotomy, Segmental, Anterior with Transfer of Mental Eminence Osteotomy, Segmental, Anterior, w/o the Transfer of Mental Eminence Osteotomy, Segmental, Posterior Osteotomy, Lower Border, Mandible Osteotomy, Total Dento-Alveolar, Mandible Osteteotomy, Segmental, Anterior – for Distraction Osteogenesis Osteteotomy, Segmental, Posterior – for Distraction Osteogenesis Activation of Distraction Device Removal of Segmental Mandibular Distraction Device Corticotomy Interdental Septotomy Surgical Expansion of the Palate Surgical Expansion of Alveolar Ridge – Ridge Splitting Technique, Maxilla – per sextant Surgical Expansion of Alveolar Ridge – Ridge Splitting Technique, Mandible – per sextant 609.36 609.36 1044.38 I.C. I.C. PALATORRHAPHY 77701 77702 77703 77704 Palatorrhaphy, Anterior (closure of palatine fissure) Palatorrhaphy, Posterior Palatorrhaphy, Total Palatorrhaphy, with Bone Graft Page 73 2088.78 2088.78 2611.00 3481.31 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 2262.84 77705 Palatorrhaphy, Bone Graft to Anterior Alveolar Ridge 77800 FRENECTOMY/FRENOPLASTY 77801 77802 77803 77804 77805 77806 77900 295.62 254.62 228.62 391.82 342.95 342.95 Frenectomy, Upper Labial Frenectomy, Lower Labial Frenectomy, Lower Lingual or "Z" Plasty Frenectomy, Lower Lingual or "Z" Plasty with Myotomy of Genioglossus Frenoplasty, Upper "Z" Frenoplasty, Lower "Z" GLOSSECTOMY 77901 Glossectomy, Partial, Anterior Wedge 77902 Glossectomy, Partial, for Orthodontic Purposes 77903 Glossectomy, Full Postero-Anterior Wedge 77910 609.36 609.36 1131.41 CLEFT SURGERY 77911 77912 77913 77914 77915 77916 77917 77920 1174.94 1174.94 1566.59 1566.59 1566.59 1958.25 1958.25 Primary Unilateral Cleft Lip Repair Secondary Unilateral Cleft Lip Repair Primary Bilateral Cleft Lip Repair Secondary Bilateral Cleft Lip Repair Reconstruction of Cleft Lip with Lip Switch Flap Complex Reconstruction or Revision of Cleft Lip Closure of Alveolar Cleft (see grafting Codes) ORAL NASAL FISTULA 77921 77922 77923 77924 77925 77930 696.25 1044.38 1044.38 1174.94 1044.38 Primary Closure at Time of Initial Surgery Secondary Closure with Palatal Flap Secondary Closure with Pharyngeal Flap Secondary Closure with Tongue Flap Secondary Closure with Buccal Flap RIGID FIXATION 77931 77932 77933 77934 Rigid Internal Rigid Internal Rigid Internal Rigid Internal Fixation Fixation using Bone Fixation using Alloplast Fixation using Cartilage +E 78000 TEMPOROMANDIBULAR JOINT DYSFUNCTIONS, TREATMENT OF 78100 TEMPOROMANDIBULAR JOINT, DISLOCATION MANAGEMENT OF Add 25% to Surgical Fee (Sedation and general anaesthesia services to be coded separately with appropriate 90000 series codes) 78101 TMJ, Dislocation, Open Reduction 78102 TMJ, Dislocation, Closed Reduction, Uncomplicated to Page 74 1131.41 196.45 206.91 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 78200 78103 TMJ, Dislocation, Closed Reduction, Complicated (Requiring Sedation or General Anaesthesia) Average Fee 217.76 78104 TMJ, Subluxation, Closed Reduction, Uncomplicated 78105 TMJ, Subluxation, Closed Reduction, Complicated (Requiring Sedation or General Anaesthesia) 206.91 217.76 78106 TMJ, Manipulation, under Sedation or General Anaesthesia 78107 TMJ, Fixation (Application of devices to prevent recurrent dislocation in the short term (arch bars, MMF screws, Ivy Loops)) 326.64 326.64 TEMPOROMANDIBULAR JOINT, OPEN PROCEDURES (ARTHROTOMY) 78201 78202 78203 78204 78205 78206 78207 78208 78209 78300 1740.66 1044.38 1871.22 1871.22 1871.22 1740.66 1871.22 1871.22 1871.22 Condyloplasty Condylotomy Condylectomy Eminoplasty Re-contour of Glenoid Fossa Menisectomy Plication of Meniscus Repair of Meniscus Replacement of Meniscus (see grafting codes) TEMPOROMANDIBULAR JOINT, ARTHROTOMY FOR MAJOR RECONSTRUCTION 78301 Fossa Replacement (see grafting codes) 78302 Condylar Replacement (see grafting codes) 78303 Gap, Arthroplasty for Ankylosis (see grafting codes) 78400 TEMPOROMANDIBULAR JOINT, ARTHROSCOPY OF TEMPOROMANDIBULAR JOINT 78401 78402 78403 78404 78405 78406 78407 78408 78409 78411 78412 78413 78500 1871.22 1871.22 2959.12 522.19 739.78 739.78 522.19 739.78 1131.41 1131.41 1131.41 1131.41 1305.50 1305.50 1305.50 TMJ Arthroscopic Examination Biopsy Removal of Loose Bodies Lavage Lysis of Adhesions Synovectomy Condyloplasty Eminoplasty Re-contour of Glenoid Fossa Menisectomy Plication of Meniscus Repair of Meniscus TEMPOROMANDIBULAR JOINT, ARTHROCENTESIS (puncture and aspiration) 78501 One unit of time 78502 Two units 78509 Each additional unit over two 78600 125.16 250.35 125.16 TEMPOROMANDIBULAR JOINT, MANAGEMENT BY INJECTIONS 78601 Injection, therapeutic drug with or without local anaesthetic drug, "per site", Page 75 +E 130.59 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 130.59 78602 Injection, with Sclerosing Agent 78700 TEMPOROMANDIBULAR JOINT, APPLIANCE SPLINTS, ORTHOPEDIC REHABILITATION (post operative) 78701 Appliance Splint, Maxillary 78702 Appliance Splint, Mandibular 79000 ORAL SURGERY PROCEDURES, OTHER 79100 SALIVARY GLANDS, TREATMENT OF 79101 79102 79103 79104 79110 +L +L Salivary Duct, Dilation of Salivary Duct, Insertion of Polyethylene Tube Salivary Duct, Sialodochoplasty Salivary Duct, Reconstruction of 179.60 239.50 522.44 783.68 SALIVARY DUCT, SIALOLITHOTOMY 79111 Sialolithotomy, Anterior 1/3 of Canal 79112 Sialolithotomy, Posterior 2/3 of Canal 79113 Sialolithotomy, External Approach 79120 479.00 1306.12 2023.60 SALIVARY GLAND, EXCISIONS 79121 79122 79123 79124 79125 79130 1305.61 1632.03 163.32 522.44 479.00 Excision of Submaxillary Gland Excision of Sublingual Gland Excision of Mucocele Excision of Ranula Marsupialization of Ranula SALIVARY GLAND, REMOVAL 79131 Salivary Gland, Removal, Parotid (sub total) 79132 Salivary Gland, Removal, Parotid (radical, including facial nerve) 79200 881.45 881.45 1740.66 2785.06 NEUROLOGICAL DISTURBANCES, TREATMENT OF 79210 NEUROLOGICAL DISTURBANCES, TRIGEMINAL NERVE 79211 79212 79213 79214 79215 79216 Trigeminal Nerve, Injection for Destruction Trigeminal Nerve, Avulsion at Periphery Trigeminal Nerve, Total Avulsion of a Branch Trigeminal Nerve, Alcoholization of a Branch Trigeminal Nerve, Infiltration of a Branch for Diagnosis Trigeminal Nerve, Intraoperative, diagnostic or physiologic monitoring (stimulation with recording evoked potentials, ultrasound, or impedance) 79217 Trigeminal Nerve, Neurolysis or tumor excision of trigeminal nerve branch in soft tissue 79218 Trigeminal Nerve, Neurolysis or tumor excision of trigeminal nerve branch in bone (mandible, maxilla or orbit) (not to include osteotomy) Page 76 261.21 544.18 990.33 261.21 125.16 239.50 783.68 1523.40 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 79220 NEUROLOGICAL DISTURBANCES, MENTAL NERVE 79221 Mental Nerve, Transportation of 79222 Mental Nerve, Decompression in Canal 79230 914.04 914.04 NEUROLOGICAL DISTURBANCES, INFERIOR DENTAL NERVE 79231 Inferior Dental Nerve, Complete Avulsion 79232 Inferior Dental Nerve, Decompression in the Canal 914.04 946.63 79240 - 79250 NEUROLOGICAL DISTURBANCES, SURGERY 79241 79242 79243 79244 79245 79246 79247 79248 79251 79252 79253 79254 79255 79256 79258 79300 Injured Nerve Repair, Primary Injured Nerve Repair, Secondary Injured Nerve Repair, Secondary, (when repair delayed more than four weeks) Neural Transposition and Decompression Implantation of Electrode for Peripheral Nerve Stimulation Excision of Tumor or Neuroma Nerve Repair with Graft Harvesting of Nerve Graft Epineurial Suture of Trigeminal Nerve Branch per Anastomosis Fascicular Suture of Trigeminal Nerve Branch per Anastomosis Conduit Implant for Repair of Nerve Gap up to 3 cm. Conduit Implant for Repair of Nerve Gap greater than 3 cm. Fibrin adhesive per nerve anastomosis Laser coagulation per verve anastomosis In addition to above procedures, when using operating microscopes +E 1218.72 3089.69 3481.31 914.04 1218.72 1305.61 4351.65 1523.40 946.63 946.63 2436.94 3481.31 609.36 652.81 130.59 ANTRAL SURGERY 79310 ANTRAL SURGERY, RECOVERY, FOREIGN BODIES 79311 Antral Surgery, Immediate Recovery of a Dental Root or Foreign Body from the Antrum to 79312 Antral Surgery, Immediate Closure of Antrum by Another Dental Surgeon to 79313 Antral Surgery, Delayed Recovery of a Dental Root with Oral Antrostomy to 79314 Antral Surgery with Nasal Antrostomy to 79320 ANTRAL SURGERY, LAVAGE 79321 Lavage, Oral Approach 79322 Lavage, Nasal Approach 79330 544.18 816.27 544.18 816.27 544.18 816.27 544.18 816.27 114.31 114.31 ANTRAL SURGERY, ORO-ANTRAL FISTULA CLOSURE, (same session) 79331 Oro-Antral Fistula Closure with Buccal Flap 79332 Oro-Antral Fistula Closure with Gold Plate Page 77 to +L 522.44 783.68 522.44 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 to 79333 Oro-Antral Fistula Closure with Palatal Flap to 79340 Average Fee 783.68 522.44 783.68 ANTRAL SURGERY, ORO-ANTRAL FISTULA CLOSURE, (subsequent session) 79341 Oro-Antral Fistula Closure with Buccal Flap 522.44 783.68 522.44 783.68 522.44 783.68 to 79342 Oro-Antral Fistula Closure with Gold Plate to 79343 Oro-Antral Fistula Closure with Palatal Flap to 79350 Sinus Osseous Augmentation 79351 79352 79353 79354 79355 79356 79400 Sinus Osseous Augmentation, Open Lateral Approach - Autograft Sinus Osseous Augmentation, Open Lateral Approach – Allograft Sinus Osseous Augmentation, Open Lateral Approach – Xenograft Sinus Osseous Augmentation, Indirect Inferior Approach – Autograft Sinus Osseous Augmentation, Indirect Inferior Approach – Allograft Sinus Osseous Augmentation, Indirect Inferior Approach – Xenograft +E +E +E +E +E +E HEMORRHAGE, CONTROL OF 79401 Primary Hemorrhage, Control to 79402 Secondary Hemorrhage, Control to 79403 Hemorrhage Control, using Compression and Hemostatic Agent to 79404 Hemorrhage Control, using Hemostatic Substance and Suture (including removal of bony tissue, if necessary) 79500 I.C. I.C. I.C. I.C. I.C. I.C. to 130.59 522.44 152.33 1523.40 152.33 1523.40 152.33 1523.40 GRAFTS, SURGICAL 79510 HARVESTING OF INTRAORAL TISSUE FOR GRAFTING TO OPERATIVE SITE 79511 79512 79513 79514 79515 79516 79517 79520 440.72 440.72 440.72 440.72 440.72 440.72 440.72 Bone Cartilage Skin Mucosa Fascia Muscle Dermis HARVESTING OF EXTRAORAL TISSUE FOR GRAFTING TO OPERATIVE SITE (TO INCLUDE ILIUM, RIB, ETC.) 79521 Bone 79522 Cartilage 609.36 609.36 Page 78 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 79523 79524 79525 79526 79527 79528 79529 79530 Average Fee 609.36 609.36 609.36 609.36 609.36 609.36 I.C. Costochondral Skin Mucosa Fascia Muscle Dermis Nerve VASCULARIZED TISSUE FLAPS 79531 Free 79532 Attached 79539 Micro-anastomosis of tissue flap (arterial and venous) 79540 Harvesting and Preparation of Platelet Rich Plasma 79541 Harvesting and Preparation of Platelet Rich Plasma 79550 +E I.C. +E +E +E I.C. I.C. I.C. Delivery of Growth Factors 79551 Delivery of Growth Factors – Autologous – per site 79552 Delivery of Growth Factors – Allogenic – per site 97553 Delivery of Growth Factors – Human Recombinant – per site 79600 I.C. I.C. I.C. POST SURGICAL CARE (Required by complications and unusual circumstances, refer to comment under section heading 70000) 79601 Post Surgical Care, Subsequent to Initial Post Surgical Treatment, Minor, by Treating Dentist 108.88 79602 Post Surgical Care, Minor, by Other Than Treating Dentist 79603 Post Surgical Care, Major, by Treating Dentist 114.31 114.31 1143.19 114.31 1143.19 114.31 117.31 to 79604 Post Surgical Care, Major, by Other Than Treating Dentist to 79605 Post Surgical Care, Alveolitis, Treatment of (without anesthesia) 79606 Post Surgical Care, Alveolitis, Treatment of (with anesthesia) 79700 EMERGENCY OFFICE PROCEDURES 79701 Emergency Procedure, Tracheotomy 79702 Emergency Procedure, Crico-Thyroidotomy 79800 MUSCULAR DISORDERS, TREATMENT OF 79801 Treatment of Muscular Dysfunctions 79802 Myotomy 79900 696.25 696.25 I.C. I.C. IMPLANTOLOGY Page 79 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee (Includes placement of implant, post-surgical care, uncovering and placement of attachment but not prosthesis) 79910 IMPLANTS, BLADE 79911 Maxillary per implant 79912 Mandibular per implant 79920 I.C. I.C. Implants, Subperiosteal 79921 Maxillary 79922 Mandibular 79930 +L +L Implants, Ossenointegrated, Root Form, More 79931 79932 79933 79934 +E 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 Transmucusal Element – per Implant Surgical Re-entry, Removal of Healing Screw and Placement of Healing Transmucosal Element – +E per Implant 79935 Surgical Re-entry, Removal of Healing Screw and Placement of Final Standard Transmucosal +E Element – per Implant 79936 Surgical Re-entry, Removal of Healing Screw and Placement of Final Custom Transmucosal +L +E Element – per Implant 79940 I.C. I.C. +E I.C. Implants, Osseointegrated, Provisional 79951 Installation of Provisional Implant – per Implant 79952 Removal of Provisional Implant – per Implant 79960 I.C. I.C. I.C. I.C. Implants Osseointegrated, Root Form, Single Component 79941 Surgical Installation of Implant – per Implant 79950 I.C. I.C. I.C. I.C. Implants, Removal of 79961 Per implant, Uncomplicated 79962 Per implant, Complicated I.C. I.C. ORTHODONTICS 80000 ORTHODONTIC SERVICES, MISCELLANEOUS 80600 ORTHODONTIC, OBSERVATIONS AND ADJUSTMENTS 80601 Orthodontic Observation - for Tooth Guidance (i.e. tooth position, eruption sequence, serial extraction supervision, etc.) per appointment 80602 Orthodontic Observation and adjustment - to Orthodontic Appliances and/or the Reduction of Proximal Surfaces of Teeth per appointment Page 80 81.48 87.71 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 80630 REPAIRS TO REMOVABLE OR FIXED APPLIANCES (not including removal and recementation) 80631 One unit of time 80632 Two units 80639 Each additional unit over two 80640 +L +L 83.71 167.45 83.71 +L +L 83.71 167.45 83.71 ALTERATIONS TO REMOVABLE OR FIXED APPLIANCES 80641 One unit of time 80642 Two units 80649 Each additional unit over two 80650 RECEMENTATION OF FIXED APPLIANCES 80651 One unit of time 80659 Each additional unit of time 80660 83.71 83.71 SEPARATION (except where included in the fabrication of an appliance) 80661 One unit of time 80669 Each addition unit of time 80670 83.71 83.71 REMOVAL OF FIXED ORTHODONTIC APPLIANCES (BY A PRACTITIONER OTHER THAN THE ORIGINAL TREATMENT PRACTICE OR PRACTITIONER) 80671 One unit of time 80679 Each additional unit of time 83.71 83.71 81000 APPLIANCES, ACTIVE, FOR TOOTH GUIDANCE OR MINOR TOOTH MOVEMENT 81100 APPLIANCES, REMOVABLE A maximum of eight observations or adjustment appointments may be charged for these appliances. 81110 APPLIANCES, REMOVABLE, SPACE REGAINING 81111 81112 81113 81114 81120 Appliance, Maxillary, Unilateral Appliance, Mandibular, Unilateral Appliance, Maxillary, Bilateral Appliance, Mandibular, Bilateral 386.89 348.89 334.89 334.89 +L +L 334.65 334.89 +L +L 452.89 412.89 APPLIANCES, REMOVABLE, CROSS-BITE CORRECTION 81121 Appliance, Maxillary, Simple 81122 Appliance, Mandibular, Simple 81130 +L +L +L +L APPLIANCES, REMOVABLE, DENTAL ARCH EXPANSION 81131 Appliance, Maxillary, Simple 81132 Appliances, Mandibular, Simple Page 81 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 81140 APPLIANCES, REMOVABLE, CLOSURE OF DIASTEMAS 81141 Appliance, Maxillary, Simple 81142 Appliance, Mandibular, Simple 81150 334.89 334.89 +L +L 386.89 696.89 +L +L 339.89 334.89 +L +L 251.16 264.16 +L +L 335.89 334.89 +L +L +L 367.89 334.89 268.16 +L +L +L 467.61 471.61 399.89 +L +L 334.89 334.89 +L 1239.61 APPLIANCES, REMOVABLE, ALIGNMENT OF ANTERIOR TEETH 81151 Appliance, Maxillary, Simple 81152 Appliance, Mandibular, Simple 81200 +L +L APPLIANCES, FIXED OR CEMENTED A maximum of eight observations or adjustment appointments may be charged for these appliances. 81210 APPLIANCE, FIXED, SPACE REGAINING (e.g. lingual or labial arch with molar bands, tubes, locks) 81211 Appliance, Maxillary 81212 Appliance, Mandibular 81220 APPLIANCE, FIXED, SPACE REGAINING, UNILATERAL 81221 Appliance, Maxillary 81222 Appliance, Mandibular 81230 APPLIANCE, FIXED, CROSS-BITE CORRECTION - ANTERIOR 81231 Appliance, Maxillary 81232 Appliance, Mandibular 81240 APPLIANCE, FIXED, CROSS-BITE CORRECTION - POSTERIOR 81241 Appliance, Maxillary 81242 Appliance, Mandibular 81243 Appliance, Two-Molar Band, Hooked and Elastics 81250 APPLIANCE, FIXED, DENTAL ARCH EXPANSION 81251 Appliance, Maxillary 81252 Appliance, Mandibular 81253 Appliance, Maxillary, Rapid Expansion 81260 APPLIANCE, FIXED, CLOSURE OF DIASTEMAS 81261 Appliance, Maxillary, Simple 81262 Appliance, Mandibular, Simple 81270 APPLIANCE, FIXED, ALIGNMENT OF INCISOR TEETH 81271 Appliance, Maxillary, Simple Page 82 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 81272 Appliance, Mandibular, Simple 81280 Average Fee 418.61 +L 83.71 +L +L +L +L 334.89 334.89 334.89 334.89 +L +L +L 251.16 251.16 251.16 +L +L 334.89 334.89 APPLIANCES, FIXED, LIGATURES 81281 Grassline or Elastic Ligatures per visit 81290 APPLIANCES, FIXED, MECHANICAL ERUPTION OF TOOTH/TEETH 81291 81292 81293 81294 Appliance, Maxillary, Impaction Appliance, Mandibular, Impaction Appliance, Maxillary, Erupted Appliance, Mandibular, Erupted 83000 APPLIANCES, RETENTION, ORTHODONTIC RETAINING APPLIANCES 83100 APPLIANCES, REMOVABLE, RETENTION 83101 Appliance, Maxillary 83102 Appliance, Mandibular 83103 Appliance, Tooth Positioner 83200 +L APPLIANCES, FIXED/CEMENTED, RETENTION 83201 Appliance, Maxillary 83202 Appliance, Mandibular COMPREHENSIVE ORTHODONTIC TREATMENT CASE TYPE - Fixed Appliance (includes formal full banded treatment and retention) The range of fees with these procedure codes reflects such variables as length of time required to complete the treatment, degree of difficulty, co-operation of the patient, etc. and the fee charged should be determined accordingly. 84000 PERMANENT DENTITION 84101 Class l Malocclusion to 84201 Class ll Malocclusion to 84301 Class lll Malocclusions to 84401 Malocclusions Not Requiring Complete Banding to 85000 3348.99 10046.96 5023.47 13395.96 5023.47 13395.96 1674.48 4186.24 MIXED DENTITION 85101 Class l Malocclusion to 85201 Class ll Malocclusion Page 83 3348.99 10046.96 5023.47 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 to 85301 Class lll Malocclusion to Average Fee 13395.96 5023.47 13395.96 CASE TYPE - Removable Appliances (includes removable appliance therapy and retention; e.g. functional appliances) 88000 MIXED DENTITION 88101 Class l Malocclusion to 1674.48 5023.47 2511.73 6697.97 2511.73 6697.97 +L to +L to +L to +L to +L to +L to 334.89 3014.07 334.89 3014.07 1255.86 2511.73 1255.86 2511.73 2511.73 6697.97 5023.47 13395.96 to 88201 Class ll Malocclusion to 88301 Class lll Malocclusion NEONATAL DENTO-FACIAL ORTHOPEDICS (comprehensive treatment for first six months of life) (1) (2) (3) (4) (5) (6) (7) Diagnostic procedures (includes radiographs and/or photographs); Parent consultation; Impression and appliance construction Insertion and parent instruction; Post treatment evaluation; Adjustment of appliances (includes soft relin Reconstruction and/or reevaluation (may include up to two remakes). 89501 Expansion Appliance for Infants with Cleft Palate 89502 Extra Oral Retraction Appliance for Infants with Cleft Palate 89503 Stage l - Initial Expansion 89504 Stage ll - Anterior Alignment 89505 Stage lll - Final Alignment (complete banding) 89506 Stage lll - Where Stage l and ll were not provided for ADJUNCTIVE GENERAL SERVICES 91000 UNCLASSIFIED TREATMENTS 91100 UNCLASSIFIED TREATMENT, DENTAL PAIN 91110 PALLIATIVE (emergency) TREATMENT OF DENTAL PAIN, MINOR PROCEDURE 91111 One unit of time 91112 Two units 103.45 206.91 Page 84 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 310.36 103.45 91113 Three units 91119 Each additional unit over three 91120 EMERGENCY SERVICES NOT OTHERWISE SPECIFIED IN GUIDE 91121 91122 91123 91129 91200 108.88 217.76 326.64 108.88 One unit of time Two units Three units Each additional unit over three UNCLASSIFIED TREATMENT, UNUSUAL TIME AND RESPONSIBILITIES (Note: If the service affected is anaesthesia, code series 92000, and the unusual time and responsibility is the result of a patient BMI of 35 or above, refer to code series 92900) 91210 UNUSUAL TIME AND RESPONSIBILITY REQUIREMENT, IN ADDITION TO USUAL PROCEDURES IN GUIDE 91211 91212 91213 91219 91220 119.73 239.50 359.23 119.73 One unit of time Two units Three units Each additional unit over three SECOND SURGEON (team approach) 91221 91222 91223 91224 91225 91226 91227 91228 91229 91230 103.45 206.91 310.36 413.81 517.27 620.72 724.17 827.63 103.45 One unit of time Two units Three units Four units Five units Six units Seven units Eight units Each additional unit over eight MANAGEMENT OF EXCEPTIONAL PATIENT 91231 91232 91233 91234 91239 119.73 239.50 359.23 479.00 119.73 One unit of time Two units Three units Four units Each additional unit over four 92000 ANESTHESIA 92100 ANAESTHESIA, LOCAL (not in conjunction with operative or surgical procedures, includes pre-anaesthetic evaluation and post-anaesthetic evaluation and post-anaesthetic follow-up) 92101 Regional Block Anesthesia (not in conjunction with operative or surgical procedures) 92102 Trigeminal Division Block (not in conjunction with operative or surgical procedures) Page 85 108.88 108.88 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 92200 ANAESTHESIA, GENERAL (includes pre-anaesthetic evaluation and post-anaesthetic evaluation and post-anaesthetic followup) 92210 GENERAL ANESTHESIA 92212 92213 92214 92215 92216 92217 92218 92219 92220 228.62 342.95 457.26 571.60 685.90 800.21 914.55 114.31 Two units of time Three units Four units Five units Six units Seven units Eight units Each additional unit over eight Provision of facilities, equipment and support services for general anaesthesia 92222 92223 92224 92225 92226 92227 92228 92229 92300 228.62 342.95 457.26 571.60 685.90 800.21 914.55 114.31 Two units of time Three units Four units Five units Six units Seven units Eight units Each additional unit over eight Anesthesia, Deep Sedation - a controlled state of depressed consciousness accompanied by partial loss of protective reflexes, including inability to respond purposefully to verbal command. These states apply 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 anaesthesia, regardless of route of administration, would fall within this category of service. (includes pre-anesthetic evaluation and post anesthetic follow-up) 92302 92303 92304 92305 92306 92307 92308 92309 92320 206.91 310.36 413.81 517.27 620.72 724.17 827.63 103.45 Two units of time Three units Four units Five units Six units Seven units Eight units Each additional unit over eight Provision of facilities, equipment and support services for deep sedation when provided by a separate practitioner 92322 92323 92324 92325 206.91 310.36 413.81 517.27 Two units Three units Four units Five units Page 86 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 92326 92327 92328 92329 92400 Average Fee 620.72 724.17 827.63 103.45 Six units Seven units Eight units Each additional unit over eight ANESTHESIA, CONSCIOUS SEDATION Anaesthesia, 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, e.g.., "open your eyes". (includes pre-anaesthetic evaluation and post anaesthetic follow-up) 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 Anaesthesia in Dental Practice. The Guidelines should be consulted and observed. 92410 Nitrous Oxide Time is measured from the placement of the inhalation device and terminates with the removal of the inhalation device 92411 92412 92413 92414 92415 92416 92417 92418 92419 92420 54.69 87.05 131.41 175.78 219.14 263.50 307.86 351.22 43.36 One unit of time Two units of time Three units Four units Five units Six units Seven units Eight units Each additional unit over eight Oral Sedation Sedation sufficient to require monitored care. 92421 92422 92423 92424 92425 92426 92427 92428 92429 92440 149.40 55.57 71.76 87.93 104.13 120.30 136.49 152.66 19.01 One unit of time Two units of time Three units of time Four units of time Five units of time Six units of time Seven units of time Eight units of time Each addition unit over eight Parenteral Conscious Sedation (regardless of method -IM or IV) 92441 92442 92443 92444 92445 67.69 135.05 203.41 271.78 339.14 One unit Two units Three units Four units Five units Page 87 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 92446 92447 92448 92449 92500 Average Fee 407.50 475.86 543.22 67.36 Six units Seven units Eight units Each additional unit over eight NON PHARAMACOLOGICAL PAIN CONTROL AND PATIENT MANAGEMENT 92510 HYPNOSIS 92511 92512 92513 92514 92519 92520 ACUPUNCTURE 92521 92522 92523 92524 92529 92530 54.69 84.05 127.41 170.78 41.36 One unit of time Two units Three units Four units Each additional unit over four Electronic Dental Anesthesia 92531 92532 92533 92534 92539 92900 54.69 84.05 127.41 170.78 41.36 One unit of time Two units Three units Four units Each additional unit over four 54.69 84.05 127.41 170.78 41.36 One Unit of Time Two units Three units Four units Each additional unit over four ANAESTHESIA – GENERAL ANAESTHESIA OR DEEP SEDATION, UNUSUAL TIME AND RESPONSIBILITY 92901 Management of patient with BMI 35 or above, in addition to code series 92200 or 92300 93000 I.C. PROFESSIONAL CONSULTATIONS (diagnostic services provided by dentist other than practitioner providing treatment) 93100 PROFESSIONAL COMMUNICATIONS 93110 Consultation with Member of the Profession or other Healthcare Providers, in or out of the office 93111 One unit of time 93112 Two units 93119 Each additional unit over two 93120 +E +E +E DENTAL LEGAL LETTERS, REPORTS AND OPINIONS Page 88 93.12 186.25 93.12 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 72.33 93121 A dental-legal report - a short factually written or verbal communication givento any lay person (e.g. lawyer, insurance representative, local, municipal or government agency, etc.) in relation the patient with prior patient approval. to 177.66 93122 A dental-legal report - a comprehensive written report with patient approval, on systems, 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. 144.66 to 93123 A dental-legal opinion - a comprehensive written report primarily 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 judgment with respect to the facts leading to a detailed prognosis. 93130 I.C. CONSULTATION AND/OR PARTICIPATION DURING AUTOPSY (other than forensic) 93131 One unit of time 93132 Two units 93139 Each additional unit over two 93300 355.32 +E +E 116.12 232.23 116.12 CLAIM FORMS AND TREATMENT FORMS 93301 Completing CDA "Blank" Approved Standard Claim Forms. 93302 Upon request, Providing a Written Treatment Plan/Outline for a Patient, Similar to the Example in the CDA Policy Manual on Claim Form Completion. 93303 Completing Prepaid Claim Forms which do not conform with Code 93301 93310 NO FEE NO FEE 29.34 FOR EXTRAORDINARY TIME SPENT IN RELATION TO CLAIM FORMS/TREATMENT PLAN FORMS, THE CLAIM PROBLEM OF THE PATIENT OR PROCESSING OF PAYMENTS 93311 93312 93318 93319 93320 One unit of time Two units Zero units Each additional unit over two +E +E +E 97.92 195.84 NO FEE 97.92 +E +E 22.34 44.68 22.34 FOR EXTRAORDINARY OFFICE TIME SPENT, IN FORWARDING PREDETERMINATION RECORDS, IN PREDETERMINATION SITUATIONS, TO THIRD PARTIES PLUS EXPENSES (i.e. registration, postage, etc.) 93321 One unit of time 93322 Two units 93329 Each additional unit over two Page 89 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 94000 PROFESSIONAL VISITS 94100 HOUSE CALLS 94101 House Call, Non Emergency Visit (in addition to procedures performed) 94102 House Call, Emergency Visit, when one must immediately leave home, office or hospital (in addition to procedures performed) 94300 OFFICE OR INSTITUTIONAL VISITS 94301 Office (of another professional) or Institutional Visit, During Regular Scheduled Office Hours (in addition to services performed) 94302 Office or Institutional Visit Unscheduled, After Regular Scheduled Office Hours (in addition to services performed) 94303 Missed or Canceled Appointment, with Insufficient Notice, During Regular Scheduled Office Hours 94304 Missed or Canceled Appointment with insufficient Notice, being a Special Appointment Outside Regular Scheduled Office Hours 94305 Traveling Expenses 94306 Professional Visits Out of Office, plus actual services performed, out of pocket expenses, etc. 94400 106.31 212.62 77.33 104.53 55.85 79.92 to 391.70 I.C. +E 165.46 COURT APPEARANCE AND/OR PREPARATION 94410 PREPARATION AS AN EXPERT WITNESS 94411 94412 94413 94414 94419 94420 I.C. I.C. I.C. I.C. I.C. One unit of time Two units Three units Four units Each additional unit over four COURT APPEARANCE AS AN EXPERT WITNESS 94421 One half day 94422 Full day 95000 FORENSIC DENTAL SERVICES 95100 FORENSIC SERVICES, MISCELLANEOUS I.C. I.C. 95101 Identification - opinion as an expert assisting in civil or criminal cases +E 95102 Full or Part Time Participation in Civil Disaster +E 95104 Written Odontology Report +E to 95105 Post Mortem Examination of Tissues in Forensic Cases (non-identification) 95106 Management of Oral Disease or Abnormality to Page 90 491.48 per hour 2703.77 per diem 45.04 566.07 I.C. 79.92 195.84 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 Average Fee 95200 IDENTIFICATION SYSTEMS 95201 Identification Disk System, Acid Etch/Bonded 96000 DRUGS/MEDICATION, DISPENSING 96100 PRESCRIPTIONS 96101 Prescription, Emergency 96102 Emergency Dispensing of One or Two Doses of a Therapeutic Drug, plus Giving a Written Prescription 96103 Dispensing, Non Emergency (e.g. fluorides, vitamins, other drugs/medications) 96200 88.33 +E 34.60 47.11 +E 37.92 INJECTIONS, THERAPEUTIC 96201 Intramuscular Drug Injection 96202 Intravenous Drug Injection 96203 Intralesional Delivery (Intra-articular Injections - see 78600) 96300 +L +E +E +E 92.86 65.86 50.86 INJECTIONS AESTHETIC – ADMINISTRATION OF AESTHETIC NEUROMODULATORS (EG. BOTULINUM TOXIN TYPE A) (Note “units” refers to a drug dosage) 96301 96302 96303 96304 96305 96306 96307 96308 96309 96400 Injections of Injections of Injections of Injections of Injections of Injections of Injections of Injections of Injections of neuromodulator, aesthetic neuromodulator, aesthetic neuromodulator, aesthetic neuromodulator, aesthetic neuromodulator, aesthetic neuromodulator, aesthetic neuromodulator, aesthetic neuromodulator, aesthetic neuromodulator, aesthetic 1 to 5 units 6 to 10 units 11 to 20 units 21 to 30 units 31 to 40 units 41 to 50 units 51 to 60 units 61 to 70 units more than 70 units I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. +E +E I.C. I.C. INJECTIONS AESTHETIC – ADMINISTRATION OF AESTHETIC DERMAL FILLERS 96401 Aesthetic dermal filler first syringe 96409 Aesthetic dermal filler subsequent syringe (use once for each syringe) 97000 +E +E +E +E +E +E +E +E +E BLEACHING, VITAL 97110 BLEACHING, VITAL, IN OFFICE 97111 97112 97113 97119 97120 97.92 195.84 293.78 97.92 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) 97121 Maxillary Arch +L Page 91 279.37 Alberta Dental Association and College Dental Fee Guide Effective: September 1, 2017 +E +L +E 97122 Mandibular Arch 97130 MICRO-ABRASION 97131 97132 97133 97134 97139 98000 87.33 176.66 265.99 354.32 87.33 One unit of time Two units of time Three units of time Four units of time Each additional unit over four COUNSELING 98100 TOBACCO-USE CESSATION SERVICES To include: identifying patients who use tobacco, informing patients of oral health consequences associated with tobacco; advising tobacco users to quit; provide appropriate self-help material; and discuss treatment options. 98101 One unit of time 98102 Two units of time 98109 Each additionial unit of time 99000 Average Fee and/or 279.37 and/or +E +E +E 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 are 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. 99111 "+L" Commercial Laboratory Procedures (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 99222 "+L" For oral pathology biopsy services when provided in relation to surgical services from the 30000, 40000, or 70000 code services. +L 99333 "+L" In-Office Laboratory Procedures (An in-office laboratory is defined as a laboratory service(s) performed within the same business entity). +L 99555 "+E" Additional Expense of Materials +E Page 92 87.33 176.66 87.33 Appendix Guide Structure 1. The numbers assigned accurately describe the procedures provided and are divided into various categories of services. The inclusion of a code in a category does not restrict that procedure to a specific specialty. The classification is as follows: 01000-09999 10000-19999 20000-29999 30000-39999 40000-49999 50000-59999 60000-69999 70000-79999 80000-89999 90000-99999 2. Diagnosis Prevention Restoration Endodontics Periodontics Prosthodontics - Removable Prosthodontics - Fixed Oral and Maxillofacial Surgery Orthodontics Adjunctive General Services The numbers used to describe a service must accurately conform to the following principles, where the: 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 2"1"221 21"2"21 212"2"1 2122"1" represents the category "restorative" represents the classification "amalgam restorations" represents the sub-classification "amalgams permanent dentition" represents the service title "permanent molars" represents the specific service "permanent molars one surface" Page 93 3. The units of time and/or the letters following procedures conform to the following principles: Units of time follow a procedure code, the designation is that of "fifteen minute intervals" Where: The letter "L" follows a procedure code, the designation is that of "laboratory procedures extra" The letter "E" follows a procedure code, the designation is that of "expenses extra" (not intended to cover expenses already factored into the fee for the procedure) The letters "I.C." follows a procedure code, the designation is "Independent Consideration" and is utilized where the procedure involves complexities which are too variable to designate a specific fee. 4. Where individual teeth/sites are designated use the FD! 2-digit notation and ISO 3950 Designation system for teeth and areas of the oral cavity: Oral cavity 00 Maxillary area 01 Quadrant 03 Sextant 18 17 16 Designation of teeth• 48 Sextant Quadrant Mandibular area 20 10 47 46 04 05 15 14 13 12 11 21 22 23 24 25 55 85 54 84 53 83 52 82 51 81 61 71 62 72 63 73 64 74 65 75 45 44 43 42 41 31 32 33 34 35 08 40 ! I 07 26 27 28 36 37 38 06 I 30 02 • Designation of teeth First digit: Digits 1 to 4 represent permanent dentition and digits 5 to 8 represent deciduous dentition, clockwise from the upper right side. Second digit: Teeth in the same quadrant are represented by the second digit from 1 to 8, from the median line in a distal direction. Page 94