Dental Fee Guide General 2013

The Alberta Blue CrossDental Schedule® Effective January 01, 2013 © 2005 ABC Benefits Corporation. All rights reserved. ® Alberta Blue Cross symbol and name and Alberta Blue Cross Dental Schedule name are registered trade-marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans, and are licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan. ABC 830851/40450 (R2012/11) The Alberta Blue Cross Dental Schedule Preamble The Alberta Blue Cross Dental Schedule Preamble Preamble 1. The Alberta Blue Cross Dental Schedule (ABCDS) was prepared and published by Alberta Blue Cross. This schedule is for Alberta Blue Cross dental plans that have incorporated the ABCDS. It is not a list of covered services but a schedule that forms the basis of the plans’ payments. Plan provisions, limitations, exclusions and co-insurance will apply. 2. For consistency within Alberta, the Alberta Blue Cross Dental Schedule utilizes the exact procedure codes of the previously-published Alberta Dental Association Suggested Fee Guide. The numbers assigned accurately describe the services provided and are divided into various disciplines of dentistry. The classification is as follows: 00000- 09999 10000- 19999 20000- 29999 30000- 39999 40000- 49999 50000- 59999 60000- 69999 70000- 79999 80000- 89999 90000- 99999 Diagnostic Preventive Restorative Endodontics Periodontics Prosthodontics - Removable Prosthodontics - Fixed Oral and Maxillofacial Surgery Orthodontics Adjunctive General Services The Units of Time and/or the Letters following procedures must conform to the following principles: Where the: Letter “L” follows a procedure code, the designation is that of “Laboratory Procedures Extra”. Units of Time follows a procedure code, the designation is that of “Fifteen Minute Intervals”. Letter “E” follows a procedure code, the designation is that of “Expenses Extra”. BR follows a procedure code, the designation is that of “By Report”. Identification of treatment sites must be identified thus: 00 01 02 (a) Where individual teeth/sites are designated, the International Tooth Codes are the recognized system of coding. (b) Where grouping of treatment by teeth/sites are indicated, the following codes are used: Designates Full Mouth Designates Maxillary Arch Designates Mandibular Arch 43 08 Designates from 44 . If you have any questions or comments regarding this schedule. please call us at: Edmonton: Calgary: Toll free: 780-498-8889 403-294-4043 1-888-258-5465 .28 06 Designates from 38 .14 04 Designates from 13 .34 07 Designates from 33 .The Alberta Blue Cross Dental Schedule Preamble For Quadrants: 10 Designates the Upper Right Quadrant 20 Designates the Upper Left Quadrant 30 Designates the Lower Left Quadrant 40 Designates the Lower Right Quadrant For Sextants: 03 Designates from 18 .23 05 Designates from 24 .48 3. .Fixed 53 Oral and Maxillofacial Surgery 59 Orthodontics 77 Adjunctive General Services 81 Tip: Click on any title in the Table of Contents to go to the section.Removable 39 Prosthodontics .2013 Alberta Blue Cross Dental Schedule 2013 Alberta Blue Cross Dental Schedule For General Practitioners TABLE OF CONTENTS Diagnostic 1 Preventive 11 Restorative Services 18 Endodontics 27 Periodontics 33 Prosthodontics . 2013 Alberta Blue Cross Dental Schedule . Assessment to include: family dental history. ORAL 01201 Examination and Diagnosis: Limited.20 102. Medical and Dental. ORAL. including checking occlusion and appliances. New Patient Examination and diagnosis of hard and soft tissues. (c) Radiographs extra. interproximal tooth contact relationships. including above description as per 01100 98. including: carious lesions. pulp vitality tests/analysis where necessary. 49.20 1 .jaw size assessment 01103 Examination and Diagnosis: Complete.20 01206 Analysis.90 01102 Examination and Diagnosis: Complete. charting. oral hygiene. as for 01100 (May include PSR) 49. gingival contours. to include (a) Extended examination and diagnosis on permanent dentition. but not including specific tests/analysis.20 01202 Examination and Diagnosis: Limited. treatment planning and case presentation. including above description as per 01100 69. recording history. occlusion of teeth. missing teeth.20 01205 Examination and Diagnosis: Emergency Examination and diagnosis for the investigation of discomfort and/or infection in a localized area 49. and any other pertinent factors. fluoride exposure. determination of sulcular depth. treatment planning and case presentation. Primary Dentition.20 01204 Examination and Diagnosis: Specific Examination and evaluation of a specific situation 49. mobility of teeth. charting. including above description as per 01100 Eruption sequence. Mixed Dentition 49. oral habits. recording history. Permanent Dentition. but not including specific tests/analysis. TMJ. TO INCLUDE: (a) History. (b) Clinical Examination and diagnosis of Hard and Soft tissues. Anticipatory guidance with parent/guardian. including checking of occlusion and appliances. to include (a) (b) Extended examination and diagnosis on mixed dentition. dietary/feeding practices.50 01200 EXAMINATIONS AND DIAGNOSIS: LIMITED. as for 01100 49.2013 Alberta Blue Cross Dental Schedule General Practitioner • DIAGNOSTIC DIAGNOSTIC 00001 EXAMINATIONS AND DIAGNOSIS: CLINICAL ORAL 00010 FIRST DENTAL VISIT/ORIENTATION 00011 Oral assessment for patients up to the age of 3 years inclusive. Oral. Oral. charting. 01101 Examination and Diagnosis: Complete.20 01100 EXAMINATIONS AND DIAGNOSIS: COMPLETE. to include (a) Extended examination and diagnosis on primary dentition. Mixed Dentition. tooth size . recording history. as required. Previous Patient (recall) Examination of hard and soft tissues. treatment planning and case presentation. 00 . to include (a) History. including occlusal analysis. consultation with other health care professionals.00 01400 EXAMINATIONS AND DIAGNOSIS: ORAL PATHOLOGY 01401 Examination and Diagnosis: Oral Pathology. evaluation of occlusion. Comprehensive. Dental. Intraoral examination of hard and soft tissues. 01602 Examination and Diagnosis: Surgical. Stomatognathic. Pain/Dysfunction (b) Clinical Examination to include: general appraisal. review of previous records. General (a) History. furcation involvement. Limited (previous patient) 49. occlusal factors.2013 Alberta Blue Cross Dental Schedule General Practitioner • DIAGNOSTIC 01300 EXAMINATIONS AND DIAGNOSIS: STOMATOGNATHIC. TMJ. Medical and Dental (b) Clinical Examination includes evaluation of topography of the gingiva and related structures. degree of gingival inflammation.90 01302 Examination and Diagnosis. Specific 2 117. Dysfunctional. Specific (or repeat examination within 90 days for the same illness) 62. General Recording History. Specific 49. ordering of appropriate tests/analysis and consultations. Medical and Dental (b) Clinical Examination including: in-depth analysis of medical status. 178. location. 178. mobility of teeth. initial consultation with referring dentist or physician. including radiographs. evaluation of existing restorative and/or prosthetic appliances.20 01503 Examination and Diagnosis: Periodontal. initial consultation.70 62. DYSFUNCTIONAL 01301 Examination and Diagnosis: Stomatognathic. medication. examination of oral soft tissue pathosis. evaluation of source of chief complaint.00 01600 01502 Examination and Diagnosis: Periodontal. mobility of teeth. to include: (a) History.00 01500 EXAMINATIONS AND DIAGNOSIS: PERIODONTAL 01501 Examination and Diagnosis: Periodontal. evaluation of the diagnosis and prognosis and formulation of a treatment plan.70 01402 Examination and Diagnosis: Oral Pathology. Charting. Medical. parent or guardian. evaluation of pulpal vitality. Medical and Dental (b) Clinical Examination as above. Treatment Planning and Case Presentation: (a) History. 117. General. tooth contact relationships. Dysfunctional.20 EXAMINATIONS AND DIAGNOSIS: SURGICAL 01601 Examination and Diagnosis: Surgical. with referring dentist or physician. extent. or where the patient is to be admitted to hospital for dental procedures. caries and pulpal vitality. anesthetic and surgical risk. TMJ. Limited 62. sulcular depth. examination of head and neck. musculoskeletal system (static and functional). may include in-depth analysis of medical status. transillumination. Specific 49. Prosthodontic. Medical and Dental (b) Clinical Examination and Diagnosis may include: vitality tests/analysis. percussion. head and neck (include TMJ). and including evaluation for implant-supported or retained prosthesis. charting treatment planning and case history. TMJ. Complete Endodontic examination and diagnosis and/or complicated diagnosis. thermal tests/analysis.2013 Alberta Blue Cross Dental Schedule General Practitioner • DIAGNOSTIC 01700 EXAMINATIONS AND DIAGNOSIS: PROSTHODONTIC 01701 Examination and Diagnosis. (c) Evaluation of specific sites for implant-supported or retained prosthesis. lips.20 01703 Examination and Diagnosis: Prosthodontic. Fixed Oral Rehabilitation. cracked tooth tests/analysis. Medical and Dental (b) Clinical Examination of Hard and Soft Tissues. determination of sulcular depth. salivary glands and lymph nodes. anesthetic tests/analysis and mobility tests/analysis 01802 Examination and Diagnosis: Endodontic.10 +L 62. (d) Radiographs extra.70 62.30 01702 Examination and Diagnosis: Prosthodontic. interproximal tooth contact relationships. palpation. to include (a) History. General. tongue. Recording history. Specific Endodontic examination and evaluation of a specific situation in a localized area and vitality tests/analysis 117. Edentulous (a) Extended Examination of the Edentulous Mouth. gingival contours.00 01900 EXAMINATIONS AND DIAGNOSIS: ORTHODONTIC 01901 Examination and Diagnosis: Orthodontic. Specific 326. or panoramic film. 117. consultation and case presentation 01902 Examination and Diagnosis: Orthodontic. mobility of teeth. Includes the following: (a) History. 70. occlusal exams. prosthetic history) visual and digital examination of the oral structures. pulp vitality tests/analysis where necessary and any other pertinent factors. oral pharynx.00 3 . complete intraoral radiograph series. cephalograms. facial and intraoral photographs. missing teeth. oral mucosa. as required. To include: (a) Diagnostic models. occlusion of teeth. including detailed Medical and Dental History (incl.70 01800 EXAMINATION AND DIAGNOSIS: ENDODONTIC 01801 Examination and Diagnosis: Endodontic. including carious lesions. 2013 Alberta Blue Cross Dental Schedule General Practitioner • DIAGNOSTIC 02000 RADIOGRAPHS (INCLUDING RADIOGRAPHIC EXAMINATION AND DIAGNOSIS AND INTERPRETATION) 02100 RADIOGRAPHS: REGIONAL/LOCALIZED 02101 Radiographs. Complete Series (minimum of 16 images incl.90 69. bitewings) 97. BITEWING Single Film Two Films Three Films Four Films Five Films Six Films 19.10 67.00 27.00 61.50 02130 02131 02132 02133 02134 RADIOGRAPHS: INTRAORAL.90 02300 RADIOGRAPHS: POSTERO-ANTERIOR AND LATERAL SKULL AND FACIAL BONE 02301 02302 02303 02304 Single Film Two Films Three Films Sinus Examination and diagnosis .00 20.90 108.80 20.80 90.00 95.00 44.30 02110 02111 02112 02113 02114 02115 02116 02117 02118 02119 02120 RADIOGRAPHS: PERIAPICAL Single Image Two Images Three Images Four Images Five Images Six Images Seven Images Eight Images Nine Images Ten Images 19.00 104.50 53.00 87.90 108.00 27.50 53.00 44.50 87. Complete Series (minimum of 12 images incl.00 78.Minimum four films identified as: 1) Waters 2) Caldwell 3) Lateral Skull 4) Basal 02309 Each Additional Film Over Four 46.50 36. OCCLUSAL Single Film Two Films Three Films Four Films 28.80 20.10 67.00 87.90 02400 RADIOGRAPHS: SIALOGRAPHY 02401 Single Film 02402 Two Films 02409 Each Additional Film Over Two 4 46. bitewings) 02102 Radiographs.50 36.50 02200 RADIOGRAPHS: EXTRAORAL 02201 Single Film 02202 Two Films 02203 Three Films 02204 Four Films 02209 Each Additional Film Over Four 46.70 02140 02141 02142 02143 02144 02145 02146 RADIOGRAPHS: INTRAORAL.90 .10 67.50 70.00 61.00 48. 90 137.R.50 RADIOGRAPHS: CEPHALOMETRIC.20 02700 RADIOGRAPHS: CEPHALOMETRIC 02701 02702 02703 02704 02709 02750 02751 02752 02759 Single Film Two Films Three Films Four Films Each Additional Film Over Four 71. MRI SCANS OR THE INTERPRETATION MUST BE RECEIVED FROM ANOTHER SOURCE) 02801 One Unit of Time 02802 Two Units of Time 02809 Each Additional Unit Over Two 52.40 +E 104.60 31.70 02800 RADIOGRAPHS: COMPUTERIZED AXIAL TOMOGRAMS (CT).).2013 Alberta Blue Cross Dental Schedule General Practitioner • DIAGNOSTIC 02410 RADIOPAQUE DYES: USE OF.40 +E 5 . CT SCANS.60 02510 ANTHROGRAPHY OF TEMPOROMANDIBULAR JOINT 02511 Performing the Anthrographic Procedure 178.10 102.). POSITRON EMISSION TOMOGRAPHY (P.90 02520 INTERPRETATION OF THE ANTHROGRAM 02521 One unit of Time 52.70 78. TRACING AND INTERPRETATION One Unit of Time Two Units of Time Each Additional Unit Over Two 52. TO DEMONSTRATE LESIONS 02411 One Unit of Time 02412 Two Units of Time 02419 Each Additional Unit Over Two BR BR BR 02500 RADIOGRAPHS: TEMPOROMANDIBULAR JOINT 02501 02502 02503 02504 02509 Single Film Two Films Three Films Four Films (Minimum Examination Closed & Open Each Side) Each Additional Film Over Four 48.40 52. INTERPRETATION (EITHER THE RADIOGRAPHS.40 02600 RADIOGRAPHS: PANORAMIC 02601 Single Film 70.80 +E 52. MAGNETIC RESONANCE IMAGES (M.E.30 107.10 165.60 134.70 105.I.50 29. PET SCANS.40 02529 Each additional Unit of Time 52.T. 80 30.00 33.20 20.10 109. with radio-opaque markers for pre-surgical assessment of alvelor bone and vital structures as potential osseo-integrated implant site(s)) 02951 Maxillary Guide 02952 Mandibular Guide 17.60 26.40 23.30 23.60 3.20 36.20 62.70 133.50 86.40 39.60 BR 02950 6 BR+L+E BR+L+E .2013 Alberta Blue Cross Dental Schedule General Practitioner • DIAGNOSTIC 02900 RADIOGRAPHS: OTHER 02910 02911 02912 02913 02914 02915 02916 02917 02918 02919 RADIOGRAPHS: DUPLICATE Single Film Two Films Three Films Four Films Five Films Six Films Seven Films Eight Films Each Additional Film Over Eight 02930 02931 02932 02933 02934 02939 RADIOGRAPHS: TOMOGRAPHY Single View Two Views Three Views Four Views Each Additional View Over Four 02940 RADIOGRAPHS: HAND AND WRIST 02941 Radiographs: Hand and Wrist (as a diagnostic aid for dental treatment) per case RADIOGRAPHIC GUIDE (Includes diagnostic wax-up. 00 +L +L +L +L +L 7 .By Puncture Biopsy: Soft Oral Tissue . Also used to locate and orient osseo-integrated implants).70 +L 04200 TESTS/ANALYSIS: CARIES SUSCEPTIBILITY (TECHNICAL PROCEDURE ONLY) 04201 Bacteriological Test/Analysis for the Determination of Dental Caries Susceptibility 48.By Puncture Biopsy: Hard Oral Tissue . 03001 Maxillary Template 03002 Mandibular Template 58. Other 53.By Incision Biopsy: Hard Oral Tissue .20 +L 53.00 57.By Aspiration 90.90+L+E 58.90 +L 04320 04321 04322 04323 TESTS/ANALYSIS: HISTOPATHOLOGICAL.70 to 189.00 171.00 59.00 55.90 +L 147. HARD TISSUE Biopsy: Hard Oral Tissue .By Incision Biopsy: Soft Oral Tissue . DIAGNOSTIC (PILOT EQUILIBRATION) FOR EXTENSIVE OR COMPLICATED RESTORATIVE DENTISTRY One Unit of Time Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 57.10 +L 64. CASTS.70 +L 54.90+L+E 04000 TESTS/ANALYSIS/ LABORATORY PROCEDURES/INTERPRETATION AND/OR REPORTS 04100 TESTS/ANALYSIS: MICROBIOLOGICAL (TECHNICAL PROCEDURE ONLY) 04101 Microbiological Test/Analysis for the Determination of Pathological Agents 48.20 to 164.70 +L 04300 TESTS/ANALYSIS: HISTOPATHOLOGICAL (TECHNICAL PROCEDURE ONLY) 04310 04311 04312 04313 TESTS/ANALYSIS: HISTOPATHOLOGICAL.20 +E 59.80 +L BR 04700 SUPPLEMENTARY DIAGNOSTIC PROCEDURES (INTERPRETATION ONLY) 04710 04711 04712 04713 04714 04719 EQUILIBRATION.10 +L 90.2013 Alberta Blue Cross Dental Schedule General Practitioner • DIAGNOSTIC 03000 TEMPLATE SURGICAL (Includes diagnostic wax-up.00 114. SOFT TISSUE Biopsy: Soft Oral Tissue .00 228.By Aspiration BR BR BR 04400 TESTS/ANALYSIS: CYTOLOGICAL (TECHNICAL PROCEDURE ONLY) 04401 Cytological Smear From the Oral Cavity + E 04402 Vital Staining of Oral Mucosal Tissues 04500 TESTS/ANALYSIS: PULP VITALITY AND INTERPRETATION 04501 One Unit of Time 04509 Each Additional Unit of Time 04600 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. MOUNTED Casts: Diagnostic.10 +L BR BR BR +L . Unmounted.70 +L 162. UNMOUNTED Casts: Diagnostic.40 173. and 04942 04942 Three Dimensional Recordings of Patient's Dynamic Movements for Programming of Fully Adjustable Articulators 04943 Custom Incisal Guide 8 70.40 32.10 230. Mounted. Mounted.70 +L +L +L +L +L SPLIT CAST MOUNTING: DIAGNOSTIC One Unit of Time Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 57. Upper and Lower Combined 04920 04921 04922 04923 04924 CASTS: DIAGNOSTIC. Using Face Bow Transfer Casts: Diagnostic.40 +L 70.60 54. Using Face Bow and Occlusal Records Casts: Diagnostic.2013 Alberta Blue Cross Dental Schedule 04720 04721 04722 04723 04724 04729 04730 04731 04732 04733 04734 04739 General Practitioner • DIAGNOSTIC WAX-UP.70 115.60 32. 04923.80 57.80 65. Orthodontic (Unmounted.60 98. MISCELLANEOUS PROCEDURES 04941 Transverse Axis Location and Transfer. DIAGNOSTIC (TO EVALUATE COSMETIC AND/OR PREPARATION DESIGN AND/OR OCCLUSAL CONSIDERATIONS) (GNATHOLOGICAL WAXUP) One Unit of Time Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 57. ORTHODONTIC 04931 Casts: Diagnostic. Mounted.40 173.80 57. Using Fully Adjustable Articulator (used with 04941 and 04942) 04930 CASTS: DIAGNOSTIC. Mounted Casts: Diagnostic.80 04900 CASTS: DIAGNOSTIC (TECHNICAL PROCEDURE ONLY) 04910 04911 04912 04913 CASTS: DIAGNOSTIC. Unmounted.10 230.80 +L 90.00 +L BR 113.70 115. Unmounted Casts: Diagnostic. Duplicate Casts: Diagnostic.80 +L 35.20 +L 326.70 +L +L +L +L +L 04740 INTERPRETATION OF DIAGNOSTIC CASTS 04741 First Unit of Time 04749 Each Additional Unit of Time 04800 PHOTOGRAPHS: DIAGNOSTIC (TECHNICAL PROCEDURE ONLY) 04801 Single Photograph 04802 Two Photographs 04803 Three Photographs 04809 Each Additional Photograph Over Three 54. Angle Trimmed & Soaped) 04940 CASTS: DIAGNOSTIC. used in conjunction with 04922. Magnetic Resonance Images.20 54. Positron Emission Tomograms Magnetic Resonance Images.40 05109 Each Additional Unit Over Four 54. MAGNETIC RESONANCE IMAGES (MRI) INTERPRETATION (includes the production of a radiographic report and may include image processing and measurements) 06180 Radiographs. CAT scan. POSITRON EMISSION TOMOGRAPHY (PET) . Computerized Axial Tomograms. Specialist Other than Oral Radiologist 06830 Radiographs.10 05200 CONSULTATION: WITH PATIENT 05201 One Unit of Time 05202 Two Units of Time 05209 Each Additional Unit Over Two 54. Computerized Axial Tomograms. PET scan.10 05102 Two Units of Time 108.) 05101 One Unit of Time 54. Oral Radiologist 06820 Radiographs.20 05103 Three Units of Time 162. or the interpretation is received from another source) BR BR BR 9 . Magnetic Resonance Images. Positron Emission Tomograms. COMPUTERIZED AXIAL TOMOGRAMS (CT). Interpretation.10 06800 RADIOGRAPHS.30 05104 Four Units of Time 216.10 108. Interpretation (when either the radiograph. Positron Emission Tomograms. Computerized Axial Tomograms. Usual case presentation time and usual treatment planning time are implicit in the examination and diagnosis fee and in the radiographic interpretation fee.2013 Alberta Blue Cross Dental Schedule General Practitioner • DIAGNOSTIC 05000 CASE PRESENTATION/TREATMENT PLANNING 05100 TREATMENT PLANNING (This service is only for extra time spent on unusually complicated cases or where the patient demands unusual time in explanation or where diagnostic material is received from another source. Intrepretation. MRI scan. 2013 Alberta Blue Cross Dental Schedule 10 General Practitioner • DIAGNOSTIC . 00 298.60 18.Maxillary Arch 12702 Medication: Custom Appliance .80 158.80 99.80 39. Self-Administered Brush-In 18.40 19.70 +L 12700 MEDICATION: CUSTOM APPLIANCE 12701 Medication: Custom Appliance .60 20.70 +L 70.90 49.80 158.60 149.20 118.20 249.80 83.60 79.80 12100 FLUORIDE TREATMENTS 12101 Fluoride Treatment: Topical Application 12102 Fluoride Treatment: Supervised.70 +L 70.40 199.60 12600 FLUORIDE: CUSTOM APPLIANCES.90 49.80 24.60 11 .60 13200 ORAL HYGIENE INSTRUCTION/PLAQUE CONTROL To include: brushing and/or flossing and/or embrasure cleaning 13210 13211 13212 13213 13214 13217 13219 INDIVIDUAL INSTRUCTION (ONE INSTRUCTOR TO ONE PATIENT) EXCLUDING AUDIO-VISUAL TIME One Unit of Time Two Units of Time Three Units of Time Four Units of Time 1/2 Unit of Time Each Additional Unit Over Four 39.Mandibular Arch 70.20 118.70 +L 13000 PREVENTIVE SERVICES: OTHER 13100 NUTRITIONAL COUNSELING Including: recording and analysis of up to seven day dietary intake and consultation 13101 One Unit of Time 13102 Two Units of Time 13103 Three Units of Time 13104 Four Units of Time 13109 Each Additional Unit Over Four 39. (HOME APPLICATIONS) 12601 Fluoride: Custom Appliance .Mandibular Arch 70.40 39.2013 Alberta Blue Cross Dental Schedule General Practitioner • PREVENTIVE PREVENTIVE 11100 POLISHING 11101 One Unit of Time 11102 Two Units of Time 11107 1/2 Unit of Time 11110 11111 11112 11113 11114 11115 11116 11117 11119 SCALING One Unit of Time Two Units of Time Three Units of Time Four Units of Time Five Units of Time Six Units of Time 1/2 Unit of Time Each Additional Unit Over Six 41.60 79.Maxillary Arch 12602 Fluoride: Custom Appliance . Same Quadrant PREVENTIVE RESTORATIVE RESIN (procedure that involves some preparation of the pits and/or fissures in tooth enamel and may extend into dentin in limited areas) 13411 First Tooth 13419 Each Additional Tooth Same Quadrant 39.60 13400 SEALANTS: PIT AND FISSURE (MECHANICAL AND/OR CHEMICAL PREPARATION INCLUDED) 13401 First Tooth 13409 Each Additional Tooth.g.70 +L 769.70 +L 384.60 28.Psychological Approach (e.) 14311 First Unit of Time Per Visit 14312 Two Units of Time 14319 Each Additional Unit Over Two 64. Per Visit MYOFUNCTIONAL THERAPY (e. tongue thrust.2013 Alberta Blue Cross Dental Schedule General Practitioner • PREVENTIVE 13220 13221 13222 13223 13224 13229 GROUP INSTRUCTION .40 39. Maxillary & Mandibular 384.40 +L 14200 APPLIANCES: FIXED/CEMENTED. CONTROL OF ORAL HABITS 14201 Appliance: Maxillary 14202 Appliance: Mandibular 449.EXCLUDING AUDIO-VISUAL TIME One Unit of Time Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 13230 13231 13232 13239 RE-INSTRUCTION (WITHIN 6 MONTHS) .00 +L 128. thumb sucking.g.30 +E 13602 Two Units of Time 90.00 +L 14310 12 64. to correct mouth breathing.00 +L 64.60 79.00 .10 +L 14300 CONTROL OF ORAL HABITS: MISCELLANEOUS 14301 Motivation of Patient .80 158. abnormal swallowing. etc.20 118.30 14000 APPLIANCES 14100 APPLIANCES: REMOVABLE.10 +L 449. etc.20 39.00 13410 53.60 +E 13609 Each Additional Unit Over Two 45.60 79.50 13600 TOPICAL APPLICATION TO HARD TISSUE OF AN ANTIMICROBIAL OR REMINERALIZATION AGENT 13601 One Unit of Time 45.EXCLUDING AUDIO-VISUAL TIME One Unit of Time Two Units of Time Each Additional Unit Over Two 39.10 14. CONTROL OF ORAL HABITS 14101 Appliance: Maxillary 14102 Appliance: Mandibular 14103 Appliances.).60 13240 13241 13242 13249 ORAL HYGIENE INSTRUCTION .AUDIO-VISUAL One Unit of Time Two Units of Time Each Additional Unit Over Two 39.50 53. lip biting.20 39.60 79. INTRAORAL REPOSITIONING.80 155.30 14500 APPLIANCES.60 +L 125. REPAIRS One Unit of Time Two Units of Time Three Units of Time Each Additional Unit Over Three 14740 APPLIANCES: TMJ. INSERTION AND INSERTION ADJUSTMENT (NO POST-INSERTION ADJUSTMENTS) 14721 Maxillary Appliance 14722 Mandibular Appliance 366.80 +L 256.60 +L 14403 Three Units of Time 174.50 101.80 +L 62.70 +L 14600 APPLIANCES: PERIODONTAL (SEE SEPARATE CODES FOR CONTROL OF ORAL HABITS 14000.30 +L 14402 Two Units of Time 116. INCLUDES IMPRESSION. Protective Mouth Guards. INCLUDES IMPRESSION. INSERTION AND INSERTION ADJUSTMENT (NO POSTINSERTION ADJUSTMENTS) 14711 Maxillary Appliance 14712 Mandibular Appliance APPLIANCES: TMJ.60 +L 188. ADJUSTMENTS.10 +L 62. RELINES 14741 Reline: Direct 14742 Reline: Processed 683.90 +L 14409 Each Additional Unit Over Three 58.2013 Alberta Blue Cross Dental Schedule General Practitioner • PREVENTIVE 14400 APPLIANCES: CONTROL OF ORAL HABITS. REPAIR One Unit of Time Two Units of Time Three Units of Time Each Additional Unit Over Three 14630 APPLIANCES. Processed 50.80 +L 62.60 +L 14720 14730 14731 14732 14733 14739 APPLIANCES: TMJ.20 +L 187. PERIODIC MAINTENANCE.40 +L 62.20 155.80 +L 125. MAINTENANCE 14401 One Unit of Time 58. PROTECTIVE MOUTH GUARDS 14501 Appliance. DIAGNOSTIC AND OR THERAPEUTIC. PROTECTIVE MOUTH GUARDS 14500. Preformed 14502 Appliance Protective Mouth Guards. RELINE 14631 Reline: Direct 14632 Reline: Processed 256.20 155. INSERTION AND INSERTION ADJUSTMENT (NO POST-INSERTION ADJUSTMENTS) 14611 Maxillary Appliance 14612 Mandibular Appliance 14620 14621 14622 14623 14629 APPLIANCES: ADJUSTMENTS.20 +L 13 . ADJUSTMENTS. TMJ 14700 + TMJ APPLIANCES 78700) 14610 APPLIANCES: PERIODONTAL (INCLUDING BRUXISM APPLIANCES). REPAIRS. INCLUDES IMPRESSION.60 +L 366.20 +L 14700 APPLIANCES: TEMPOROMANDIBULAR JOINT 14710 APPLIANCES: TMJ.10 +L 683.60 155. INTRAORAL. FOR THE TREATMENT OF OBSTRUCTIVE AIRWAY DISORDERS. TO TREAT MEDICALLY DIAGNOSED OBSTRUCTIVE SLEEP APNEA. and insertion adjustment (no post-insertion adjustment) 14811 Maxillary Appliance 683. UPPER AIRWAY RESISTANCE SYNDROME (UARS) WITH OR WITHOUT APNEA (INCLUDES MODELS. ALSO PLEASE NOTE THAT HEALTH SERVICES CLAIMS CANNOT HAVE PAYMENT ASSIGNED TO THE DENTAL PROVIDER) 14901 APPLIANCE. MYOFACIAL PAIN DYSFUNCTION SYNDROME. GNATHOLOGICAL DETERMINANTS. PERIODIC MAINTENANCE. INTRAORAL. PERIODIC MAINTENANCE. (TO INCLUDE: MODELS. GNATHOLOGICAL DETERMINANTS) Appliance construction only. FOR THE TREATMENT OF OBSTRUCTIVE AIRWAY DISORDERS.2013 Alberta Blue Cross Dental Schedule General Practitioner • PREVENTIVE 14800 APPLIANCES: MYOFACIAL PAIN DYSFUNCTION SYNDROME (CONDITIONS THAT ORIGINATE OUTSIDE THE TEMPOROMANDIBULAR JOINT) 14810 APPLIANCE.60 +L 125.20 +L 187. RIDGE OR TOOTH SUPPORTED BR +L 14902 APPLIANCE. MONITORING To include monitoring patient to ensure proper use of appliances and evaluation for referrals to other health care professionals for appropriate medical management 14921 One Unit of Time 14922 Two Units of Time 14929 Each Additional Unit Over Two BR +L BR +L BR +L 14920 14 BR BR BR . THESE SERVICES ARE NOT ELIGIBLE UNDER ALBERTA BLUE CROSS DENTAL PLANS. APPLIANCE CONSTRUCTION AND INSERTION ADJUSTMENT (NO POST-INSERTION ADJUSTMENTS) (*PLEASE NOTE THAT SERVICES UNDER THE 14900 SERIES OF PROCEDURE CODES MUST BE SUBMITTED TO ALBERTA BLUE CROSS ON A HEALTH SERVICES CLAIMS FORM FOR CONSIDERATION.80 +L 62. SNORING.10 +L 14812 Mandibular Appliance 683. FOR THE TREATMENT OF OBSTRUCTIVE AIRWAY DISORDERS BR +E 14910 APPLIANCE. INTRAORAL.60 14900 APPLIANCES: INTRAORAL. ADJUSTMENTS AND REPAIRS 14911 One Unit of Time 14912 Two Units of Time 14919 Each Additional Unit Over Two APPLIANCE. ADJUSTMENT AND REPAIRS One Unit of Time Two Units of Time Three Units of Time Each Additional Unit Over Three 62.10 +L 14820 14821 14822 14823 14829 APPLIANCES: MYOFACIAL PAIN DYSFUNCTION SYNDROME. FOR THE TREATMENT OF OBSTRUCTIVE AIRWAY DISORDERS. TONGUE RETAINING DEVICE. to include: adjustment and/or recementation after 30 days from insertion 15602 Maintenance: Space Maintainer Appliance.80 +L 15200 SPACE MAINTAINERS: STAINLESS STEEL CROWN TYPE 15201 Space Maintainer: Stainless Steel Crown Type. Fixed 15302 Space Maintainer: Cast Type. REMOVABLE 15401 Space Maintainer: Acrylic.50 15 . PONTIC TYPE 15501 Space Maintainer: Bonded.10 +L 15500 SPACE MAINTAINERS: BONDED. Removable.80 +L 15300 SPACE MAINTAINERS: CAST TYPE 15301 Space Maintainer: Cast Type. No Clasps 216.40 +L 161.10 +L 176. Bilateral Clasps. Bilateral (Soldered Lingual Arch) With Teeth Attached 15105 Space Maintainer: Band Type. Unilateral With Intra-Alveolar Attachment 15103 Space Maintainer: Band Type. Fixed. addition of clasps and/or activating wires 15603 Repairs: Space Maintainer Appliance (including recementation) 15604 Removal of Fixed Space Maintainer Appliance By Second Dentist 197. FABRICATION. INSERTION. Fixed. Fixed.10 +L 15400 SPACE MAINTAINERS: ACRYLIC. Pontic Type 168. Bilateral (Soldered Lingual Arch) 15104 Space Maintainer: Band Type.20 +L 226. Fixed 15202 Space Maintainer: Stainless Steel Crown Type. AND WHERE APPLICABLE INITIAL CEMENTATION AND REMOVAL) 15100 SPACE MAINTAINERS: BAND TYPE 15101 Space Maintainer: Band Type.2013 Alberta Blue Cross Dental Schedule General Practitioner • PREVENTIVE 15000 SPACE MAINTAINERS (INCLUDES THE DESIGN. Unilateral 15102 Space Maintainer: Band Type.50 56. Removable. Fixed. Bilateral Clasps.10 +L 224.80 +L 252. Fixed. With Intra-Alveolar Attachment 224.80 +L 252. Bilateral Tubes And Locking Wire 168.50 +L 56.50 +L 56. Retaining Wires With Teeth 15403 Space Maintainer: Acrylic. Fixed.60 +L 192. SEPARATION. With Intra-Alveolar Attachment 156.60 +L 56. Retaining Wires 15402 Space Maintainer: Acrylic. Removable.60 +L 15600 SPACE MAINTAINERS: MAINTENANCE OF 15601 Maintenance: Space Maintainer Appliance. Fixed. (when restorations were performed by another dentist or restorations are over two years old) 16101 16102 16103 16104 16109 One Unit of Time Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 16200 DISKING OF TEETH: INTERPROXIMAL 16201 One Unit of Time 16202 Two Units of Time 16203 Three Units of Time 16209 Each Additional Unit Over Three 49. refining marginal ridges and occlusal surfaces.40 56.70 259.90 129.60 64. c) Not to be used in conjunction with the delivery and post-insertion care of: 1) fixed or removable prosthesis (50000 and 60000 code series) by the same dentist for a period of three months.30 60.90 .30 98.2013 Alberta Blue Cross Dental Schedule General Practitioner • PREVENTIVE 16100 FINISHING RESTORATIONS To include: polishing. removal of overhangs.30 16400 RECONTOURING OF TEETH FOR FUNCTIONAL REASON (NOT ASSOCIATED WITH DELIVERY OF A SINGLE OR MULTIPLE PROSTHESIS) 16401 One Unit of Time 16409 Each Additional Unit of Time 60. etc.20 49.60 170.30 60.30 56.60 147.30 16500 OCCLUSION 16510 OCCLUSAL ADJUSTMENTS/EQUILIBRATION a) May require several sessions b) May be used in conjunction with basic restorative treatment only when occlusal adjustments/equilibration is not required as a result of that restoration.80 113.80 194.80 16300 RECONTOURING OF NATURAL TEETH FOR AESTHETIC REASONS 16301 One Unit of Time 16309 Each Additional Unit of Time 60.90 197. 16511 One Unit of Time 16512 Two Units of Time 16513 Three Units of Time 16514 Four Units of Time 16519 Each Additional Unit Over Four 16 64. 2013 Alberta Blue Cross Dental Schedule General Practitioner • PREVENTIVE 17 . PRIMARY TEETH One Surface Two Surfaces Three Surfaces Four Surfaces Five Surfaces or Maximum Surfaces Per Tooth 86. at the same appointment.10 129.40 171. 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.70 140.40 141.40 126. in order to conserve tooth structure.80 21120 21121 21122 21123 21124 21125 RESTORATIONS: AMALGAM.30 88. Same Quadrant 160.50 57.20 21000 RESTORATIONS: AMALGAM 21100 RESTORATIONS: AMALGAM. AS A SEPARATE PROCEDURE) 20111 First Tooth 20119 Each Additional Tooth. PRIMARY TEETH One Surface Two Surfaces Three Surfaces Four Surfaces Five Surfaces or Maximum Surfaces Per Tooth 101. BONDED. (See 16100) 20100 CARIES. when one restoration might have been done. this should be considered as one restoration in assessing the fee. Same Quadrant 104.60 109. Note 2: Where. AS A SEPARATE PROCEDURE) 20121 First Tooth 20129 Each Additional Tooth. two separate restorations are performed on the same tooth involving a common surface.40 18 .20 153.20 49.2013 Alberta Blue Cross Dental Schedule General Practitioner • RESTORATIVE SERVICES RESTORATIVE SERVICES Note 1: Treatment of dental caries includes pulp protection and local anaesthesia. Note 3: Finishing restorations is a separate procedure done at a separate appointment. INCLUDES PULP CAPS WHEN NECESSARY. Same Quadrant CARIES/TRAUMA/PAIN CONTROL (REMOVAL OF CARIOUS LESIONS OR EXISTING RESTORATIONS OR GINGIVALLY ATTACHED TOOTH FRAGMENTS AND PLACEMENT OF SEDATIVE/PROTECTIVE DRESSINGS.50 20120 20130 TRAUMA CONTROL: SMOOTHING OF FRACTURED SURFACES PER TOOTH 20131 First Tooth 20139 Each Additional Tooth.50 27. INCLUDES PULP CAPS WHEN NECESSARY AND THE USE OF A BAND FOR RETENTION AND SUPPORT. NON-BONDED.90 189. PRIMARY TEETH 21110 21111 21112 21113 21114 21115 RESTORATIONS: AMALGAM. 10 166.80 261. PERMANENT BICUSPIDS AND ANTERIORS One Surface Two Surfaces Three Surfaces Four Surfaces Five Surfaces or Maximum Surfaces Per Tooth 109. PERMANENT TEETH 21210 RESTORATIONS: AMALGAM.90 21230 RESTORATIONS: AMALGAM.80 21302 Restoration: Amalgam Core.30 145.70 123. In Conjunction With Crown or Fixed Bridge Retainer 164.60 203.30 21400 PINS: RETENTIVE PER RESTORATION (FOR AMALGAM AND TOOTH COLOURED RESTORATIONS) 21401 One Pin 21402 Two Pins 21403 Three Pins 21404 Four Pins 21405 Five Pins or More 29.10 243. PERMANENT MOLARS One Surface Two Surfaces Three Surfaces Four Surfaces Five Surfaces or Maximum Surfaces Per Tooth 105. Bonded.2013 Alberta Blue Cross Dental Schedule General Practitioner • RESTORATIVE SERVICES 21200 RESTORATIONS: AMALGAM. BONDED.40 149.20 199.50 183.80 74. NON-BONDED.30 RESTORATIONS: AMALGAM. PERMANENT MOLARS One Surface Two Surfaces Three Surfaces Four Surfaces Five Surfaces or Maximum Surfaces per Tooth 120.10 21211 21212 21213 21214 21215 21231 21232 21233 21234 21235 21240 21241 21242 21243 21244 21245 21300 RESTORATIONS: AMALGAM CORES 21301 Restoration: Amalgam Core.20 40. PERMANENT BICUSPIDS AND ANTERIORS One Surface Two Surfaces Three Surfaces Four Surfaces Five Surfaces or Maximum Surfaces Per Tooth 94.00 162.50 193.20 139.00 21500 RESTORATIONS MADE TO A TOOTH SUPPORTING AN EXISTING PARTIAL DENTURE CLASP (ADDITIONAL TO RESTORATION) 21501 Per Restoration 54.50 228.40 219.60 62.10 19 .90 159. In Conjunction With Crown or Fixed Bridge Retainer 150. BONDED.40 51. Non-Bonded. NON-BONDED.70 156.30 21220 21221 21222 21223 21224 21225 RESTORATIONS: AMALGAM. Bonded 23123 Tooth Coloured Veneer Application .90 217. PERMANENT TEETH 22501 Permanent Anterior 22511 Permanent Posterior 217.20 118. BONDED TECHNIQUE (NOT TO BE USED FOR VENEER APPLICATIONS OR DIASTEMA CLOSURES) One Surface Two Surfaces (Continuous) Three Surfaces (Continuous) Four Surfaces (Continuous) Five Surfaces (Continuous or Maximum Surfaces Per Tooth) 23120 RESTORATIONS: TOOTH COLOURED.50 188.90 217.Non Prefabricated Direct Buildup .Open Face 22311 Permanent Posterior 22312 Permanent Posterior . PRIMARY TEETH 22401 Primary Anterior 22411 Primary Posterior 188.90 22500 RESTORATIONS: PREFABRICATED.60 265.Diastema Closure. PLASTIC. FULL COVERAGE 22200 RESTORATIONS: PREFABRICATED.10 214.50 174.00 141.Open Face 188.10 250. PLASTIC.50 188. METAL. PRIMARY TEETH 22201 Primary Anterior 22202 Primary Anterior .50 22400 RESTORATIONS: PREFABRICATED.2013 Alberta Blue Cross Dental Schedule General Practitioner • RESTORATIVE SERVICES 22000 RESTORATIONS: PREFABRICATED.30 138. METAL.50 186.90 217.50 22300 RESTORATIONS: PREFABRICATED. Interproximal Only.40 163.90 188. PERMANENT ANTERIORS.90 217. NON BONDED TECHNIQUE 23101 One Surface 23102 Two Surfaces (Continuous) 23103 Three Surfaces (Continuous) 23104 Four Surfaces (Continuous) 23105 Five Surfaces (Continuous or Maximum Surfaces Per Tooth) 23110 23111 23112 23113 23114 23115 RESTORATIONS: PERMANENT ANTERIORS.Open Face 188.50 217. VENEER APPLICATIONS 23122 Tooth Coloured Veneer Application .50 23000 RESTORATIONS: TOOTH COLOURED/PLASTIC WITH/WITHOUT SILVER FILINGS 23100 RESTORATIONS: TOOTH COLOURED.70 271.40 . Bonded 20 98. PERMANENT TEETH 22301 Permanent Anterior 22302 Permanent Anterior .Open Face/Acrylic Veneer 22211 Primary Posterior 22212 Primary Posterior .70 115. 60 151.80 106. BONDED TECHNIQUE 23411 One Surface 23412 Two Surfaces (Continuous) 23413 Three Surfaces (Continuous) 23414 Four Surfaces (Continuous) 23415 Five Surfaces (Continuous or Maximum Surfaces Per Tooth) 105.40 209. BONDED 23310 23311 23312 23313 23314 23315 PERMANENT BICUSPIDS One Surface Two Surfaces Three Surfaces Four Surfaces Five Surfaces or Maximum Surfaces Per Tooth 132.40 151.80 131.30 318. PRIMARY.50 185. PERMANENT POSTERIORS. NON BONDED 23501 One Surface 23502 Two Surfaces 23503 Three Surfaces 23504 Four Surfaces 23505 Five Surfaces or Maximum Surfaces Per Tooth 92.30 278.20 176. POSTERIOR.40 250.70 110.20 23500 RESTORATIONS: TOOTH COLOURED/PLASTIC WITH/WITHOUT SILVER FILINGS. PRIMARY.50 23220 23221 23222 23223 23224 23225 PERMANENT MOLARS One Surface Two Surfaces Three Surfaces Four Surfaces Five Surfaces or Maximum Surfaces Per Tooth 99.60 152.30 137.60 23320 23321 23322 23323 23324 23325 PERMANENT MOLARS One Surface Two Surfaces Three Surfaces Four Surfaces Five Surfaces or Maximum Surfaces Per Tooth 142. ANTERIOR.10 190.2013 Alberta Blue Cross Dental Schedule General Practitioner • RESTORATIVE SERVICES 23200 RESTORATIONS: TOOTH COLOURED/PLASTIC WITH/WITHOUT SILVER FILINGS.80 132.60 23410 RESTORATIONS: TOOTH COLOURED.90 211.30 116.10 185.00 228.70 23300 RESTORATIONS: TOOTH COLOURED.20 201.50 130. PERMANENT POSTERIORS NON BONDED 23210 23211 23212 23213 23214 23215 PERMANENT BICUSPIDS One Surface Two Surfaces Three Surfaces Four Surfaces Five Surfaces or Maximum Surfaces Per Tooth 99. NON BONDED 23401 One Surface 23402 Two Surfaces (Continuous) 23403 Three Surfaces (Continuous) 23404 Four Surfaces (Continuous) 23405 Five Surfaces (Continuous or Maximum Surfaces Per Tooth) 90.80 176.90 128.50 177. PRIMARY.30 162.00 250.50 271.50 149.50 21 . ANTERIOR.50 23400 RESTORATIONS: TOOTH COLOURED. ONLAYS.20 23602 Restoration.70 589. ANTERIORS 24101 Class I 24102 Class III 24103 Class V 24104 Class IV 455. POSTERIORS 24201 Class I 24202 Class II 24203 Class V 662. PINS AND POSTS 25100 RESTORATIONS: INLAYS 25110 25111 25112 25113 25114 INLAYS: METAL One Surface Two Surfaces Three Surfaces Three Surfaces.10 559. Bonded. Modified 373. Non Bonded Core.20 206.00 157.10 529.40 638.70 589. PRIMARY.80 25000 RESTORATIONS: INLAYS. In Conjunction With Crown or Fixed Bridge Retainer 150.90 594.10 24200 RESTORATIONS: FOIL. GOLD 24100 RESTORATIONS: FOIL. GOLD. Modified 416. CORES 23601 Restoration: Tooth Coloured.10 559. Core.70 +L +L +L +L 22 .80 564. INDIRECT (BONDED) One Surface Two Surfaces Three Surfaces Three Surfaces. Modified 373.80 662.90 250.80 564.50 24000 RESTORATIONS: FOIL.30 632.50 177. In Conjunction With Crown or Fixed Bridge Retainer 165.10 662. Tooth Coloured.90 594. BONDED TECHNIQUE 23511 One Surface 23512 Two Surfaces 23513 Three Surfaces 23514 Four Surfaces 23515 Five Surfaces or Maximum Surfaces Per Tooth 117.30 +L +L +L +L 25120 25121 25122 25123 25124 INLAYS: COMPOSITE/COMPOMER.2013 Alberta Blue Cross Dental Schedule General Practitioner • RESTORATIVE SERVICES 23510 RESTORATIONS: TOOTH COLOURED. Modified 416.70 662. POSTERIOR.10 23600 RESTORATIONS: TOOTH COLOURED/PLASTIC WITH/WITHOUT SILVER FILINGS. GOLD.40 638.30 +L +L +L +L 25140 25141 25142 25143 25144 INLAYS: PORCELAIN/CERAMIC/POLYMER GLASS (BONDED) One Surface Two Surfaces Three Surfaces Three Surfaces.10 529.30 632.70 +L +L +L +L 25130 25131 25132 25133 25134 INLAYS: PORCELAIN/CERAMIC/POLYMER GLASS One Surface Two Surfaces Three Surfaces Three Surfaces. (INCLUDING CORE) AS A SEPARATE PROCEDURE Single Section Two Sections Three Sections POSTS: CAST METAL.40 +L+E 25770 POSTS: PROVISIONAL 25771 Per Post 25780 POSTS: REMOVAL 25781 One Unit of Time 25782 Two Units of Time 25783 Three Units of Time 25784 Four Units of Time 25789 Each Additional Unit Over Four 74.00 +L 25520 ONLAYS: COMPOSITE/COMPOMER.10 +L 25600 PINS: RETENTIVE (FOR INLAYS. Indirect 715. Composite/Compomer.50 +L 451.00 82.70 +L+E 344.2013 Alberta Blue Cross Dental Schedule General Practitioner • RESTORATIVE SERVICES 25500 RESTORATIONS: ONLAYS (WHERE ONE OR MORE CUSPS ARE RESTORED) 25510 ONLAYS: CAST METAL.80 115.10 +L 25730 25731 25732 25733 POSTS: PREFABRICATED RETENTIVE One Post Two Posts Same Tooth Three Posts Same Tooth 179.20 +E 318.60 228. (INCLUDING CORE) CONCURRENT WITH IMPRESSIONS FOR CROWN 25721 Single Section 25722 Two Sections 25723 Three Sections 324.10 +L+E 413. INDIRECT 25511 Onlay. ONLAYS AND CROWNS PER TOOTH) 25601 One Pin/Tooth 25602 Two Pins/Tooth 25603 Three Pins/Tooth 25604 Four Pins/Tooth 25605 Five or More Pins/Tooth 49.30 152.20 76.90 305. Porcelain/Ceramic/Polymer Glass (Bonded) 726. Cast Metal.70 +L 199.40 98.30 23 .50 +L 25530 ONLAYS: PORCELAIN/CERAMIC/POLYMER GLASS (BONDED) 25531 Onlay.50 +E 254.60 66.30 +E 25740 25741 25742 25743 POSTS: PREFABRICATED.90 +L 393.20 +L +L +L +L +L 25700 POSTS 25710 25711 25712 25713 POSTS: CAST METAL. Indirect (Bonded) 659.80 +L 266.70 +E and/or +L 76.80 +L 25720 155. RETENTIVE AND CAST CORE One Post And Cast Core Two Posts (Same Tooth) And Cast Core Three Posts (Same Tooth) And Cast Core 273. PROCESSED (BONDED) 25521 Onlay. 27100 CROWNS: ACRYLIC/COMPOSITE/COMPOMER (WITH OR WITHOUT CAST OR PREFABRICATED METAL BASES) 27110 CROWNS: ACRYLIC/COMPOSITE/COMPOMER.20 +E BR +E 27130 598. Direct.00 +L 27220 CROWNS.30 720. Porcelain/Ceramic/Polymer Glass 27222 Crown.30 +L 27200 CROWNS: PORCELAIN/CERAMIC/POLYMER GLASS 27201 27202 27205 27206 Crown: Porcelain/Ceramic/Polymer Glass Crown: Porcelain/Ceramic/Polymer Glass. Indirect 577. Porcelain/Ceramic/Polymer Glass.20 +L 27120 CROWNS: ACRYLIC/COMPOSITE/COMPOMER. RETAINED BY EITHER A CEMENTED POST OR SCREW).Complicated (Restorative. (With Intra-Oral Preparation) Per Implant Site BR +L+E BR +L+E BR +E 27000 CROWNS: SINGLE UNITS ONLY (INCLUDES TEMPORARY PROTECTION AND LOCAL ANAESTHETIC. Per Implant Indirect. Angulated or Transmucosal Prefabricated Abutment. Positional and/or Aesthetic) 27215 Crown: Porcelain/Ceramic/Polymer Glass Fused To Metal. PORCELAIN/CERAMIC/POLYMER GLASS 27221 Crown.90 +L 27112 Crown: Acrylic/Composite/Compomer.30 +L 27113 Crown: Acrylic/Composite/Compomer Provisional [Long Term]. Indirect. DIRECT 27121 Crown: Acrylic/Composite/Compomer. Complicated Crown: Porcelain/Ceramic/Polymer Glass.2013 Alberta Blue Cross Dental Schedule General Practitioner • RESTORATIVE SERVICES 26000 MESOSTRUCTURES (A SEPARATE COMPONENT POSITIONED BETWEEN THE HEAD OF AN IMPLANT AND THE FINAL RESTORATION.60 875. Provisional. INDIRECT 27131 Crown: Acrylic/Composite/Compomer/Cast Metal Base. Positional and/or Aesthetic) 693. Implant-Supported 27136 Crown: Acrylic/Composite/Compomer/Cast Metal Base.00 +L +L +L+E +L 27210 CROWNS: 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. EXTENSIVE RESTORATION. with Cast Metal Post Retention 875. with Cast Post Retention 181. IMPLANT-SUPPORTED Indirect. Implant-Supported 27216 Crown: Porcelain/Ceramic/Polymer Glass Fused To Metal.60 +L 864.30 +L 24 720.Indirect (lab fabricated/relined intra-orally) 141. 26100 26101 26102 26103 MESOSTRUCTURES.60 +L 864.60 +L+E . Custom Laboratory Fabricated.60 +L 598. 3/4. Complicated (Restorative. CARIES REMOVAL. Provisional (Chairside) 27125 Crown: Acrylic/Composite/Compomer.60 864. REQUIRING PINS OR DOWELS EXTRA. complicated 720.60 +L+E 732. Implant-Supported Crown: Porcelain/Ceramic/Polymer Glass.INDIRECT 27111 Crown: Acrylic/Composite/Compomer. Indirect 27135 Crown: Acrylic/Composite/Compomer/Cast Metal Base.30 +L 720. Per Implant Direct. with Cast Ceramic Post Retention 720. 3/4. AND UNCOMPLICATED RESTORATION PRIOR TO CROWN PREPARATION). Direct. 3/4. Implant-Supported CROWNS: ACRYLIC/COMPOSITE/COMPOMER/CAST METAL BASE. OSSEO-INTEGRATED. 30 720. DOES NOT INCLUDE REMOVAL AND RECEMENTATION) 27710 REPAIRS: INLAYS.60 875.TRANSFER (THIMBLE) CONCURRENT WITH IMPRESSION FOR CROWN 27521 Coping.2013 Alberta Blue Cross Dental Schedule General Practitioner • RESTORATIVE SERVICES 27300 CROWNS: CAST METAL 27301 Crown: Cast Metal 27302 Crown: Cast Metal. Direct REPAIRS: INLAYS.00 73.30 113.30 27500 COPINGS: METAL/ACRYLIC. Indirect 128.80 27720 27800 RECONTOURING OF EXISTING CROWNS PER TOOTH 27801 One Unit of Time 27809 Each Additional Unit of Time 128.60 +L BR 766. Bonded 27602 Veneers: Porcelain/Ceramic/Polymer Glass. Transfer (Thimble) Concurrent with Impression for Crown 27600 VENEERS: LABORATORY PROCESSED 27601 Veneers: Acrylic/Composite/Compomer. Complicated Crown: 3/4 Cast Metal. Porcelain/Ceramic/Polymer Glass. Porcelain/Ceramic/Polymer Glass.50 +L 472.60 +L 27700 REPAIRS: (SINGLE UNITS ONLY.40 +L 113. Onlays or Crowns. With Direct Tooth Coloured Corner 27400 CROWNS: MADE TO AN EXISTING PARTIAL DENTURE CLASP (ADDITIONAL TO CROWN) 27401 One Crown 27409 Each Additional Crown 720. ONLAYS OR CROWNS.80 128. TRANSFER (THIMBLE TYPE) 27510 COPINGS: METAL/ACRYLIC. Metal/Acrylic. TRANSFER (THIMBLE) AS A SEPARATE PROCEDURE 27511 Coping.60 864. ACRYLIC/COMPOSITE/COMPOMER (SINGLE UNITS) 27711 Repairs: Acrylic/Composite/Compomer. Positional) 27305 Crown: Cast Metal. Onlays or Crowns. ONLAYS OR CROWNS. Fused to Metal Base.80 +L 73. Bonded 250.00 25 .00 +L 524.00 +L 64. PORCELAIN/CERAMIC/POLYMER GLASS/FUSED TO METAL BASE (SINGLE UNITS) 27721 Repairs: Inlays.00 BR +L +L +L+E +L BR 720. Implant-Supported 27306 Crown: Cast Metal. Direct 27722 Repairs: Inlays. Metal/Acrylic. Complicated (Restorative. Fused to Metal Base. Transfer (Thimble) as a Separate Procedure 27520 COPINGS: METAL/ACRYLIC. with Cast Metal Post Retention 27307 Semi-precision Rest (Interlock)(in additionto Cast Metal Crown) 27308 Semi-precision or Precision Attachment RPD Retainer (in addition to Cast Metal Crown) 27310 27311 27312 27313 CROWNS: 3/4 CAST METAL Crown: 3/4 Cast Metal Crown: 3/4 Cast Metal. Indirect Coping Crown: Cast Metal .No Attachment. as an Internal/External Overdenture Retentive Device.90 137. DIRECT 28101 Natural Tooth Preparation. Direct to a Natural Tooth (Used with the Appropriate Denture Code) Per Tooth 28105 Implant-Supported Prefabricated Attachment as an Overdenture Retentive Device. VENEERS (SINGLE UNITS ONLY) 29301 One Unit of Time 29302 Two Units of Time 29303 Three Units of Time 29304 Four Units of Time 68.Endodontically Treated Tooth 28102 Natural Tooth Preparation and Fluoride Application.60 +L 347. INDIRECT 28210 28211 28215 28216 COPING CROWNS: CAST METAL.80 206.No Attachment.70 275.80 206.60 29400 STAINING: PORCELAIN (CHAIRSIDE) 29401 One Unit of Time 29402 Two Units of Time 29403 Three Units of Time 29404 Four Units of Time 68.70 275.70 127.10 +L+E 289.70 29104 Four Units of Time 275. Direct 97.10 +L+E 28220 28221 28225 28226 COPING CROWNS: CAST METAL. WITH ATTACHMENT. Implant-Supported.90 137.90 29102 Two Units of Time 137.80 29103 Three Units of Time 206.60 29300 REMOVAL: INLAYS/ONLAYS. INDIRECT Coping Crown: Cast Metal. INDIRECT Coping Crown: Cast Metal .30 +L and/or +E 406. With Attachment 406. Indirect Coping Crown: Cast Metal. NO ATTACHMENTS. CROWNS. Vital Tooth 28103 Prefabricated Attachment. With Cast Metal Retentive Post. Placement of Pulp Chamber Restoration (Amalgam or Composite) and Fluoride Application.2013 Alberta Blue Cross Dental Schedule General Practitioner • RESTORATIVE SERVICES 28000 RESTORATIVE PROCEDURES: OVERDENTURES 28100 RESTORATIVE PROCEDURES: OVERDENTURES.60 26 +L +L +L +L +L +L +L +L . With Attachment. Indirect Coping Crown: Cast Metal.30 +L+E 560.60 +L+E 502.90 +L+E 29000 RESTORATIVE SERVICES: OTHER 29100 RECEMENTATION/REBONDING: INLAYS/ONLAYS/CROWNS/VENEERS/POSTS/NATURAL TOOTH FRAGMENTS (SINGLE UNITS ONLY) (+L WHERE LABORATORY CHARGES ARE INCURRED DURING REPAIR OF THE UNIT) 29101 One Unit of Time 68. With Cast Metal Retentive Post. No Attachments 347. Implant-Supported with Attachment Coping Crown: Cast Metal.10 +L+E 28200 RESTORATIVE PROCEDURES: OVERDENTURES.10 289. through complex restorations e. clinical procedures (i. 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. (EXCLUDING FINAL RESTORATION) 32200 PULPOTOMY 32220 PULPOTOMY: PERMANENT TEETH (AS A SEPARATE EMERGENCY PROCEDURE) 32221 Anterior and Bicuspid Teeth 32222 Molar Teeth 32230 PULPOTOMY: PRIMARY TEETH 32231 Primary Tooth. tooth position. post/core build-ups Exceptional Anatomy . Definitions: Uncomplicated .Re-treatment of previously completed therapy 27 . concurrent with restoration (but excluding final restoration) 32300 PULPECTOMY (AN EMERGENCY PROCEDURE AND/OR AS A PRE-EMTIVE PHASE TO THE PREPARATION OF THE ROOT CANAL SYSTEM FOR OBTURATION) 32310 PULPECTOMY: PERMANENT TEETH/RETAINED PRIMARY TEETH 32311 One Canal 32312 Two Canals 32313 Three Canals 32314 Four or More Canals 32320 PULPECTOMY: PRIMARY TEETH 32321 Anterior Tooth 32322 Posterior Tooth 107.30 134.2013 Alberta Blue Cross Dental Schedule General Practitioner • ENDODONTICS ENDODONTICS General Endodontic Procedures There are certain Endodontic cases.Unable to penetrate with size ten file and not clearly discernable on a radiograph Re-treatment .Limited jaw opening. anatomy and/or stage of development. 31100 PULP CAPPING (REFER TO CODE 20100) 32000 PULP CHAMBER: TREATMENT OF. crowns.Virtually straight canal penetrated by size fifteen file Difficult Access .g. Excludes final restoration. dens-in-dente or partially developed roots.40 213.Canal size same as uncomplicated. Conservative root canal therapy includes treatment plan. clinical procedures with appropriate follow up care. require additional time and care.30 68. biomechanical preparation. pulpectomy. as a result of a previous treatment. but made complicated by virtue of shape and anatomy e. Such situations could merit an additional fee. dilacerated. internal/external resorption Calcified Canals . unfavourable tooth inclination.50 119. which.10 33000 ROOT CANAL THERAPY To include: treatment plan. chemotherapeutic treatment and obturation). as a separate procedure 32232 Primary Tooth.e. arborized.60 265. 33100 ROOT CANALS: PERMANENT TEETH/RETAINED PRIMARY TEETH Includes: Clinical procedures with appropriate radiographs.20 80. taurodont. with appropriate radiographs. s-shaped. excluding final restoration.30 134.40 162.g.20 262. excluding final restoration. 00 176.50 112.80 914.004.00 1. TWO CANALS Two Canals Difficult Access Exceptional Anatomy Calcified Canals Retreatment of Previously Completed Therapy 633. FOUR OR MORE CANALS Four or More Canals Difficult Access Exceptional Anatomy Calcified Canals Retreatment of Previously Completed Therapy 33600 APEXIFICATION/APEXOGENESIS/INDUCTION OF HARD TISSUE REPAIR (to include biomechanical preparation and placement of dentogenic media) 33601 One Canal 33602 Two Canals 33603 Three Canals 33604 Four or More Canals 33610 33611 33612 33613 33614 28 RE-INSERTION OF DENTOGENIC MEDIA PER VISIT One Canal Two Canals Three Canals Four or More Canals 901. ONE CANAL One Canal Difficult Access Exceptional Anatomy Calcified Canal Retreatment of Previously Completed Therapy 472.004.70 99. THREE CANALS Three Canals Difficult Access Exceptional Anatomy Calcified Canals Retreatment of Previously Completed Therapy 783.20 535.60 85.00 1.00 1.50 329.20 ROOT CANALS: PERMANENT TEETH/RETAINED PRIMARY TEETH.70 ROOT CANALS: PERMANENT TEETH/RETAINED PRIMARY TEETH.10 77.70 780.00 780.10 914.20 396.00 1.00 250.004.80 914.004.2013 Alberta Blue Cross Dental Schedule 33110 33111 33112 33113 33114 33115 33120 33121 33122 33123 33124 33125 33130 33131 33132 33133 33134 33135 33140 33141 33142 33143 33144 33145 General Practitioner • ENDODONTICS ROOT CANALS: PERMANENT TEETH/RETAINED PRIMARY TEETH.80 914.20 535.70 780.20 .20 535.90 535.80 ROOT CANALS: PERMANENT TEETH/RETAINED PRIMARY TEETH.70 780. 10 34140 MANDIBULAR ANTERIOR 34141 One Root 34142 Two or More Roots 364.20 112.60 476.20 112.60 472.20 34220 34221 34222 34223 34224 MAXILLARY BICUSPID One Canal Two Canals Three Canals Four or More Canals 75.20 162.20 506.90 213.90 213.10 548.50 34240 MANDIBULAR ANTERIOR 34241 One Canal 34242 Two or More Canals 75.00 34160 34161 34162 34163 MANDIBULAR MOLAR One Root Two Roots Three or More Roots 435.20 112.20 162.20 112.60 697.10 34200 RETROFILLING 34210 MAXILLARY ANTERIOR 34211 One Canal 34212 Two or More Canals 75.60 34120 34121 34122 34123 MAXILLARY BICUSPID One Root Two Roots Three Roots 374.80 709.80 34150 34151 34152 34153 MANDIBULAR BICUSPID One Root Two Roots Three or More Roots 394.2013 Alberta Blue Cross Dental Schedule General Practitioner • ENDODONTICS 34000 PERIAPICAL SERVICES 34100 APICOECTOMY/APICAL CURETTAGE 34110 MAXILLARY ANTERIOR 34111 One Root 34112 Two Roots 356.80 499.50 34230 34231 34232 34233 34234 MAXILLARY MOLAR One Canal Two Canals Three Canals Four or More Canals 75.20 29 .40 547.80 564.70 34130 34131 34132 34133 MAXILLARY MOLAR One Root Two Roots Three or More Roots 422.20 433. 20 162.20 184.2013 Alberta Blue Cross Dental Schedule General Practitioner • ENDODONTICS 34250 34251 34252 34253 34254 MANDIBULAR BICUSPID One Canal Two Canals Three Canals Four or More Canals 75.20 184.90 213.90 34400 SURGICAL SERVICES: MISCELLANEOUS 34410 AMPUTATIONS: ROOT (INCLUDES RECONTOURING TOOTH AND FURCA) 34411 One Root 34412 Two Roots 315.50 34260 34261 34262 34263 34264 MANDIBULAR MOLAR One Canal Two Canals Three Canals Four or More Canals 75.90 213.30 755.20 112.70 562.20 585.10 34360 34361 34362 34363 MANDIBULAR MOLAR One Root Two Roots Three Roots 475.50 510.60 34420 34421 34422 34423 184.50 515.20 162.70 378.20 615.90 584.20 112.00 34340 MANDIBULAR ANTERIOR 34341 One Root 34342 Two Or More Roots 420.50 34300 RETREATMENT: APICOECTOMY/APICAL CURETTAGE 34310 MAXILLARY ANTERIOR 34311 One Root 34312 Two Roots 390.00 34320 34321 34322 34323 MAXILLARY BICUSPID One Root Two Roots Three Roots 410.80 743.50 34350 34351 34352 34353 MANDIBULAR BICUSPID One Root Two Roots Three Roots 420.50 552.50 34330 34331 34332 34333 MAXILLARY MOLAR One Root Two Roots Three Roots 452.20 30 HEMISECTION Maxillary Bicuspid Maxillary Molar Mandibular Molar .80 492. 20 381.70 370. EXPLORATORY Maxillary Anterior Maxillary Bicuspid Maxillary Molar Mandibular Anterior Mandibular Bicuspid Mandibular Molar 34450 REMOVAL: INTENTIONAL. 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 OPEN AND DRAIN (SEPARATE EMERGENCY PROCEDURES) 39201 Anteriors and Bicuspids 39202 Molars 39210 OPENING THROUGH ARTIFICIAL CROWN (IN ADDITION TO PROCEDURES) 39211 Anteriors and Bicuspids 39212 Molars 114. NON-SURGICAL 34511 Per Tooth PERFORATIONS/RESORPTIVE DEFECT(S): PULP CHAMBER REPAIR. OF TOOTH.80 34520 265.30 34440 34441 34442 34443 34444 34445 34446 147.40 173.2013 Alberta Blue Cross Dental Schedule General Practitioner • ENDODONTICS 34430 DECOMPRESSION: PERIO-RADICULAR LESION 34431 First Visit 34432 Each Additional Visit 266.30 201.40 39000 ENDODONTIC: PROCEDURES.40 147.40 SURGERY: ENDODONTIC.90 34602 In Calcified Canals 191. APICAL FILLING AND REPLANTATION (SPLINTING ADDITIONAL) 34451 Single Rooted Tooth 34452 Two Rooted Tooth 34453 Three Rooted Tooth or More 254.50 72.40 34600 ENLARGEMENT: CANAL AND/OR PULP CHAMBER (PREPARATION OF POST SPACE) 34601 In Previously Filled Tooth when Root Canal Treatment Done by Another Practitioner 63. SURGICAL 34521 Anterior Tooth 34522 Bicuspid Tooth 34523 Molar Tooth 181.30 201.30 34500 PERFORATIONS 34510 PERFORATIONS/RESORPTIVE DEFECT(S): PULP CHAMBER REPAIR.60 88. OR ROOT REPAIR.70 133.00 88.00 31 .60 72.40 173.90 424. OR ROOT REPAIR.20 460. 00 .50 39400 EXPLORATORY ACCESS THROUGH CLINICAL CROWN OF PREVIOUSLY TREATED TOOTH 39410 39411 39412 39413 32 EXPLORATORY ACCESS Anterior Bicuspid Molar 75.00 75.50 109.2013 Alberta Blue Cross Dental Schedule General Practitioner • ENDODONTICS 39300 BLEACHING: NON VITAL 39310 39311 39312 39313 39319 BLEACHING: ENDODONTICALLY TREATED TOOTH/TEETH One Unit of Time Two Units of Time Three Units of Time Each Additional Unit Over Three 54.50 54.00 163.00 75. g.) 41301 One Unit of Time 41302 Two Units of Time 41309 Each Additional Unit Over Two 54.40 255. 41000 PERIODONTAL SERVICES: NON SURGICAL 41200 ORAL DISEASE: MANAGEMENT OF 41210 41211 41212 41213 41214 41219 41220 41221 41222 41223 41224 41229 41230 41231 41232 41233 41234 41239 ORAL MANIFESTATIONS: ORAL MUCOSAL DISORDERS.50 290.e. One Time Unit Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 63. neoplasms. dysfunction. post injection trismus. burning mouth syndrome.80 127.g. lichen planus. e.20 63. Disorders of facial sensation and motor dysfunction at the jaw. In most instances the time required to perform a certain procedure could. post operative neuropathics. muscular and joint pain syndrome.60 191.50 41300 DESENSITIZATION (THIS MAY INVOLVE APPLICATION AND BURNISHING OF MEDICINAL AIDS ON ROOT OR THE USE OF A VARIETY OF THERAPEUTIC PROCEDURES. and usually does. e.2013 Alberta Blue Cross Dental Schedule General Practitioner • PERIODONTICS PERIODONTICS In the treatment of periodontal diseases. 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. post surgical or radiation therapy. salivary and gland tumours.80 ORAL MANIFESTATIONS OF SYSTEMIC DISEASE or complications of medical therapy e. fibroma. trigeminal neuralgia. variables such as the severity of the patient’s periodontal condition and the distribution (i. dyskenesia.80 NERVOUS AND MUSCULAR DISORDERS. verrucae. hairy leukoplakia.60 191. haemophilia) One Unit of Time Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 72. One Time Unit Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 63. atypical facial pain.00 54.00 33 . MORE THAN ONE APPOINTMENT MAY BE NECESSARY. complications of chemotherapy.g.00 217. aphthous stomatitis. atypical odontologia. etc.50 145. radiation therapy. extent) of the condition may require a relatively wide selection of therapeutic procedures and involve considerable variation in time and expense. polyps. pemphigus.20 63. benign mucous membrane pemphigoid.00 108. leukoplakia with and without dysphasia. diabetes and bleeding disorders (e.40 255.00 72. oral manifestations of lupus erythematosis and systemic disease including leukemia.80 127.g. Mucocutaneous disorders and diseases of localized mucosal conditions. 10 42330 GINGIVAL FIBER INCISION (SUPRA CRESTAL FIBROTOMY) 42331 First Tooth 42339 Each Additional Tooth 116. SOFT TISSUE 42510 GRAFTS: SOFT TISSUE. WHEN THE POCKET IS UNCOMPLICATED BY EXTENSION INTO THE UNDERLYING BONE.30 42500 PERIODONTAL SURGERY: FLAPS.80 42400 PERIODONTAL SURGERY: FLAP APPROACH 42410 FLAP APPROACH: WITH OSTEOPLASTY/OSTECTOMY 42411 Per Sextant 838. SUTURING AND THE PLACEMENT AND REMOVAL OF INITIAL SURGICAL DRESSING.80 40.50 59.70 42300 PERIODONTAL SURGERY: GINGIVECTOMY (THE PROCEDURE BY WHICH GINGIVAL DEFORMITIES ARE REDUCED AND RESHAPED TO CREATE NORMAL AND FUNCTIONAL FORM.40 42430 FLAP APPROACH: WITH CURETTAGE OF OSSEOUS DEFECT AND OSTEOPLASTY 42431 Per Sextant 42440 FLAP APPROACH: EXPLORATORY (FOR DIAGNOSIS) 42441 Per Site 733. A SURGICAL SITE IS AN AREA THAT LENDS ITSELF TO ONE OR MORE PROCEDURES. DOES NOT INCLUDE LIMITED RE-CONTOURING TO FACILITATE RESTORATIVE SERVICES). SEXTANT OR GROUP OF TEETH OR IN SOME CASES A SINGLE TOOTH.00 42420 FLAP APPROACH: WITH CURETTAGE OF OSSEOUS DEFECT 42421 Per Sextant 649.2013 Alberta Blue Cross Dental Schedule General Practitioner • PERIODONTICS 42000 PERIODONTAL SERVICES: SURGICAL (INCLUDES LOCAL ANAESTHETIC.50 403.60 42320 GINGIVECTOMY: WITH CURETTAGE 42321 Per Sextant 293. GRAFTS. PEDICLE (INCLUDING APICALLY OR LATERAL SLIDING AND ROTATED FLAPS) 42511 Per Site 42512 Periosteal Stimulation in addition to 42511 34 493. 42310 GINGIVECTOMY: UNCOMPLICATED 42311 Per Sextant 245. IT IS CONSIDERED TO INCLUDE A FULL QUADRANT.) 42100 PERIODONTAL SURGERY: GINGIVAL CURETTAGE 42110 SURGICAL CURETTAGE: TO INCLUDE DEFINITIVE ROOT PLANING 42111 Per Sextant 42200 PERIODONTAL SURGERY: GINGIVOPLASTY (DOES NOT INCLUDE LIMITED RECONTOURING TO FACILITATE RESTORATIVE SERVICES) 42201 Per Sextant 233.00 .60 235. Per Site 42703 Guided Tissue Regeneration – Non-resorbable Membrane.20 +E 1. PEDICLE.00 42580 GRAFTS: GINGIVAL ONLAY (FOR RIDGE AUGMENTATION) 42581 Per Site 542. PEDICLE (CORONALLY POSITIONED) 42521 Per Site 42522 Periosteal Stimulation in addition to 42521 540.178. OSSEOUS. OSSEOUS. PEDICLE WITH FREE GRAFT FOR ROOT COVERAGE 42571 Per Site 796.20 +E 42630 GRAFTS.178.20 +E 1.20 42720 +E 35 .00 42530 GRAFTS: FREE SOFT TISSUE 42531 Per Site 540.20 +E 42700 GUIDED TISSUE REGENERATION 42701 Guided Tissue Regeneration – Non-resorbable Membrane.00 42570 GRAFTS: CONNECTIVE TISSUE. OSSEOUS TISSUE 42610 GRAFTS.2013 Alberta Blue Cross Dental Schedule General Practitioner • PERIODONTICS 42520 GRAFTS: SOFT TISSUE. AUTOGRAFT (INCLUDING FLAP ENTRY.90 42560 GRAFTS: FREE CONNECTIVE TISSUE (FOR RIDGE AUGMENTATION) 42561 Per Site 796. WITH FREE GRAFT PLACED IN PEDICLE DONOR SITE 42541 Per Site 574. ONLAY (FOR RIDGE AUGMENTATION) 42591 Autograft – Per Site 42592 Allograft – Per Site 542.20 42620 GRAFTS. GRAFTS. Per Site 42702 Guided Tissue Regeneration – Resorbable Membrane. OSSEOUS.10 42540 GRAFTS: SOFT TISSUE.70 +E 42600 PERIODONTAL SURGERY: FLAPS.10 59.70 42590 GRAFTS: DERMAL.70 542. Surgical Re-entry for Removal BIOLOGICAL MATERIALS TO AID IN SOFT AND OSSEOUS TISSUE REGENERATION (NOT INCLUDING SURGICAL ENTRY AND CLOSURE) 42721 Per Site 1. CLOSURE AND DONOR SITE) 42611 Per Site 732. ALLOGRAFT (INCLUDING FLAP ENTRY AND CLOSURE) 42621 Per Site 732.178.ZENOGRAFT (INCLUDING FLAP ENTRY AND CLOSURE) 42631 Per Site 732.90 42550 GRAFTS: FREE CONNECTIVE TISSUE (FOR ROOT COVERAGE) 42551 Per Site 574. 43110 “A” SPLINT (RESTORATIVE MATERIAL PLUS WIRE.60 186. Per Site 42820 42821 42822 42823 42829 42830 42831 42832 42833 42834 42839 370.2013 Alberta Blue Cross Dental Schedule General Practitioner • PERIODONTICS 42800 PERIODONTAL SURGERY: MISCELLANEOUS PROCEDURES 42810 PROXIMAL WEDGE PROCEDURE (AS A SEPARATE PROCEDURE) 42811 With Flap Curettage.10 43230 WIRE LIGATION 43231 Per Joint 52.50 43000 PERIODONTAL PROCEDURES: ADJUNCTIVE (WHEN PER JOINT IS DESIGNATED. EXTRA CORONAL 43220 BONDED. WHERE THE TOOTH TO THE RIGHT OF THE JOINT IS UTILIZED.30 42840 FLAP APPROACH FOR CREATION OF INTERDENTAL PAPILLAE 42841 Per Site 493. FIBRE RIBBON OR ROPE) 43111 Per Joint 59. SCALING.30 124. Per Site 42819 With Flap Curettage and Ostectomy/Osteoplasty. EXCEPT AT THE MIDLINE. SURGERY OR MEDICATION One Unit of Time Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 62.40 PERIODONTAL ABSCESS OR PERICORONITIS.70 POST SURGICAL PERIODONTAL TREATMENT VISIT PER DRESSING CHANGE One Unit of Time Two Units of Time Three Units of Time Each Additional Unit Over Three 58.60 +E 43200 PERIODONTAL SPLINT OR LIGATION: PROVISIONAL. THE CORRESPONDING TOOTH CODE IS REPRESENTED BY THE MESIAL OF THE TOOTH INVOLVED. INTERPROXIMAL ENAMEL SPLINT 43221 Per Joint 64.80 +L 36 . MAY INCLUDE ANY ONE OF THE FOLLOWING PROCEDURES: LANCING.20 58.60 +E 43270 CAST/SOLDERED/CERAMIC/POLYMER GLASS SPLINT BONDED 43271 Per Abutment 83. CURETTAGE.20 62.00 43240 WIRE LIGATION. INTRA CORONAL Note: This procedure is in addition to the usual code for the tooth restoration on either side.60 43260 ORTHODONTIC BAND SPLINT 43261 Per Band 59.60 451.) 43100 PERIODONTAL SPLINT OR LIGATION: PROVISIONAL.80 175.40 116.90 249. RESTORATIVE MATERIAL COVERED 43241 Per Joint 59. 80 24.60 149.20 249.40 +E 37 . 49101 One Unit of Time 49102 Two Units of Time 49109 Each Additional Unit Over Two 53.60 59.60 43400 ROOT PLANING: PERIODONTAL 43420 43421 43422 43423 43424 43425 43426 43427 43429 ROOT PLANING One Unit of Time Two Units of Time Three Units of Time Four Units of Time Five Units of Time Six Units of Time 1/2 Unit of Time Each Additional Unit Over Six 49.40 49200 PERIODONTAL IRRIGATION: SUBGINGIVAL 49210 PERIODONTAL IRRIGATION: SUBGINGIVAL 49211 One Unit of Time 49219 Each Additional Unit of Time 57.80 99.60 +E 62.80 43500 CHEMOTHERAPEUTIC AND/OR ANTIMICROBIAL AGENTS 43510 CHEMOTHERAPEUTIC AND/OR ANTIMICROBIAL AGENTS: TOPICAL APPLICATION 43511 One Unit of Time 43519 Each Additional Unit of Time CHEMOTHERAPEUTIC AND/OR ANTIMICROBIAL THERAPY: INTRASULCULAR APPLICATION 43521 One Unit of Time 43529 Each Additional Unit of Time 53.40 53.60 +E 49000 PERIODONTAL SERVICES: MISCELLANEOUS 49100 PERIODONTAL RE-EVALUATION/EVALUATION Note: This follow-up service applies to the evaluation of ongoing periodontal treatment or to a post-surgical re-evaluation performed more than one (1) month after surgery.40 199.80 53.40 +E 57.2013 Alberta Blue Cross Dental Schedule General Practitioner • PERIODONTICS 43280 REMOVAL OF FIXED PERIODONTAL SPLINTS 43281 One Unit of Time 43289 Each Additional Unit of Time 59.40 43520 62. or if performed by another practitioner.00 298.40 106.90 49. 2013 Alberta Blue Cross Dental Schedule 38 General Practitioner • PERIODONTICS . REMOVABLE PROSTHODONTICS .10 +L 925.90 +L 425. STANDARD 51101 Maxillary 51102 Mandibular 51104 Liners: Processed.10 +L 51500 DENTURES: COMPLETE. separate fees 51000 DENTURES COMPLETE (INCLUDES: IMPRESSIONS. COMPLEX 51201 Maxillary 51202 Mandibular 51204 Liners: Processed.60 +L 51400 DENTURES: SURGICAL. Resilient.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS . INCLUDING THREE MONTHS POST INSERTION CARE) 51100 DENTURES: COMPLETE. (IMMEDIATE) (INCLUDES FIRST TISSUE CONDITIONER.60 +L 674. PROVISIONAL 51601 Maxillary 51602 Mandibular BR BR 425. Special aesthetic and functional laboratory costs beyond normal laboratory charges will require an increase over the basic fee. COMPLEX.90 +L 39 . (IMMEDIATE) (INCLUDES FIRST TISSUE CONDITIONER. GNATHOLOGICAL (CAST BASE AND METAL OCCLUSALS) 51501 Maxillary 51502 Mandibular 51600 DENTURES: COMPLETE.10 +L 925. in addition to above 925. BUT NOT A PROCESSED RELINE) 51301 Maxillary 51302 Mandibular 674.REMOVABLE Special aesthetic and anatomical considerations involving additional chair time and/or responsibility may require an increase over the basic fee. Diagnosis and Treatment Plan . INITIAL AND FINAL JAW RELATION RECORDS.Refer to Diagnostic Services. INSERTION AND ADJUSTMENTS. STANDARD. Examination. BUT NOT A PROCESSSED RELINE) 51401 Maxillary 51402 Mandibular 925. Resilient.10 +L LAB 51300 DENTURES: SURGICAL.60 +L LAB 51200 DENTURES: COMPLETE. TRY-IN EVALUATION AND CHECK RECORDS. in addition to above 674.60 +L 674. BUT NOT A PROCESSED RELINE) 51811 Maxillary 51812 Mandibular 674. TISSUE BORNE. SUPPORTED BY IMPLANTS WITH OR WITHOUT COPING CROWNS.60 +L 51920 DENTURES: COMPLETE. NO ATTACHMENTS 51731 Maxillary 51732 Mandibular 674.60 +L 51720 DENTURES: COMPLETE. TISSUE BORNE. (IMMEDIATE).60 +L 674. TISSUE BORNE.60 +L 51800 DENTURES: COMPLETE. SUPPORTED BY A COMBINATION OF NATURAL TEETH AND IMPLANTS WITH OR WITHOUT COPING CROWNS. NO ATTACHMENTS 51710 DENTURES: COMPLETE. TISSUE BORNE.60 +L 674. NO ATTACHMENTS 51721 Maxillary 51722 Mandibular 674. OVERDENTURES. TISSUE BORNE. WITH OR WITHOUT COPING CROWNS. WITH INDEPENDENT ATTACHMENTS SECURED TO A COMBINATION OF NATURAL TEETH AND IMPLANTS WITH OR WITHOUT COPING CROWNS 51931 Maxillary 51932 Mandibular BR +L BR +L 51930 40 BR +L BR +L .60 +L 51900 DENTURES: COMPLETE. TISSUE BORNE. OVERDENTURES. OVERDENTURES. WITH INDEPENDENT ATTACHMENTS SECURED TO IMPLANTS WITH OR WITHOUT COPING CROWNS 51921 Maxillary 51922 Mandibular 674. TISSUE BORNE. OVERDENTURES. WITH OR WITHOUT COPING CROWNS. SECURED BY ATTACHMENTS TO NATURAL TEETH OR IMPLANTS 51910 DENTURES: COMPLETE. OVERDENTURES. WITH INDEPENDENT ATTACHMENTS SECURED TO NATURAL TEETH WITH OR WITHOUT COPING CROWNS 51911 Maxillary 51912 Mandibular DENTURES: COMPLETE. SUPPORTED BY NATURAL TEETH. SUPPORTED BY NATURAL TEETH WITH OR WITHOUT COPING CROWNS. TISSUE BORNE.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS . OVERDENTURES. TISSUE BORNE. NO ATTACHMENTS 51810 DENTURES: COMPLETE. OVERDENTURES.60 +L 674. OVERDENTURES. (IMMEDIATE).REMOVABLE 51700 DENTURES: COMPLETE. TISSUE BORNE. NO ATTACHMENTS 51711 Maxillary 51712 Mandibular DENTURES: COMPLETE.60 +L 51730 674. WITH OR WITHOUT COPING CROWNS. OVERDENTURES. SUPPORTED BY NATURAL TEETH OR IMPLANTS. NO ATTACHMENTS (INCLUDES FIRST TISSUE CONDITIONER. OVERDENTURES.60 +L 674. SUPPORTED BY NATURAL TEETH OR IMPLANTS.60 +L 674. 30 +L 52300 DENTURES: PARTIAL.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS . RESILIENT RETAINER. TISSUE BORNE. OVERDENTURES.50 +L 41 .40 +L 345.40 +L 52110 52200 DENTURES: PARTIAL. WITH METAL WROUGHT/CAST CLASPS AND/OR RESTS 52301 Maxillary 452. ACRYLIC. WITH OR WITHOUT CLASPS (PROVISIONAL) 52101 Maxillary 52102 Mandibular DENTURES: PARTIAL.30 +L 52210 345.40 +L 238. BUT NOT A PROCESSED RELINE) 52211 Maxillary 52212 Mandibular 238. ACRYLIC BASE. SECURED TO COPING CROWNS SUPPORTED BY IMPLANTS 51951 Maxillary 51952 Mandibular DENTURES: COMPLETE.30 +L 345. WITH RETENTION FROM A RETENTIVE BAR.50 +L 52402 Mandibular 452. (IMMEDIATE) (INCLUDES FIRST TISSUE CONDITIONER. ACRYLIC 52100 DENTURES: PARTIAL.REMOVABLE 51950 DENTURES: COMPLETE. SECURED TO COPING CROWNS SUPPORTED BY A COMBINATION OF NATURAL TEETH AND IMPLANTS (SEE 62105 FOR RETENTIVE BAR) 51961 Maxillary 51962 Mandibular BR +L BR +L 51960 BR +L BR +L 52000 DENTURES: PARTIAL. ACRYLIC. (IMMEDIATE) (INCLUDES FIRST TISSUE CONDITIONER. TISSUE BORNE.50 +L 52302 Mandibular 452. ACRYLIC. RESILIENT RETAINER 52201 Maxillary 52202 Mandibular DENTURES: PARTIAL. ACRYLIC. (IMMEDIATE) (INCLUDES FIRST TISSUE CONDITIONER. BUT NOT A PROCESSED RELINE) 52311 Maxillary 52312 Mandibular 452. OVERDENTURES. ACRYLIC BASE.50 +L 452. WITH METAL WROUGHT/CAST CLASPS AND/OR RESTS.40 +L 238.50 +L 52310 DENTURES: PARTIALS. WITH RETENTION FROM A RETENTIVE BAR. ACRYLIC.30 +L 345. BUT NOT A PROCESSED RELINE) 52111 Maxillary 52112 Mandibular 238.50 +L 52400 DENTURES: PARTIAL. WITH METAL WROUGHT PALATAL/LINGUAL BAR AND CLASPS AND/OR RESTS 52401 Maxillary 452. 90 +L 52720 DENTURES: PARTIAL.90 +L . OVERDENTURES. ACRYLIC. BUT NOT A PROCESSED RELINE) 52411 Maxillary 52412 Mandibular 52510 52511 52512 52513 DENTURES: PARTIAL.90 +L 600. ACRYLIC. WITH CAST/WROUGHT CLASPS AND/OR RESTS SUPPORTED BY A COMBINATION OF NATURAL TEETH AND IMPLANTS WITH OR WITHOUT COPING CROWNS. NO ATTACHMENTS 52711 Maxillary 52712 Mandibular DENTURES: PARTIAL.REMOVABLE 52410 DENTURES: PARTIAL.90 +L 52800 DENTURES: PARTIAL. OVERDENTURES. OVERDENTURES (IMMEDIATE). ACRYLIC. BUT NOT A PROCESSED RELINE) 52821 Maxillary 52822 Mandibular 600. WITH CAST/WROUGHT CLASPS AND/OR RESTS SUPPORTED BY IMPLANTS WITH OR WITHOUT COPING CROWNS. ACRYLIC. NON METAL. OVERDENTURES (IMMEDIATE). WITH METAL WROUGHT PALATAL/LINGUAL BAR AND CLASPS AND/OR RESTS. NO ATTACHMENTS (INCLUDES FIRST TISSUE CONDITIONER. NO ATTACHMENTS 52731 Maxillary 52732 Mandibular 600. (IMMEDIATE) (INCLUDES FIRST TISSUE CONDITIONER.50 +L 452.90 +L 600. NO ATTACHMENTS (INCLUDES FIRST TISSUE CONDITIONER.90 +L 52730 600. NO ATTACHMENTS 52810 DENTURES: PARTIAL. ACRYLIC. WITH CAST/WROUGHT CLASPS AND/OR RESTS SUPPORTED BY NATURAL TEETH OR IMPLANTS WITH OR WITHOUT COPING CROWNS.90 +L 600.00 +L 52700 DENTURES: PARTIAL.40 +L 238.40 +L 477.50 +L 238. WITH CAST/WROUGHT CLASPS AND/OR RESTS SUPPORTED BY IMPLANTS WITH OR WITHOUT COPING CROWNS. WITH CAST/WROUGHT CLASPS AND/OR RESTS SUPPORTED BY NATURAL TEETH WITH OR WITHOUT COPING CROWNS.90 +L 600.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS . BUT NOT A PROCESSED RELINE) 52811 Maxillary 52812 Mandibular DENTURES: PARTIAL. NO ATTACHMENTS 52710 DENTURES: PARTIAL. ACRYLIC.90 +L 600. NON ACRYLIC) Maxillary Mandibular Maxillary plus Mandibular 452. ACRYLIC. OVERDENTURES. NO ATTACHMENTS 52721 Maxillary 52722 Mandibular 600. OVERDENTURES (IMMEDIATE). OVERDENTURES.90 +L 52820 42 600. ACRYLIC. (FLEXIBLE. WITH CAST/WROUGHT CLASPS AND/OR RESTS SUPPORTED BY NATURAL TEETH OR IMPLANTS WITH OR WITHOUT COPING CROWNS. WITH CAST/WROUGHT CLASPS AND/OR RESTS SUPPORTED BY NATURAL TEETH WITH OR WITHOUT COPING CROWNS. OVERDENTURES.90 +L 600.90 +L 600. OVERDENTURES.90 +L 52940 DENTURES: PARTIAL. ACRYLIC.90 +L 52960 600. BUT NOT A PROCESSED RELINE) 52831 Maxillary 52832 Mandibular BR +L BR +L 52900 DENTURES: PARTIAL. SECURED TO COPING CROWNS. OVERDENTURES.90 +L 600.90 +L 43 . 28225. NO ATTACHMENTS (INCLUDES FIRST TISSUE CONDITIONER.90 +L 52950 DENTURES: PARTIAL. WITH CAST/WROUGHT CLASPS AND/OR RESTS WITH INDEPENDENT ATTACHMENTS SECURED TO A COMBINATION OF NATURAL TEETH AND IMPLANTS WITH OR WTHOUT COPING CROWNS (USED WITH 26101.90 +L 600.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS . ACRYLIC.90 +L 52920 DENTURES: PARTIAL. SUPPORTED BY IMPLANTS (SEE 62105 FOR RETENTIVE BAR) 52951 Maxillary 52952 Mandibular 600. WITH CAST/WROUGHT CLASPS AND/OR RESTS WITH RETENTION FROM A RETENTIVE BAR. WITH CAST/WROUGHT CLASPS AND/OR RESTS SECURED BY NATURAL TEETH OR IMPLANTS 52910 DENTURES: PARTIAL. 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 DENTURES: PARTIAL.REMOVABLE 52830 DENTURES: PARTIAL. SECURED TO COPING CROWNS. OVERDENTURES. OVERDENTURES.90 +L 600. WITH CAST/WROUGHT CLASPS AND/OR RESTS SUPPORTED BY A COMBINATION OF NATURAL TEETH AND IMPLANTS WITH OR WITHOUT COPING CROWNS.90 +L 600. SECURED TO COPING CROWNS. ACRYLIC. ACRYLIC. ACRYLIC. OVERDENTURES (IMMEDIATE). 28226 (CAST METAL COPING CROWNS) WITH OR WITHOUT ATACHMENTS) 52931 Maxillary 52932 Mandibular 600. WITH CAST/WROUGHT CLASPS AND/OR RESTS WITH RETENTION FROM A RETENTIVE BAR. ACRYLIC. WITH CAST/WROUGHT CLASPS AND/OR RESTS WITH RETENTION FROM A RETENTIVE BAR. SUPPORTED BY NATURAL TEETH (SEE 62105 FOR RETENTIVE BAR) 52941 Maxillary 52942 Mandibular 600. ACRYLIC. ACRYLIC. OVERDENTURES. WITH CAST/WROUGHT CLASPS AND/OR RESTS WITH INDEPENDENT ATTACHMENTS SECURED TO IMPLANTS WITH OR WITHOUT COPING CROWNS 52921 Maxillary 52922 Mandibular 600. OR 28221. 26103 (MESOSTRUCTURES).90 +L 52930 DENTURES: PARTIAL. OVERDENTURES. SUPPORTED BY A COMBINATION OF NATURAL TEETH AND IMPLANTS (SEE 62105 FOR RETENTIVE BAR) 52961 Maxillary 52962 Mandibular 600. 90 +L 285.197. (EQUILIBRATED) 53221 Maxillary 1. (IMMEDIATE) (INCLUDES FIRST TISSUE CONDITIONER.20 +L 53220 DENTURES: PARTIAL.10 +L 53200 DENTURES: PARTIAL.90 +L 778.10 +L 53132 Mandibular 1. CLASPS AND REST 53201 Maxillary 53202 Mandibular 53205 Unilateral. One Piece Casting. CAST. CAST.197. FREE END. PRECISION ATTACHMENTS 53401 Maxillary 53402 Mandibular 53404 Altered Cast Impression Technique done in conjunction with above mentioned codes BR BR BR 53500 DENTURES: PARTIAL.00 +L 778. CLASPS AND REST. CAST FRAME/CONNECTOR.10 +L 53110 53120 DENTURES: PARTIAL.90 +L 746.REMOVABLE 53000 DENTURES: PARTIAL. SEMI-PRECISION ATTACHMENTS 53501 Maxillary 53502 Mandibular 53504 Altered Cast Impression Technique done in conjunction with above mentioned codes BR BR BR 44 . FREE END. BUT NOT A PROCESSED RELINE) 53111 Maxillary 53112 Mandibular 778.00 +L 191.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS . SWING LOCK/CONNECTOR 53121 Maxillary 53122 Mandibular 746. CLASPS AND REST. TOOTH BORNE.30 +L 53130 DENTURES: PARTIAL. BUT NOT A PROCESSED RELINE) 53211 Maxillary 53212 Mandibular 53215 Unilateral.40 +L 286. FREE END. (EQUILIBRATED) 53131 Maxillary 1. CLASPS AND RESTS 53101 Maxillary 53102 Mandibular 53104 Altered Cast Impression Technique in conjunction with 53101and 53102 DENTURES: PARTIAL. CAST FRAME/CONNECTOR. CAST WITH ACRYLIC BASE 53100 DENTURES: PARTIAL.40 +L 696. FREE END. CLASPS AND RESTS.10 +L 53400 DENTURES: PARTIAL.30 +L 778.10 +L 53222 Mandibular 1.90 +L 746. One Piece Casting.197. Clasps and Pontics DENTURES: PARTIAL. CAST FRAME/CONNECTOR. TOOTH BORNE. (IMMEDIATE) (INCLUDES FIRST TISSUE CONDITIONER. CAST FRAME/CONNECTOR.00 +L 53210 746. CAST FRAME/CONNECTOR.197. Clasps and Pontics 696. CLASPS AND RESTS. CAST FRAME/CONNECTOR. TOOTH BORNE. STRESS BREAKER ATTACHMENTS Maxillary (Resilient) BR Maxillary (One Hinge) BR Maxillary (Two Hinges) BR Altered Cast Impression Technique done in conjunction with above mentioned codes 191. CAST.40 +L 53812 Mandibular 867. CAST. STRESS BREAKER ATTACHMENTS 53610 53611 53612 53613 53614 53620 53621 53622 53623 53624 DENTURES. MAXILLARY. BUT NOT A PROCESSED RELINE) 53821 Maxillary 867.10 45 . SUPPORTED BY NATURAL TEETH WITH OR WITHOUT COPING CROWNS. OVERDENTURE. NO ATTACHMENTS 53711 Maxillary 867.40 +L 53734 Altered Cast Impression Technique done in conjunction with above mentioned codes 191. CAST PARTIAL.40 +L 53722 Mandibular 867. NO ATTACHMENTS 53731 Maxillary 867. BUT NOT A PROCESSED RELINE) 53811 Maxillary 867. OVERDENTURE. MANDIBULAR. NO ATTACHMENTS (INCLUDES FIRST TISSUE CONDITIONER. CAST PARTIAL.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS . CAST. CAST. NO ATTACHMENTS 53810 DENTURES: PARTIAL.REMOVABLE 53600 DENTURES: PARTIAL. NO ATTACHMENTS (INCLUDES FIRST TISSUE CONDITIONER. OVERDENTURE (IMMEDIATE).40 +L 53822 Mandibular 867.40 +L 53814 Altered Cast Impression Technique done in conjunction with above mentioned codes 191.40 +L 53714 Altered Cast Impression Technique done in conjunction with above mentioned codes 191.10 53800 DENTURES: PARTIAL.40 +L 53732 Mandibular 867.40 +L 53824 Altered Cast Impression Technique done in conjunction with above mentioned codes 191. OVERDENTURE.40 +L 53724 Altered Cast Impression Technique done in conjunction with above mentioned codes 191.10 DENTURES. CAST. SUPPORTED BY IMPLANTS WITH OR WITHOUT COPING CROWNS. OVERDENTURE. SUPPORTED BY NATURAL TEETH OR IMPLANTS WITH OR WITHOUT COPING CROWNS. OVERDENTURE (IMMEDIATE). NO ATTACHMENTS 53710 DENTURES: PARTIAL.10 53720 DENTURES: PARTIAL. SUPPORTED BY A COMBINATION OF NATURAL TEETH AND IMPLANTS WITH OR WITHOUT COPING CROWNS.10 53820 DENTURES: PARTIAL. SUPPORTED BY NATURAL TEETH WITH OR WITHOUT COPING CROWNS. NO ATTACHMENTS 53721 Maxillary 867.10 53730 DENTURES: PARTIAL.40 +L 53712 Mandibular 867. CAST. OVERDENTURE (IMMEDIATE). STRESS BREAKER ATTACHMENTS Mandibular (Resilient) BR Mandibular (One Hinge) BR Mandibular (Two Hinges) BR Altered Cast Impression Technique done in conjunction with above mentioned codes 191. SUPPORTED BY NATURAL TEETH WITH OR WITHOUT COPING CROWNS.10 53700 DENTURES: PARTIAL. SUPPORTED BY IMPLANTS WITH OR WITHOUT COPING CROWNS. CAST. CAST. 40 +L 53924 Altered Cast Impression Technique done in conjunction with above mentioned codes 191.40 +L 53922 Mandibular 867. OVERDENTURE. CAST. WITH INDEPENDENT ATTACHMENTS SECURED TO A COMBINATION OF NATURAL TEETH AND IMPLANTS. NO ATTACHMENTS (INCLUDES FIRST TISSUE CONDITIONER.10 53920 DENTURES: PARTIAL. WITH RETENTION FROM A RETENTIVE BAR.40 +L 53934 Altered Cast Impression Technique done in conjunction with above mentioned codes 191. CAST. WITH OR WITHOUT COPING CROWNS 53911 Maxillary 867. OVERDENTURE. CAST. OVERDENTURE. OVERDENTURE. CAST. CAST. WITH OR WITHOUT COPING CROWNS 53931 Maxillary 867.40 +L 53914 Altered Cast Impression Technique done in conjunction with above mentioned codes 191.40 +L .40 +L 867. WITH INDEPENDENT ATTACHMENTS SECURED TO IMPLANTS. SECURED BY ATTACHMENTS TO NATURAL TEETH OR IMPLANTS 53910 DENTURES: PARTIAL. BUT NOT A PROCESSED RELINE) 53831 Maxillary 867.10 53930 DENTURES: PARTIAL.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS .REMOVABLE 53830 DENTURES: PARTIAL. SECURED TO COPING CROWNS SUPPORTED BY NATURAL TEETH (SEE 62105 FOR RETENTIVE BAR) 53941 Maxillary 53942 Mandibular 46 867. CAST.40 +L 53834 Altered Cast Impression Technique done in conjunction with above mentioned codes 191.40 +L 53912 Mandibular 867. OVERDENTURE. OVERDENTURE (IMMEDIATE).10 53900 DENTURES: PARTIAL.40 +L 53932 Mandibular 867.10 53940 DENTURES: PARTIAL. WITH INDEPENDENT ATTACHMENTS SECURED TO NATURAL TEETH. WITH OR WITHOUT COPING CROWNS 53921 Maxillary 867. SUPPORTED BY A COMBINATION OF NATURAL TEETH AND IMPLANTS WITH OR WITHOUT COPING CROWNS.40 +L 53832 Mandibular 867. 60 +L 55000 DENTURES: REPAIRS/ADDITIONS 55100 DENTURES: REPAIR: COMPLETE DENTURE. CAST.40 +L 53952 Mandibular 867.60 +L 59. OVERDENTURE.40 +L 53964 Altered Cast Impression Technique done in conjunction with above mentioned codes 191.60 +L 402. MINOR 54201 One Unit of Time 54202 Two Units of Time 54209 Each Additional Unit Over Two 59. WITH CAST METAL OCCLUSAL SURFACES.70 +L 130.10 53960 DENTURES: PARTIAL.REMOVABLE 53950 DENTURES: PARTIAL. CAST.50 +L 47 .50 +L 130. OVERDENTURE.40 +L 53954 Altered Cast Impression Technique done in conjunction with above mentioned codes 191.40 +L 53962 Mandibular 867.60 +L 402.70 +L 65. SECURED TO COPING CROWNS SUPPORTED BY A COMBINATION OF NATURAL TEETH AND IMPLANTS (SEE 62105 FOR RETENTIVE BAR) 53961 Maxillary 867.10 54000 DENTURES: ADJUSTMENTS (AFTER THREE MONTHS INSERTION OR BY OTHER THAN THE DENTIST PROVIDING PROSTHESIS) 54200 DENTURE ADJUSTMENTS: PARTIAL OR COMPLETE DENTURE.50 +L 65.80 +L 119. WITH CAST METAL OCCLUSAL SURFACES.60 +L 54400 DENTURE ADJUSTMENTS: COMPLETE DENTURE. REMOUNT AND OCCLUSAL EQUILIBRATION 54401 Maxillary 54402 Mandibular 402. REMOUNT AND OCCLUSAL EQUILIBRATION 54501 Maxillary 54502 Mandibular 402. NO IMPRESSION REQUIRED 55301 Maxillary 55302 Mandibular 65. IMPRESSION REQUIRED 55201 Maxillary 55202 Mandibular 55300 DENTURES: REPAIRS/ADDITIONS: PARTIAL DENTURE. SECURED TO COPING CROWNS SUPPORTED BY IMPLANTS (SEE 62105 FOR RETENTIVE BAR) 53951 Maxillary 867.80 54300 DENTURE ADJUSTMENTS: PARTIAL OR COMPLETE DENTURE. WITH RETENTION FROM A RETENTIVE BAR.60 +L 402. WITH RETENTION FROM A RETENTIVE BAR. NO IMPRESSION REQUIRED 55101 Maxillary 55102 Mandibular 55200 DENTURES: REPAIR: COMPLETE DENTURE.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS .60 +L 54500 DENTURE ADJUSTMENTS: PARTIAL DENTURE.50 +L 65. REMOUNT AND OCCLUSAL EQUILIBRATION 54301 Maxillary 54302 Mandibular 402. 80 67. COMPLETE DENTURE 56211 Maxillary 56212 Mandibular 164.70 +L 55500 DENTURES/IMPLANT RETAINED PROSTHESIS: PROPHYLAXIS AND POLISHING 55501 One Unit of Time 55509 Each Additional Unit of Time 61.40 56230 DENTURE: RELINE. COMPLETE DENTURE 56231 Maxillary 56232 Mandibular 215.90 55600 DENTURES: REBUILDING WORN ACRYLIC DENTURE TEETH (DIRECT CHAIRSIDE) WITH TOOTH COLOURED MATERIALS 55601 One Unit of Time 55609 Each Additional Unit of Time 67. COMPLETE DENTURE 56251 Maxillary 56252 Mandibular 48 292.80 55700 DENTURES: CUSTOM STAINED (PIGMENTED) DENTURE BASES (DIRECT CHAIRSIDE) 55701 One Unit of Time 55709 Each Additional Unit of Time 67.80 +L 261.80 +L 56200 DENTURES: RELINING (DOES NOT INCLUDE REMOUNT . IMPRESSION REQUIRED 55401 Maxillary 55402 Mandibular 130.80 +L 56120 261.00 164. PROCESSED. COMPLETE DENTURE. PROCESSED.40 +L .40 151.40 +L 292.30 +L 56250 DENTURE: RELINE.REMOVABLE 55400 DENTURES: REPAIRS/ADDITIONS: PARTIAL DENTURE. PROCESSED.30 +L 176.10 +L 215. PARTIAL DENTURE.80 +L 261.80 67. (NO INTRA-ORAL IMPRESSION REQUIRED) 56111 Maxillary 56112 Mandibular DENTURES: REPLICATION.80 56000 DENTURES: REPLICATION. PROVISIONAL.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS . PROVISIONAL (NO INTRA-ORAL IMPRESSION REQUIRED) 56121 Maxillary 56122 Mandibular 261. PARTIAL DENTURE 56221 Maxillary 56222 Mandibular 151.10 +L 56240 DENTURE: RELINE. PROVISIONAL 56110 DENTURES: REPLICATION. DIRECT.70 +L 130.00 56220 DENTURE: RELINE. DIRECT. RELINING AND REBASING 56100 DENTURES: REPLICATION.90 +L 61. PARTIAL DENTURE 56241 Maxillary 56242 Mandibular 176.SEE 54000 SERIES) 56210 DENTURE: RELINE. FUNCTIONAL IMPRESSION REQUIRING THREE APPOINTMENTS. 90 to 353.90 +L 56330 DENTURE: REBASE.50 +L 56340 238. PROCESSED.60 +L 56530 DENTURE: TISSUE CONDITIONING. PER APPOINTMENT.60 +L 56520 DENTURE: TISSUE CONDITIONING.60 +L 94. PER APPOINTMENT. PARTIAL DENTURE 56521 Maxillary 56522 Mandibular 94.10 +L 56320 DENTURE: REBASE.10 +L 56400 DENTURES: REMAKE 56410 DENTURE: REMAKE. PROCESSED.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS .30 +L 56300 DENTURES: REBASING (WHERE THE VESTIBULAR TISSUE-CONTACTING SURFACES ARE MODIFIED) 56310 DENTURE: REBASE. PROCESSED. PARTIAL DENTURE 56261 Maxillary 56262 Mandibular 239. PARTIAL DENTURE (EQUILIBRATION) 56411 Maxillary 260.00 +L 56412 Mandibular 260.60 +L 94.00 +L 56500 DENTURES: THERAPEUTIC TISSUE CONDITIONING 56510 DENTURE: THERAPEUTIC TISSUE CONDITIONING. FUNCTIONAL IMPRESSION REQUIRING THREE APPOINTMENTS 56341 Maxillary 56342 Mandibular 290.10 +L 214.90 to 353.60 49 .60 94.90 +L 176. PER APPOINTMENT.60 56540 94. FUNCTIONAL IMPRESSION REQUIRING THREE APPOINTMENTS 56331 Maxillary 56332 Mandibular DENTURE: REBASE. USING EXISTING FRAMEWORK.30 +L 239.10 +L 238. PARTIAL DENTURE 56321 Maxillary 56322 Mandibular 176. FUNCTIONAL IMPRESSION REQUIRING THREE APPOINTMENTS. COMPLETE OVERDENTURE. IMPLANT SUPPORTED 56541 Maxillary 56542 Mandibular 94. COMPLETE DENTURE 56311 Maxillary 56312 Mandibular 214. COMPLETE OVERDENTURE. PER APPOINTMENT.REMOVABLE 56260 DENTURE: RELINE.50 +L 290. PARTIAL DENTURE.60 94. SUPPORTED BY NATURAL TEETH 56531 Maxillary 56532 Mandibular 94. COMPLETE DENTURE. COMPLETE DENTURE 56511 Maxillary 56512 Mandibular DENTURE: THERAPEUTIC TISSUE CONDITIONING. 10 to 853.60 56560 94.581. Complex 57106 Facial Moulage Impression.00 +L 426.10 +L 1.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS . Complete 57107 Facial Moulage Impression.020.20 208.40 to 597.60 to 1.020.20 +L BR 57000 PROSTHESIS: MAXILLOFACIAL 57100 PROSTHESIS: FACIAL 57101 Orbital 57102 Nose 57103 Ear 57104 Patch 57105 Facial. SUPPORTED BY NATURAL TEETH 56551 Maxillary 56552 Mandibular DENTURE: TISSUE CONDITIONING.10 to 853.10 to 853. PER APPOINTMENT.50 426.70 to 2.900.50 +L 597.20 +L 341. IMPLANT SUPPORTED 56561 Maxillary 56562 Mandibular 94.302.10 to 341.60 94.30 +L 278.60 94.10 to 341. PARTIAL OVERDENTURE.109.80 +L 341.10 +L .023. Sectional 57108 Ocular Conformer Prosthesis (Temporary Post-Surgical) 57109 Ocular Prosthesis 57200 PROSTHESIS: MAXILLOFACIAL.581.900.20 +L 88.10 to 853.70 to 3.20 +L 88.497.90 +L 88. PARTIAL OVERDENTURE.60 +L 2.40 +L 88.265.60 56600 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) LAB 202. PER APPOINTMENT.70 to 2.REMOVABLE 56550 DENTURE: TISSUE CONDITIONING.70 to 4.00 +L 1.40 +L 88. 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 50 2.30 to 2.70 +L 615.20 +L 88.40 to1. 80 to 855.40 +L 455.40 758.40 +L 1.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS .90 +L 57500 PROSTHESIS: SPLINTS 57501 Stout 57502 Cast Capped 57503 Gunning (upper and lower) 57504 Bar Splint: Cast.90 to 1.20 +L 1.80 +L 1.60 +L 175.275. Labial and Lingual 57505 Scaffolding: Rhinoplastic 57506 Cast: Adjustable 57508 Commissure Splint 57600 PROSTHESIS: STENTS 57601 Ridge Extension 57602 Palatal 57603 Skin Grafts 57604 Mucous Membrane Grafts 57650 57651 57652 57653 57654 PROSTHESIS: RADIATION APPLIANCES Radiation Vehicle Carrier Radiation Protection Shield (Extraoral) Radiation Protection Shield (Intraoral) Radiation Cone Locator 57660 PROSTHESIS: STENTS.061.90 to 1.80 +L 256.20 +L 57400 PROSTHESIS: TEMPOROMANDIBULAR JOINT 57401 Exerciser: Trismus.90 +L 878. 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 57307 Mesh Prosthesis: Chrome Cobalt Mandibular Mesh 57308 Skull Plate: Customized 57309 Akerman: Pseudotemporomandibular Joint (Prosthesis Extra) 57311 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.80 +L 1.10+L 758.023.80 +L 51 .20 to 2.109.061.30 to 2.80 +L BR BR BR BR 436.40 758.023.20 to1.40 758.558.30 to 1.40 +L 263.10 to 853.20 +L 758.558.20 +L 88. Therapy 57402 Splint: Permanent Cast Occlusal 698.405.20 +L 440.70 to 2.061.40 +L 758.80 +L 263.80 +L 1.10 to 853.70 to 1.30 to1.279. DECOMPRESSION 57661 Decompression Stent: Localized 57662 Decompression Stent (Prosthesis Extra) 57700 PROSTHESIS: ORTHOPEDIC 57701 Orthopedic Prosthesis: Extraoral 57702 Orthopedic Prosthesis: Intraoral 758. Fixed 57361 Palatal Augmentation Prosthesis 57371 Palatal Lift Prosthesis.365.80 +L BR 615.10 to 511.757.10 +L 758.50 +L 278.10 +L 615.365. Modification (relines or repairs) 57372 Gingival Prosthesis 88.061.20 +L 88.10 to1.023.061.REMOVABLE 57300 PROSTHESIS: MAXILLOFACIAL .70 +L 484.80 to 597.20 +L 511.80 +L 1.80 +L 1.60 to 853.40 +L +L +L +L 781. REMOVABLE .2013 Alberta Blue Cross Dental Schedule 52 General Practitioner • PROSTHODONTICS . PORCELAIN/CERAMIC/POLYMER GLASS 62501 Pontic: Porcelain/Ceramic/Polymer Glass Fused To Metal 62502 Pontic: Porcelain/Ceramic/Polymer Glass.60 +L 313. Fixed bridges (each abutment. Aluminous 315. with a separate code number) 62000 PONTICS: BRIDGE 62100 PONTICS: CAST METAL 62101 Pontic: Cast Metal 62102 Pontic: Cast Metal Framework With Separate Porcelain/Ceramic/Polymer Glass Jacket Pontic 62103 Pontic: Prefabricated Attachable Facing 62104 Pontic: Retentive Bar Prefabricated or custom (Dolder or Hader) Bar Attached To Retainer 62105 Pontic: Retentive Bar Prefabricated or custom (Dolder or Hader) Bar Attached To Implant Supported Retainer to Retain Removable Prosthesis.20 +L 315.70 70. Direct.FIXED PROSTHODONTICS . TRUE HINGE AXIS REGISTRATION AND TRANSFER 64121 One Unit of Time 64129 Each Additional Unit of Time 114.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS . each retainer and each pontic.50 63000 RECONTOURING OF RETAINERS/PONTICS (OF EXISTING BRIDGEWORK) 63001 One Unit of Time 63009 Each Additional Unit of Time +L +L +E +L 70.50 +L 53 .50 258. The amount of time involved in a procedure may vary considerably from those outlined in the following schedule.60 +L BR +L +E 62500 PONTICS. MAXILLO-MANDIBULAR REGISTRATIONS 64120 MASTER CAST TECHNIQUES.50 +L 114. involvement and expense. (Provisional) 62703 Pontic: Acrylic/Composite/Compomer. Bonded to adjacent teeth Direct (Provisional) 62704 Pontic: Acrylic/Composite/Compomer 315.70 64000 MASTER CAST TECHNIQUES 64100 MASTER CAST.FIXED Initial description: Fixed prosthodontic therapy requires the use of a variety of technical and therapeutic procedures depending on the nature of the problem presented in each individual case. Bonded To Adjacent Teeth (Provisional) 216. time. constitutes a separate unit in the bridge.60 +L 313. TECHNIQUES. Each Bar 313. Processed To Metal 62702 Pontic: Acrylic/Composite/Compomer. The range of these procedures extends into many areas of treatment in order to provide comprehensive therapy for the patient.90 62800 PONTICS: NATURAL TOOTH 62801 Pontic: Natural Tooth Crown.20 216.60 +L 313. Many of the procedures used vary considerably in their difficulty. Indirect.20 +L 62700 PONTICS: ACRYLIC/COMPOSITE/COMPOMER 62701 Pontic: Acrylic/Composite/Compomer.50 216. FIXED 64130 MASTER CAST TECHNIQUES.20 265.60 +L 66.80 66220 REPAIRS.60 66. CENTRIC REGISTRATION RECORDING 64131 One Unit of Time 64139 Each Additional Unit of Time MASTER CAST TECHNIQUES.80 199.20 +L 265.40 +L +L +L +L 66200 REPAIRS: REMOVAL OF EXISTING FIXED BRIDGE/PROSTHESIS 66210 66211 66212 66213 66214 66219 REPAIRS.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS .50 +L 64140 BR +L BR +L 64200 MASTER CAST MOUNTING TECHNIQUES 64220 MASTER CAST MOUNTING WITH ARBITRARY FACEBOW TRANSFER 64221 One Unit of Time 64229 Each Additional Unit of Time 114.80 141.50 +L 64300 MASTER CAST GNATHOLOGICAL WAX-UP 64301 One Unit of Time 64309 Each Additional Unit of Time BR +L BR 66000 REPAIRS 66100 REPAIRS: REPLACEMENT 66110 66111 66112 66113 66114 66119 REPLACE BROKEN PREFABRICATED ATTACHABLE FACINGS One Unit of Time Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 66.50 +L 114.40 283.40 66221 66222 66223 66224 66229 54 .20 70. THREE DIMENSIONAL RECORDINGS OF MANDIBULAR MOVEMENT (PANTOGRAPH OR STEREOGRAPH) 64141 One Unit of Time 64149 Each Additional Unit of Time 114.TO BE REPLACED BY A NEW PROSTHESIS One Unit of Time Two Units of Time Three Units of Time Four Units of Time Each Additional Unit of Time 66.40 132.40 132.60 212. REMOVAL: FIXED BRIDGE/PROSTHESIS .80 +L 199.50 +L 64230 MASTER CAST MOUNTING WITH KINEMATIC FACEBOW TRANSFER 64231 One Unit of Time 64239 Each Additional Unit of Time 114.TO BE RECEMENTED One Unit of Time Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 70. REMOVAL: FIXED BRIDGE/PROSTHESIS .50 +L 114.50 +L 114. 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 67111 67112 67113 RETAINERS: ACRYLIC/ COMPOSITE/COMPOMER.30 +L+E 55 .20 134. Direct 572. (Provisional During Healing. Implant-supported 172.40 +L 687. DIRECT (PROVISIONAL DURING HEALING. DONE AT CHAIR-SIDE) 67121 Retainer: Acrylic/Composite/Compomer. Done at Chair-side) Implant-Supported.40 +L 67120 RETAINERS: ACRYLIC/ COMPOSITE/ COMPOMER.60 66730 298.80 67.80 +L 298. IMPRESSION MADE AND PROCESSED CROWN SEATED OVER METAL) 66731 First Pontic 66739 Each Additional Pontic 108. Done at Chair-side) 67125 Retainer: Acrylic/Composite/Compomer. Indirect.00 108.60 +L 53. Indirect 67135 Retainer: Compomer/Composite Resin/Acrylic.40 201. PORCELAIN/CERAMIC/POLYMER GLASS/ACRYLIC/COMPOSITE/COMPOMER. Indirect RETAINERS: ACRYLIC/ COMPOSITE/COMPOMER. DIRECT 66711 First Tooth 66719 Each Additional Tooth 66720 REPAIRS: SOLDER INDEXING TO REPAIR BROKEN SOLDER JOINT 66721 One Unit of Time 66729 Each Additional Unit of Time REPAIR FRACTURED PORCELAIN/METAL PONTIC WITH TELESCOPING TYPE CROWN (PONTIC PREPARED.40 +L 572. INDIRECT Retainer: Acrylic/Composite/Compomer.FIXED 66300 REPAIRS: REINSERTION/RECEMENTATION (+L WHERE LABORATORY CHARGES ARE INCURRED DURING REPAIR OF BRIDGE) 66301 One Unit of Time 66302 Two Units of Time 66303 Three Units of Time 66304 Four Units of Time 66309 Each Additional Unit Over Four 67. Processed to Cast Metal.80 +L 67000 FIXED BRIDGE RETAINERS It is appropriate to use fixed bridge retainer codes.30 +L 561. Implant-Supported. INDIRECT 67131 Retainer: Compomer/Composite Resin/Acrylic.40 +E 67130 561. rather than codes for single tooth major restorations. Processed to Metal. Complicated.40 +E 172.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS . Indirect (Lab Fabricated/ Relined Intra-Orally) 67115 Retainer: Acrylic/Composite/Compomer. CAST METAL BASE.10 +L 172.00 53. Direct (Provisional During Healing.60 268. Indirect Retainer: Acrylic/Composite/Compomer.20 +L +L +L +L 66700 REPAIRS: FIXED BRIDGE/PROSTHESIS 66710 REPAIRS:FIXED BRIDGE/PROSTHESIS. Indirect Retainer: Acrylic/Composite/Compomer. Provisional. BONDED 67241 Retainers: Porcelain/Ceramic/Polymer Glass. Inlay. “MARYLAND BRIDGE”) 67221 Retainers: Porcelain/Ceramic/Polymer Glass. Onlay.20 +L 67170 RETAINERS: ACRYLIC/COMPOSITE/COMPOMER.50 +L 725. Inlay. Complicated 819.90 +L 819. Implant-Supported 703. Two Surfaces 67322 Retainer: Cast Metal. Complicated 703. Implant-Supported 639.00 +L 67250 639.90 +L 67212 Retainer: Porcelain/Ceramic/Polymer Glass Fused To Metal Base. Indirect 579. Indirect RETAINERS: ACRYLIC/COMPOSITE/COMPOMER.g. THREE SURFACE INLAY. Three Surface Inlay.90 +L . Complicated 67205 Retainer: Porcelain/Ceramic/ Polymer Glass.2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS . Onlay.30 +L 703.30 +L 703.40 +L 67320 RETAINERS: CAST METAL. BONDED 67231 Retainers: Porcelain/Ceramic/Polymer Glass. BONDED (Where One Or More Cusps Are Restored) 67251 Retainers: Porcelain/Ceramic/Polymer Glass.30 +L 67300 RETAINERS: CAST METAL 67301 Retainer: Cast Metal 67302 Retainer: Cast Metal. Bonded BR +L 67230 RETAINERS: PORCELAIN/CERAMIC/POLYMER GLASS. Indirect 550. BONDED 67161 Retainers: Acrylic/Composite/Compomer. THREE SURFACE INLAY. Partial Coverage. ONLAY.90 +L 67220 RETAINERS: PORCELAIN/CERAMIC/POLYMER GLASS.90 +L 67310 RETAINERS: ¾ CAST METAL 67311 Retainer: ¾ Cast Metal 67312 Retainer: ¾ Cast Metal.00 +L 67180 67200 RETAINERS.30 +L 67210 RETAINERS: PORCELAIN/CERAMIC/POLYMER GLASS FUSED TO METAL BASE 67211 Retainer: Porcelain/Ceramic/Polymer Glass Fused To Metal Base 703.G. BONDED (EXTERNAL RETENTION . PARTIAL COVERAGE.FIXED 67160 RETAINERS: ACRYLIC/COMPOSITE/COMPOMER. INLAY (USED WITH BROKEN STRESS TECHNIQUE) 67321 Retainer: Cast Metal.80 +L 703.e.80 +L 67215 Retainer: Porcelain/Ceramic/Polymer Glass Fused To Metal Base. Bonded 579. Complicated 67305 Retainer: Cast Metal. Bonded 550. BONDED 67181 Retainers: Acrylic/Composite/Compomer. INDIRECT. PORCELAIN/CERAMIC/POLYMER GLASS 67201 Retainer: Porcelain/Ceramic/ Polymer Glass 67202 Retainer: Porcelain/Ceramic/ Polymer Glass. Bonded (External Retention .E. Three or More Surfaces 56 672. INDIRECT. Three Surface Inlay. ONLAY. TWO SURFACE INLAY. INDIRECT. Two Surface Inlay.90 +L 139.20 +L 67240 RETAINERS: PORCELAIN/CERAMIC/POLYMER GLASS. Implant Supported 703.90 +L 676. “Maryland Bridge”) RETAINERS: PORCELAIN/CERAMIC/POLYMER GLASS. Two Surface Inlay. TWO SURFACE INLAY. BONDED 67171 Retainers: Acrylic/Composite/Compomer. 2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS - FIXED 67330 RETAINERS: CAST METAL ONLAY (INTERNAL RETENTION TYPE) 67331 Retainer: Cast Metal, Onlay 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 Tooth, (Pontic Extra) 738.60 +L 67340 418.20 +L 67400 RETAINERS, OVERDENTURES, CUSTOM CAST OR PREFABRICATED WITH NO OCCLUSAL COMPONENT. 67415 Retainer, Metal, Prefabricated or Custom Cast, Implant-Supported, With or Without Mesostructure With No Occlusal Component (See 62105 for retentive bar) 67500 FIXED PROSTHETICS: ABUTMENTS/RETAINERS, MISCELLANEOUS SERVICES 67501 Abutments Preparation Under Existing Partial Denture Clasp, in addition to retainer codes 67502 Telescoping Crown Unit BR +L+E 114.50 +L 652.50 +L 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) BR 69200 FIXED PROSTHETICS: SPLINTING 69201 Splinting, for Extensive or Complicated Restorative Dentistry (Per Tooth) BR 69300 FIXED PROSTHETICS: RETENTIVE PINS (FOR RETAINERS IN ADDITION TO RESTORATION) 69301 One Pin/Restoration 69302 Two Pins/Restoration 69303 Three Pins/Restoration 69304 Four Pins/Restoration 69305 Five Pins or More/Restoration 47.90 63.90 79.90 95.90 111.90 69700 FIXED PROSTHETICS: PROVISIONAL COVERAGE (IN EXTENSIVE OR COMPLICATED RESTORATIVE DENTISTRY) 69701 Abutment Tooth 69702 Pontic 100.20 +L 49.00 +L +L +L +L +L +L 69800 FIXED PROSTHODONTIC FRAMEWORK: OSSEO- INTEGRATED IMPLANT-SUPPORTED 69810 FIXED PROSTHODONTIC FRAMEWORK, OSSIO-INTEGRATED, ATTACHED WITH SCREWS AND INCORPORATING TEETH (DENTURE TEETH AND ACRYLIC) 69811 Maxillary 69812 Mandibular BR BR 57 2013 Alberta Blue Cross Dental Schedule General Practitioner • PROSTHODONTICS - FIXED 69820 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) 69821 Maxillary 69822 Mandibular 58 BR BR 2013 Alberta Blue Cross Dental Schedule General Practitioner • ORAL AND MAXILLOFACIAL SURGERY ORAL AND MAXILLOFACIAL SURGERY The following surgical services include necessary local anaesthetic, 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 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 118.50 71.10 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 201.10 120.70 71210 REQUIRING ELEVATION OF A FLAP, REMOVAL OF BONE AND/OR SECTIONING OF TOOTH FOR REMOVAL OF TOOTH 71211 Single Tooth 201.10 71219 Each Additional Tooth, Same Quadrant 120.70 72000 REMOVALS (EXTRACTIONS): SURGICAL 72100 REMOVALS: IMPACTIONS, SOFT TISSUE COVERAGE 72110 REMOVALS, IMPACTION, REQUIRING INCISION OF OVERLYING SOFT TISSUE AND REMOVAL OF THE TOOTH 72111 Single Tooth 72119 Each Additional Tooth, Same Quadrant 201.10 120.70 72200 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 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) 72221 Single Tooth 72229 Each Additional Tooth, Same Quadrant 243.30 146.00 72220 REMOVALS: IMPACTION, REQUIRING INCISION OF OVERLYING SOFT TISSUE, ELEVATION OF A FLAP, REMOVAL OF BONE, AND/OR SECTIONING OF TOOTH FOR REMOVAL AND/OR PRESENTS UNUSUAL DIFFICULTIES AND CIRCUMSTANCES 72231 Single Tooth 72239 Each Additional Tooth, Same Quadrant 347.90 208.70 72230 367.50 220.50 59 SOFT TISSUE COVERAGE 72321 First Tooth 72329 Each Additional Tooth. BONE TISSUE COVERAGE 72331 First Tooth 72339 Each Additional Tooth. ERUPTED 72311 First Tooth 72319 Each Additional Tooth.40 72320 REMOVALS: RESIDUAL ROOTS. UNCOMPLICATED. SOFT TISSUE COVERAGE WITH POSITIONING OF ATTACHED GINGIVAE 72541 Single Tooth 300. Same Quadrant SURGICAL EXPOSURE: UNERUPTED TOOTH.70 +E 83.70 +E 83. Same Quadrant 194. Same Quadrant 100.90 72400 ALVEOLAR BONE PRESERVATION 72410 ALVEOLAR BONE PRESERVATION . WITH ORTHODONTIC ATTACHMENT 72531 Single Tooth 72539 Each Additional Tooth.90 72330 REMOVALS: RESIDUAL ROOTS.40 72540 60 174. Same Quadrant 191.70 60.70 72530 SURGICAL EXPOSURE: UNERUPTED TOOTH.AUTOGRAFT 72411 First Tooth 72419 Each Additional Tooth 139. SOFT TISSUE COVERAGE (INCLUDES OPERCULECTOMY) 72511 Single Tooth 72519 Each Additional Tooth.10 168.70 281.20 114.60 180.2013 Alberta Blue Cross Dental Schedule General Practitioner • ORAL AND MAXILLOFACIAL SURGERY 72240 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) BR BR 72300 REMOVALS (EXTRACTIONS): RESIDUAL ROOTS 72310 REMOVALS: RESIDUAL ROOTS.50 .80 +E 72500 SURGICAL EXPOSURE OF TEETH 72510 SURGICAL EXPOSURE: UNERUPTED.90 134. Same Quadrant 224.80 +E 72420 ALVEOLAR BONE PRESERVATION – ALLOGRAFT 72421 First Tooth 72429 Each Additional Tooth 139.80 +E 72430 ALVEOLAR BONE PRESERVATION – ZENOGRAFT 72431 First Tooth 72439 Each Additional Tooth 139.70 +E 83.80 116. Same Quadrant 72520 SURGICAL EXPOSURE: COMPLEX. HARD TISSUE COVERAGE 72521 Single Tooth 72529 Each Additional Tooth. Same Quadrant 252.00 72600 SURGICAL MOVEMENT OF TEETH 72610 TRANSPLANTATION OF ERUPTED TOOTH 72611 First Tooth 72619 Each Additional Tooth.90 179.20 73150 73151 73152 73153 73154 218.20 61 .20 73000 REMODELING AND RECONTOURING ORAL TISSUES IN PREPARATION FOR REMOVABLE PROSTHESES (TO INCLUDE CODES 73110. 73160. 73120.60 283.60 283.40 224.60 72620 TRANSPLANTATION OF UNERUPTED TOOTH 72621 First Tooth 72629 Each Additional Tooth. MULTIPLE 73161 Per Quadrant 196.90 to 384.90 218. NOT IN CONJUNCTION WITH SURGICAL OR RESTORATIVE PROCEDURES ON THE SAME TOOTH 72801 First Tooth 72809 Each Additional Tooth 75.00 EXCISION OF BONE Nasal Spine: Excision Torus Palatinus: Excision Torus Mandibularis: Unilateral.60 72630 REPOSITIONING: SURGICAL 72631 First Tooth 72639 Each Additional Tooth.70 72700 ENUCLEATION: SURGICAL 72710 UNERUPTED TOOTH AND FOLLICLE 72711 First Tooth 72719 Each Additional Tooth.20 348.10 364. Same Quadrant 472.20 73140 REMODELING OF BONE 73141 Mylohyoid Ridge Remodeling 73142 Genial Tubercle Remodeling 226. Same Quadrant 298. HARD TISSUE COVERAGE WITH POSITIONING OF ATTACHED GINGIVAE 72551 Single Tooth 231.2013 Alberta Blue Cross Dental Schedule General Practitioner • ORAL AND MAXILLOFACIAL SURGERY 72550 SURGICAL EXPOSURE: UNERUPTED TOOTH. 73180) 73100 ALVEOLOPLASTY (BONE REMODELING OF RIDGE WITH SOFT TISSUE REVISIONS) 73110 ALVEOLOPLASTY: IN CONJUNCTION WITH EXTRACTIONS 73111 Per Sextant 103.20 73120 ALVEOLOPLASTY: NOT IN CONJUNCTION WITH EXTRACTIONS 73121 Per Sextant 125. 73170.40 72800 REMOVAL OF A FRACTURED CUSP AS A SEPARATE PROCEDURE. Same Quadrant 472. Excision 73160 REMOVAL OF BONE: EXOSTOSIS. Excision Torus Mandibularis: Bilateral. 73140.90 151. 73150.30 45. Pterygomaxillary Tuberosity. per tooth/implant 73230 REMOVAL: TISSUE.30 558. HYPERPLASTIC (INCLUDES THE INCISION OF THE MUCOUS MEMBRANE.80 73430 VESTIBULOPLASTY: WITH SECONDARY EPITHELIZATION 73431 Per Sextant 151. Augmentation Bilateral.00 464.60 +E 276.90 73450 VESTIBULOPLASTY: WITH SKIN GRAFT 73451 Per Sextant 278. Augmentation 285.70 +E 552.10 +E 73200 GINGIVOPLASTY AND/OR STOMATOPLASTY: ORAL SURGERY 73210 INDEPENDENT PROCEDURE 73211 Per Sextant 112. Augmentation Bilateral. THE DISSECTION AND REMOVAL OF HYPERPLASTIC TISSUE.30 73240 73300 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 112.40 57.30 MISCELLANEOUS PROCEDURES Gingivoplasty: in Conjunction With Tooth Removal Excision of Vestibular Hyperplasia. Mandibular Ridge. Augmentation Unilateral.10 569.30 251.20 73420 SULCUS DEEPENING AND RIDGE RECONSTRUCTION 73421 Per Sextant 173. Reduction 73172 Bilateral.30 112.115.70 73400 VESTIBULOPLASTY 73410 VESTIBULOPLASTY: SUB-MUCOUS 73411 Per Sextant 371. EXCESS (COMPLETE REMOVAL WITHOUT DISSECTION) 73241 Per Sextant 112.60 to 715. Pterygomaxillary Tuberosity.30 1. Per Sextant Surgical Shaving of Papillary Hyperplasia of the Palate Excision of Pericoronal Gingival (for retained tooth/implant).30 73220 73221 73222 73223 73224 112. Reduction 73180 73181 73182 73183 73184 AUGMENTATION OF BONE Unilateral.40 to 357.90 73460 VESTIBULOPLASTY: WITH MUCOSAL GRAFT 73461 Per Sextant 278.90 +E 435. THE REPLACING AND ADAPTING OF THE MUCOUS MEMBRANE) 73231 Per Sextant REMOVALS: MUCOSA.80 226.40 73440 VESTIBULOPLASTY: WITH LABIAL INVERTED FLAP 73441 Per Sextant 226.90 62 .2013 Alberta Blue Cross Dental Schedule General Practitioner • ORAL AND MAXILLOFACIAL SURGERY 73170 REDUCTION OF BONE: TUBEROSITY 73171 Unilateral. Mandibular Ridge. ALLOGRAFT 73481 Per Sextant 278. WITH AUTOGENOUS BONE 73511 Per Sextant 372.2013 Alberta Blue Cross Dental Schedule General Practitioner • ORAL AND MAXILLOFACIAL SURGERY 73470 VESTIBULOPLASTY: WITH DERMAL GRAFT.80 549.90 73500 RECONSTRUCTION: ALVEOLAR RIDGE 73510 RECONSTRUCTION: ALVEOLAR RIDGE.90 274. SCAR TISSUE.90 73490 VESTIBULOPLASTY: WITH CONNECTIVE TISSUE FOR RIDGE AUGMENTATION 73491 Per Sextant 278.40 TUMORS.40 540.10 74000 SURGICAL EXCISION (NOT IN CONJUNCTION WITH TOOTH REMOVAL.90 +E 73480 VESTIBULOPLASTY: WITH DERMAL GRAFT.50 226.70 63 . BENIGN.30 421.90 732. WITH MUCOUS GRAFT 73631 Per Sextant 270. INFLAMMATORY OR CONGENITAL LESIONS OF SOFT TISSUE OF THE ORAL CAVITY 1cm and under 1-2 cm 2-3 cm 3-4 cm 4-6 cm 6-9 cm 9-15 cm 15 cm and over 174. BENIGN 74110 74111 74112 74113 74114 74115 74116 74117 74118 74120 74121 74122 74123 74124 74125 74126 74127 74128 TUMORS.10 73630 EXTENSIONS: MUCOUS FOLDS.10 +E 73600 EXTENSIONS: MUCOUS FOLDS 73610 EXTENSIONS: MUCOUS FOLDS. WITH SECONDARY EPITHELIZATION 73611 Per Sextant 270.10 +E 73520 RECONSTRUCTION: ALVEOLAR RIDGE.80 470. BENIGN.80 313. WITH ALLOPLASTIC MATERIAL 73521 Per Sextant 372.10 73620 EXTENSIONS: MUCOUS FOLDS.70 377.90 379. BONE TISSUE 1cm and under 1-2 cm 2-3 cm 3-4 cm 4-6 cm 6-9 cm 9-15 cm 15 cm and over 209.50 290.20 842. AUTOGRAFT 73471 Per Sextant 278. WITH SKIN GRAFTS 73621 Per Sextant 270.50 479.30 650. INCLUDING BIOPSY) 74100 SURGICAL EXCISION: TUMORS. 80 279.10 +E 372. OF THE JAW 74521 Augmentation: of the Chin BR 74600 SURGICAL EXCISION: CYSTS/GRANULOMAS (BASED ON CYST SIZE) 74610 74611 74612 74613 74614 74615 74616 74617 74618 ENUCLEATION OF CYST/GRANULOMA: ODONTOGENIC AND NONODONTOGENIC. Total 74400 HARD TISSUE GRAFTS TO THE JAW 74401 Autograft . SOFT TISSUE.90 325.20 720.90 372.20 697.90 337.10 +E 74500 AUGMENTATIONS: PROSTHETIC. BONE TISSUE 74221 1cm and under 74222 1-2 cm 74223 2-3 cm 74224 3-4 cm 74225 4-6 cm 74226 6-9 cm 74227 9-15 cm 74228 15 cm and over 74300 CHEILOPLASTY (LIP SHAVE) 74301 Cheiloplasty.70 284.00 363. MALIGNANT 74210 74211 74212 74213 74214 74215 74216 74217 74218 TUMORS.40 929.80 243.40 325.20 810. Marsupialization 64 200.00 610. MALIGNANT.20 871. OF THE JAW 74520 AUGMENTATIONS: SYNTHETIC.50 523.40 453.10 549.80 .70 610. ORAL CAVITY 1cm and under 1-2 cm 2-3 cm 3-4 cm 4-6 cm 6-9 cm 9-15 cm 15 cm and over 74220 TUMORS.40 500.90 758.2013 Alberta Blue Cross Dental Schedule General Practitioner • ORAL AND MAXILLOFACIAL SURGERY 74200 SURGICAL EXCISION: TUMORS.40 243.20 421.60 to 650.50 810.10 +E 372. REQUIRING PRIOR REMOVAL OF BONY TISSUE AND SUBSEQUENT SUTURE(S) 1cm and under 1-2 cm 2-3 cm 3-4 cm 4-6 cm 6-9 cm 9-15 cm 15 cm and over 74620 MARSUPIALIZATION 74621 Cyst.40 421.30 650.50 505. MALIGNANT.Per Site – Maxilla or Mandible 74402 Allograft – Per Site – Maxilla or Mandible 74403 Xenograft – Per Site – Maxilla or Mandible 162. Partial 74302 Cheiloplasty. 20 75120 SURGICAL INCISION AND DRAINAGE AND/OR EXPLORATION: EXTRAORAL SOFT TISSUE 75211 Extraoral. Hard Tissue 75123 Intraoral.50 290.90 to 813.2013 Alberta Blue Cross Dental Schedule 74630 74631 74632 74633 74634 74635 74636 74637 74638 General Practitioner • ORAL AND MAXILLOFACIAL SURGERY EXCISION OF CYST 1cm and under 1-2 cm 2-3 cm 3-4 cm 4-6 cm 6-9 cm 9-15 cm 15 cm and over 200. Hard Tissue. Abscess.90 to 813. Abscess. Abscess. Surgical Exploration. Trephination and Drainage 75122 Intraoral.50 377. Trephination and Drainage in a Major Anatomical Area 75200 SURGICAL INCISION AND DRAINAGE AND/OR EXPLORATION: EXTRAORAL 128.80 279. Deep 136.30 650.10 549.70 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.80 416. Hard Tissue 302.00 348.80 436.00 363. Hard Tissue.80 279. Surgical Exploration. Surgical Exploration.80 75220 75300 SURGICAL INCISION FOR REMOVAL OF FOREIGN BODIES 75301 Removal: From Skin or Subcutaneous Alveolar Tissue 75302 Removal: of Reaction Producing Foreign Bodies 75303 Removal: of Needle From Musculoskeletal System 75400 SEQUESTRECTOMY (FOR OSTEOMYELITIS) 75401 Intraoral Sequestrectomy 75402 Saucerization 75403 Osteomyelitis: Non Surgical Treatment of 75410 75411 75412 75413 75414 75415 EXTRAORAL SEQUESTRECTOMY 3 cm and less 3-4 cm 4-6 cm 6-9 cm 9 cm and over 302.30 508.40 453. Superficial 75212 Extraoral.70 75210 SURGICAL INCISION AND DRAINAGE AND/OR EXPLORATION: EXTRAORAL HARD TISSUE 75221 Extraoral.80 416.20 128.50 104. Soft Tissue 75113 Intraoral.50 209.00 488. In Major Anatomical Area with Drain SURGICAL INCISION AND DRAINAGE AND/OR EXPLORATION: INTRAORAL HARD TISSUE 75121 Intraoral. Abscess. Abscess.20 871. Soft Tissue 75112 Intraoral.60 279.90 to 813.50 416.60 604.90 758.50 65 .20 218. Abscess. 50 589.10 70. Two Wiring.580.20 66 .069.50 810.70 1.10 to 1.324.20 76000 FRACTURES: TREATMENT OF 76100 INTERMAXILLARY FIXATION (WIRING) 76110 76111 76112 76113 76114 76115 76116 SPLINTS PER ARCH.30 743.10 70.40 1.50 209.40 929.10 1.10 140.00 630.2013 Alberta Blue Cross Dental Schedule General Practitioner • ORAL AND MAXILLOFACIAL SURGERY 75500 MANDIBULECTOMY 75510 75511 75512 75513 75514 75515 75516 75517 75518 MANDIBULECTOMY 3 cm and less 3-4 cm 4-6 cm 6-9 cm 9-12 cm 12-15 cm 15 cm and over Total Mandibulectomy 243.10 212.50 523.40 421.50 75600 MAXILLECTOMY 75610 75611 75612 75613 75614 75615 75616 75617 75618 MAXILLECTOMY 3 cm and less 3-4 cm 4-6 cm 6-9 cm 9-12 cm 12-15 cm 15 cm and over Total Maxillectomy 407.048.50 488. Three or Over 70. ONE OR MORE PER JAW 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 209.90 325.00 210.00 76120 76121 76122 76123 76124 76125 INTRA MAXILLARY SUSPENSION (WIRING) Nasal Spine Wiring Piriform Apertures Suspension Frontal Suspension Orbital Rim Suspension: Bilateral Head Frame Suspension 70.50 302.10 70.90 697.10 302.220.50 76130 76131 76132 76133 CIRCUMMANDIBULAR WIRING Wiring.50 70. One Wiring.80 836.00 488.78 to 1. Open Reduction 116.50 743.20 1. ZYGOMATIC ARCH 76701 Reduction. Orbital Approach With Insertion of Subperiosteal Implant 76506 Exploration: of Orbital Blowout Fracture 76507 Exploration: of Orbital Blowout Fracture and Reconstruction With Insertion of a Subperiosteal Implant 76600 FRACTURES: REDUCTIONS.00 650. External Approach 76504 Reduction. Malar Bone.30 1.40 to 697. Naso-orbital.011.40 279.60 990.619. Closed.080.20 279. Single 76303 Reduction: Maxillary.00 418. Open. Open. Multiple 76300 FRACTURES: REDUCTIONS.487.90 976. By Sinus Approach 76605 Reduction. PYRAMIDAL LE FORT’S II 76401 Reduction. Open. Unilateral 76403 Reduction. MALAR BONE 76601 Reduction. Open. MAXILLARY.80 976. Open. Open.143.60 650.00 279.40 to 1. Open. Open. Malar Bone.00 572. Maxillary. Zygomatic Arch. Maxillary. Open. Zygomatic Arch.60 900. By Simple Elevation 76603 Reduction. Open.90 418. Zygomatico-Maxillary Fracture Dislocation. Open.080.975.00 218.80 67 .10 813. Single 76203 Reduction: Mandibular.80 610. Double 76204 Reduction: Mandibular.20 279.50 813. MAXILLARY.80 976.30 650.20 505.2013 Alberta Blue Cross Dental Schedule General Practitioner • ORAL AND MAXILLOFACIAL SURGERY 76140 76141 76142 76143 76144 SPLINTS/WIRES: REMOVAL OF Removal of Wire Removal of Arch Splint (One or More Per Jaw) Removal of Interosseous Ligature or Bone Plate Removal of Intra or Periosseous Rod or Wire for Pericranial Suspension and/or Pericranial Apparatus 76145 Removal of Acrylic Prosthesis or Cap Splint. Closed 76302 Reduction: Maxillary. Temporal Approach 76703 Reduction. Intraoral Approach 76702 Reduction.70 to 1.70 1. Closed 76402 Reduction. Sinusal Approach 76505 Reduction. Open. Malar Bone. Malar Bone. Closed 76704 Reduction.00 900. Open. Multiple 76305 Reduction: Compound Fracture of Maxilla (Requiring Reduction and Soft Tissue Repair) 76400 FRACTURES: REDUCTIONS.40 116. Bilateral 76503 Reduction. Complex. Zygomatico-Maxillary Fracture Dislocation.20 1. HORIZONTAL LE FORT’S I 76301 Reduction: Maxillary.30 279. Maxillary. Closed 76602 Reduction. Naso-orbital. Closed 76202 Reduction: Mandibular.90 1. Closed. Bilateral 76500 FRACTURES: REDUCTIONS. By Osteosynthesis 76604 Reduction. MANDIBULAR 76201 Reduction: Mandibular. Malar Bone. NASO-ORBITAL 76501 Reduction. 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 FRACTURES: REDUCTIONS. Naso-orbital.90 650.60 813.20 610. Open. Double 76304 Reduction: Maxillary. Simple Fracture (Open Reduction With Antrostomy and Packing) 76700 FRACTURES: REDUCTIONS. Unilateral 76502 Reduction.30 558. 00 to 697. UNCOMPLICATED. Open 1.00 208. First Tooth 76949 Each Additional Tooth 342. Craniofacial Disjunction.40 157.00 235.70 to 726.00 76960 76961 76962 76963 76964 76965 76966 76967 76968 76969 REPAIRS: LACERATIONS.50 283.60 372. ALVEOLAR.115.20 76900 FRACTURES: REDUCTIONS.40 302.50 372.40 255.60 to 755. TEETH REMOVED 3 cm or less 3-6 cm 6 cm and over 76920 76921 76922 76923 76924 REDUCTION.20 189.00 to 733.60 to 726.70 697. DEBRIDEMENT. ALVEOLAR.2013 Alberta Blue Cross Dental Schedule General Practitioner • ORAL AND MAXILLOFACIAL SURGERY 76800 FRACTURES: REDUCTIONS. Closed 76802 Reduction.40 170. INTRAORAL OR EXTRAORAL 2 cm and 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 139.00 205.40 68 .60 to 726.50 191.00 67.10 274.00 174.10 76950 76951 76952 76959 REPOSITIONING OF TRAUMATICALLY DISPLACED TEETH One Unit of Time Two Units of Time Each Additional Unit Over Two 67.00 134.30 1. WITH TEETH (FIXATION EXTRA) 3 cm or less 3-6 cm 6-9 cm 9 cm and over 358.20 236. LE FORT’S III TRANSVERSE (SPECIFY TYPE OF PROCEDURE ACCORDING TO PREVIOUS CODE USED FOR FRACTURE) 76801 Reduction.80 372.80 372.00 to 697.60 358.580. ALVEOLAR 76910 76911 76912 76913 FRACTURES: ALVEOLAR. WITH TEETH (FIXATION EXTRA) 3 cm or less 3-6 cm 6-9 cm 9 cm and over 358.40 254.90 218.30 325.60 726.60 358.80 305. OPEN. THROUGH AND THROUGH 2 cm and 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 151.50 76970 76971 76972 76973 76974 76975 76976 76977 76978 76979 REPAIRS: LACERATIONS. CLOSED.60 697. CRANIOFACIAL DISJUNCTION.80 76940 REPLANTATION: AVULSED TOOTH/TEETH (INCLUDING SPLINTING) 76941 Replantation.00 to 697.80 76930 76931 76932 76933 76934 REDUCTION. Craniofacial Disjunction. 00 253. LeFort I.50 2.10 2.2013 Alberta Blue Cross Dental Schedule 76980 76981 76982 76983 76984 76985 76986 76987 76988 76989 General Practitioner • ORAL AND MAXILLOFACIAL SURGERY REPAIRS: LACERATIONS.10 2. Le Forte III 77304 Additional to the Above Osteotomy Requiring Two Segments 77305 Additional to the Above Osteotomy Requiring Three Segments 77306 Additional to the Above Osteotomy Requiring Four Segments 77307 Additional to the Above Osteotomy Requiring a Cranial Flap 77308 Closure of Cleft Fistula (Alveolar) 77309 Closure of Cleft Fistula (Palatal) 77311 Pharyngoplasty 77312 Submucous Resection 77313 Osteotomy: Maxillary.323.10 2.40 3.185.10 77200 OSTEOTOMY: MISCELLANEOUS 77201 Osteotomy: Oblique With Bone Graft 77202 Osteotomy: Inverted "L" 77203 Osteotomy:"C" 77204 Osteotomy: of the Ramus of the Mandible for Distraction Osteogenesis. Bilateral 2. LeFort II.486.10 395.185.20 295.70 77000 MAXILLOFACIAL DEFORMITIES: TREATMENT OF 77100 OSTEOTOMY/OSTECTOMY: RAMUS OF THE MANDIBULAR 77101 Osteotomy: Subcondylar.10 2.136.136.50 2. COMPLICATED (LOCAL TISSUE SHIFTS) 2 cm and 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 162.20 203.486. for Distraction Osteogenesis 77315 Osteogenesis: Maxillary.60 395.10 627.625. Intraoral 77105 Osteotomy/Ostectomy: Body of the Mandible 77106 Osteotomy: Coronoidectomy 77107 Osteotomy: Condylar Neck 77108 Osteotomy: Sagittal Split 2.20 395.50 2.10 1.10 2. Open 77103 Osteotomy: Ramus of the Mandible.486.323. Unilateral 77205 Osteotomy: of the Ramus of the Mandible for Distraction Osteogenisis. LeFort I Level 77317 Activation of Distraction Device. Bilateral 77208 Removal of Distraction Device.323.30 348.323. Unilateral 77209 Removal of Distraction Device.10 2.50 BR BR BR BR 77300 OSTEOTOMY: MAXILLA 77301 Osteotomy: Maxilla. Extraoral 77104 Osteotomy: Ramus of the Mandible. Bilateral 77206 Activation of Distraction Device.90 325.40 3.10 327.80 183. Oblique.60 224.486. LeFort II Level 77318 Activation of Distraction Device.10 2.10 1.50 2. Oblique. for Distraction Osteogenesis 77316 Activation of Distraction Device.40 418. LeFort III Level 77319 Removal of Maxillary Distraction Device 2. Closed 77102 Osteotomy: Subcondylar.486.20 534.00 274. LeFort III.323.486.486. Le Forte II 77303 Osteotomy: Maxilla. for Distraction Osteogenesis 77314 Osteotomy: Maxillary.486.625. Le Forte I 77302 Osteotomy: Maxilla.90 BR BR BR BR 69 .10 2. Unilateral 77207 Activation of Distraction Device.40 418. 50 +E 278.00 325.011. Without the Transfer of Mental Eminence Osteotomy: Segmental.115. MANDIBLE Osteotomy: Segmental.011. Posterior – for Distraction Osteogenesis Activation of Distraction Device Removal of Segmental Mandibular Distraction Device 1. Reduction Or Augmentation 77502 Genioplasty: Reduction (Vertical) 77503 Genioplasty: Augmentation With Graft (See Grafting Codes) 77504 Myotomy: Suprahyoid 77600 MISCELLANEOUS TREATMENT OF MAXILLOFACIAL DEFORMITIES 77601 Corticotomy 77602 Interdental Septotomy 77603 Surgical Expansion of the Palate 77604 Surgical Expansion of Alveolar Ridge – Ridge Splitting Technique.40 558. SEGMENTAL 77410 77411 77412 77413 77414 77415 77416 77417 77418 OSTEOTOMY: SEGMENTAL.115.115. Posterior Osteotomy: Lower Border.115. Per Sextant 77605 Surgical Expansion of Alveolar Ridge – Ridge Splitting Technique. TRAUMA OR RECONSTRUCTIVE PROCEDURES 77441 Using Bone 77442 Using Alloplast 77443 Using Cartilage 186.30 1.80 1.115.30 BR BR 77420 77421 77422 77423 77424 77425 77426 77427 77428 77429 OSTEOTOMY: SEGMENTAL.323.00 1. Anterior Osteotomy: Segmental.30 1.30 1. Mandible Osteotomy: Total Dento-Alveolar.40 .90 261.2013 Alberta Blue Cross Dental Schedule General Practitioner • ORAL AND MAXILLOFACIAL SURGERY 77400 OSTEOTOMY: MAXILLARY/MANDIBULAR.30 1. Anterior Osteotomy: Midpalatal Split. Anterior – for Distraction Osteogenesis Osteotomy: Segmental.00 325.90 OSTEOTOMY: WHEN “ONLAY GRAFT” IS REQUIRED FOR OSTEOTOMY. Per Sextant 70 1.30 1.50 1.40 325. Complete Osteotomy: Segmental. Anterior.115.00 BR BR 77430 77431 77432 77433 OSTEOTOMY: WHEN “INTERPOSITIONAL GRAFT” IS REQUIRED Using Bone Using Alloplast Using Cartilage 278. Anterior – for Distraction Osteogenesis Osteotomy: Segmental. Anterior.30 1.40 325.30 1. Posterior – for Distraction Osteogenesis Activation of Distraction Device Removal of Segmentation Maxillary Distraction Device 1. With Transfer of Mental Eminence Osteotomy: Segmental.00 77440 77500 GENIOPLASTY 77501 Genioplasty: Sliding.115.00 174.115.30 743.115.30 2. Maxilla. MAXILLA Osteotomy: Segmental.115. Mandible.115.50 +E 186.30 279. Mandible Osteotomy: Segmental.115. Posterior Osteotomy: Midpalatal Split.30 1. 30 183.40 325.394.115.00 1.208.40 152.115.30 77900 GLOSSECTOMY 77901 Glossectomy: Partial.50 174. Dislocation. Luxation.10 558.40 604. Reduction Without Anesthesia 78105 TMJ. Closed Reduction. Fixation 604.60 836.40 77800 FRENECTOMY/FRENOPLASTY 77801 Frenectomy: Upper Labial 77802 Frenectomy: Lower Labial 77803 Frenectomy: Lower Lingual or "Z" Plasty 77804 Frenectomy: Lower Lingual or "Z" Plasty With Myotomy of Genioglossus 77805 Frenectomy: Upper "Z" 77806 Frenectomy: Lower "Z" 227.60 558.40 152.30 77910 77911 77912 77913 77914 77915 77916 77917 CLEFT SURGERY 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) 77920 ORAL NASAL FISTULA 77921 Primary Closure at Time of Initial Surgery 77922 Secondary Closure with Palatal Flap 77923 Secondary Closure with Pharyngeal Flap 77924 Secondary Closure with Tongue Flap 77925 Secondary Closure with Buccal Flap 77930 77931 77932 77933 77934 RIGID FIXATION Rigid Internal Fixation Rigid Internal Fixation using Bone Rigid Internal Fixation using Alloplast + E Rigid Internal Fixation using Cartilage 627.50 71 .046.70 836.90 332.859. Reduction Under Anesthesia 78106 TMJ.00 558. Luxation. Under General Anesthetic 78104 TMJ.00 372. Open Reduction 78102 TMJ.00 1.30 152. Dislocation.30 1.70 1.40 227.70 836.00 Add 25% to Surgical Fee 78000 TEMPOROMANDIBULAR JOINT DYSFUNCTION: TREATMENT OF 78100 TEMPOROMANDIBULAR JOINT: DISLOCATION MANAGEMENT OF 78101 TMJ.60 627.40 174. Uncomplicated 78103 TMJ.10 1.046. Closed Reduction. Dislocation.30 1.2013 Alberta Blue Cross Dental Schedule General Practitioner • ORAL AND MAXILLOFACIAL SURGERY 77700 PALATORRHAPHY 77701 Palatorrhaphy: Anterior (Closure of Palatine Fissure) 77702 Palatorrhaphy: Posterior 77703 Palatorrhaphy: Total 77704 Palatorrhaphy: With Bone Graft 77705 Palatorrhaphy: Bone Graft to Anterior Alveolar Ridge 1.40 332. for Orthodontic Purposes 77903 Glossectomy: Full Postero-Anterior Wedge 325.40 152.90 183.00 627. Anterior Wedge 77902 Glossectomy: Partial. Manipulation Under Anesthesia 78107 TMJ. 30 78500 TEMPOROMANDIBULAR JOINT: ARTHROCENTESIS (PUNCTURE AND ASPIRATION) 78501 One Unit of Time 78502 Two Units of Time 78509 Each Additional Unit Over Two 67.00 279.20 999.40 558.30 604.30 697.30 604.20 999. Arthroplasty For Ankylosis (see grafting codes) 929.00 418.20 999.60 78700 TEMPOROMANDIBULAR JOINT: APPLIANCE SPLINTS.00 +L 78702 Appliance Splint: Mandibular 389.20 929.20 999.20 999.20 999.90 395.00 +L 79000 ORAL SURGERY PROCEDURES: OTHER 79100 SALIVARY GLANDS: TREATMENT OF 79101 Salivary Duct: Dilation of 79102 Salivary Duct: Insertion of Polyethylene Tube 79103 Salivary Duct: Sialodochoplasty 79104 Salivary Duct: Reconstruction of 72 53.00 999. ORTHOPEDIC REHABILITATION (POST OPERATIVE) 78701 Appliance Splint: Maxillary 389.10 278.60 153.30 697.90 131.10 604.20 1.40 999.30 604.90 395.00 67.10 395.580.20 78400 TEMPOROMANDIBULAR JOINT: ARTHROSCOPY OF TEMPOROMANDIBULAR JOINT 78401 TMJ Arthroscopic Examination 78402 Biopsy 78403 Removal of Loose Bodies 78404 Lavage 78405 Lysis of Adhesions 78406 Synovectomy 78407 Condyloplasty 78408 Eminoplasty 78409 Re-Contour of Glenoid Fossa 78412 Plication of Meniscus 78413 Repair of Meniscus 278.50 .2013 Alberta Blue Cross Dental Schedule General Practitioner • ORAL AND MAXILLOFACIAL SURGERY 78200 TEMPOROMANDIBULAR JOINT: OPEN PROCEDURES (ARTHROTOMY) 78201 Condyloplasty 78202 Condylotomy 78203 Condylectomy 78204 Eminoplasty 78205 Re-Contour of Glenoid Fossa 78206 Menisectomy 78207 Plication of Meniscus 78208 Repair of Meniscus 78209 Replacement of Meniscus (see grafting codes) 78300 TEMPOROMANDIBULAR JOINT: ARTHROTOMY FOR MAJOR RECONSTRUCTION 78301 Fossa Replacement (see grafting codes) 78302 Condylar Replacement (see grafting codes) 78303 Gap.00 134.00 78600 TEMPOROMANDIBULAR JOINT: MANAGEMENT BY INJECTIONS 78601 Injection: With Anti-Inflammatory Drugs 78602 Injection: With Sclerosing Agent 153. 70 87.30 79200 NEUROLOGICAL DISTURBANCES: TREATMENT OF 79210 79211 79212 79213 79214 79215 79216 NEUROLOGICAL DISTURBANCES: TRIGEMINAL NERVE 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.00 128.50 +E 813.50 813.649. including facial nerve) 256.00 697.2013 Alberta Blue Cross Dental Schedule 79110 79111 79112 79113 SALIVARY DUCT: SIALOLITHOTOMY Sialolithotomy: Anterior 1/3 of Canal Sialolithotomy: Posterior 2/3 of Canal Sialolithotomy: External Approach 79120 79121 79122 79123 79124 79125 SALIVARY GLANDS: EXCISIONS Excision of Submaxillary Gland Excision of Sublingual Gland Excision of Mucocele Excision of Ranula Marsupialization of Ranula General Practitioner • ORAL AND MAXILLOFACIAL SURGERY 79130 SALIVARY GLANDS: REMOVAL 79131 Salivary Gland: Removal.10 73 .50 650. Maxilla or Orbit) (Not to Include: Osteotomy) 79220 NEUROLOGICAL DISTURBANCES: MENTAL NERVE 79221 Mental Nerve: Transportation of 79222 Mental Nerve: Decompression in the Canal 79230 NEUROLOGICAL DISTURBANCES: INFERIOR DENTAL NERVE 79231 Inferior Dental Nerve: Complete Avulsion 79232 Inferior Dental Nerve: Decompression in the Canal 79240 . when Using Operating Microscopes 139.70 650. Ultrasound.60 1.487. or Impedence) 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.301.00 325.50 871.90 697.40 1.00 256.859. Parotid (sub total) 79132 Salivary Gland: Removal.50 488.90 1.50 505.40 1.79250 NEUROLOGICAL DISTURBANCES: SURGERY 79241 Injured Nerve Repair: Primary 79242 Injured Nerve Repair: Secondary 79243 Injured Nerve Repair: Secondary (When Repair Delayed More Than Four Weeks) 79244 Neural Transposition and Decompression 79245 Implantation of Electrode for Peripheral Nerve Stimulation 79246 Excision of Tumor or Neuroma 79247 Nerve Repair with Graft 79248 Harvesting of Nerve Graft 79251 Epineurial Suture of Trigeminal Nerve Branch Per Anastomosis 79252 Fascicular Suture of Trigeminal Nerve Branch Per Anastomosis 79253 Conduit Implant for Repair of Nerve Gap Up to 3 cm 79254 Conduit Implant for Repair of Nerve Gap Greater than 3 cm 79255 Fibrin Adhesive Per Nerve Anastomosis 79256 Laser Coagulation Per Nerve Anastomosis 79258 In Addition to Above Procedures.30 697.50 488.50 2.70 1.40 70.90 139.70 505.20 418. Diagnostic or Physiologic Monitoring (Stimulation with Recording Evoked Potentials.40 348.00 929.80 488.80 505.859.00 279. Parotid (radical.70 528.080.40 67.70 1.40 290.323.00 488. 10 to 418.10 to 418.00 to 436.40 235.50 to 813.00 to 436.40 235.00 83.70 to 279.00 to 482. FOREIGN BODIES 79311 Antral Surgery: Immediate Recovery of a Dental Root or Foreign Body from the Antrum 79312 Antral Surgery: Immediate Closure of Antrum By Another Dental Surgeon 79313 Antral Surgery: Delayed Recovery of a Dental Root with Oral Antrostomy 79314 Antral Surgery: With Nasal Antrostomy 298. Indirect Inferior Approach – Autograft Sinus Osseous Augmentation.10 to 418.50+E 286.10 298. Open Lateral Approach – Allograft Sinus Osseous Augmentation. if necessary) 71.10 to 418. Open Lateral Approach – Xenograft Sinus Osseous Augmentation.50 279.40 235.30 79320 ANTRAL SURGERY: LAVAGE 79321 Lavage: Oral Approach 79322 Lavage: Nasal Approach 79330 79331 79332 79333 ANTRAL SURGERY: ORO-ANTRAL FISTULA CLOSURE (SAME SESSION) Oro-Antral Fistula Closure With Buccal Flap Oro-Antral Fistula Closure With Gold Plate Oro-Antral Fistula Closure With Palatal Flap ANTRAL SURGERY: ORO-ANTRAL FISTULA CLOSURE (SUBSEQUENT SESSION) 79341 Oro-Antral Fistula Closure With Buccal Flap 79342 Oro-Antral Fistula Closure With Gold Plate 79343 Oro-Antral Fistula Closure With Palatal Flap 61.10 to 418.50 to 813. Indirect Inferior Approach – Xenograft 286. Indirect Inferior Approach – Allograft Sinus Osseous Augmentation.10 to 418.20 61.10 to 418.50+E 286.50 286.30 298.10 to 418.2013 Alberta Blue Cross Dental Schedule General Practitioner • ORAL AND MAXILLOFACIAL SURGERY 79300 ANTRAL SURGERY 79310 ANTRAL SURGERY: RECOVERY.50 to 813.50+E 286.50 79340 79350 79351 79352 79353 79354 79355 79356 79400 SINUS OSSEOUS AUGMENTATION Sinus Osseous Augmentation.40 235.80 83.80 83. Open Lateral Approach – Autograft Sinus Osseous Augmentation.10 to 418.10 to 418.50 286.50 298.50+E 286.10 to 418.50+E 279.50+E 286.50+E HEMORRHAGE: CONTROL OF 79401 Primary Hemorrhage: Control 79402 Secondary Hemorrhage: Control 79403 Hemorrhage Control: Using Compression and Hemostatic Agent 79404 Hemorrhage Control: Using Hemostatic Substance and Sutures (includes removal of bony tissue.50+E 286.80 79500 GRAFTS: SURGICAL 79510 79511 79512 79513 79514 79515 79516 79517 74 HARVESTING OF INTRAORAL TISSUE FOR GRAFTING TO OPERATIVE SITE Bone Cartilage Skin Mucosa Fascia Muscle Dermis 235.00 to 464.40 .10 to 418.20 279.40 235.40 235. ) Bone Cartilage Costochondral Skin Mucosa Fascia Muscle Dermis Nerve 325. REFER TO COMMENT UNDER SECTION HEADING 70000) 79601 Post Surgical Care: Subsequent to Initial Post Surgical Care.10 BR BR 79900 IMPLANTOLOGY (INCLUDES PLACEMENT OF IMPLANT. By Treating Dentist 79604 Post Surgical Care: Major.40 325.40 325.10 372. By Treating Dentist 79602 Post Surgical Care: Minor.60 61. Treatment of (With Anaesthesia) 79700 EMERGENCY OFFICE PROCEDURES 79701 Emergency Procedures: Tracheotomy 79702 Emergency Procedures: Crico-Thyroidotomy 79800 MUSCULAR DISORDERS: TREATMENT OF 79801 Treatment of Muscular Dysfunctions 79802 Myotomy 58.40 325.10 372.10 61.40 325. RIB.60 to 610. By Other Than Treating Dentist 79605 Post Surgical Care: Alveolitis. ETC. UNCOVERING AND PLACEMENT OF ATTACHMENT BUT NOT PROSTHESIS) 79910 IMPLANTS: BLADE 79911 Maxillary Per Implant 79912 Mandibular Per Implant BR BR 79920 IMPLANTS: SUBPERIOSTEAL 79921 Maxillary 79922 Mandibular BR +L BR +L 75 . POST-SURGICAL CARE. By Other Than Treating Dentist 79603 Post Surgical Care: Major.40 325. Minor.40 BR 79530 VASCULARIZED TISSUE FLAPS 79531 Free 79532 Attached BR BR 79540 HARVESTING AND PREPARATION OF PLATELET RICH PLASMA 79541 Harvesting and Preparation of Platelet Rich Plasma BR +E 79550 79551 79552 79553 BR +E BR +E BR +E DELIVERY OF GROWTH FACTORS Delivery of Growth Factors – Autologous – Per Site Delivery of Growth Factors – Allogenic – Per Site Delivery of Growth Factors – Human Recombinant – Per Site 79600 POST SURGICAL CARE (REQUIRED BY COMPLICATIONS AND UNUSUAL CIRCUMSTANCES.60 to 610. Treatment of (Without Anaesthesia) 79606 Post Surgical Care: Alveolitis.20 61.10 62.40 325.60 62.2013 Alberta Blue Cross Dental Schedule 79520 79521 79522 79523 79524 79525 79526 79527 79528 79529 General Practitioner • ORAL AND MAXILLOFACIAL SURGERY HARVESTING OF EXTRAORAL TISSUE FOR GRAFTING TO OPERATIVE SITE (TO INCLUDE ILIUM.40 325. ROOT FORM. PROVISIONAL 79951 Installation of Provisional Implant – per Implant 79952 Removal of Provisional Implant BR BR 79960 IMPLANTS: REMOVAL OF 79961 Per Implant. Complicated BR BR 76 .2013 Alberta Blue Cross Dental Schedule 79930 79931 79932 79933 79934 79935 79936 General Practitioner • ORAL AND MAXILLOFACIAL SURGERY IMPLANTS: OSSEOINTEGRATED. Removal of Healing Screw and Placement of Healing Transmucosal Element . MORE THAN ONE COMPONENT Surgical Installation of Implant with Cover Screw. Per Implant Surgical Re-entry. Per Implant BR 79950 IMPLANTS. Removal of Healing Screw and Placement of Final Custom Transmucosal Element. Uncomplicated 79962 Per Implant. Per Implant BR +E BR +E BR +E BR +E BR +E BR +E +L 79940 IMPLANTS: OSSEOINTEGRATED. Per Implant Surgical Re-entry. SINGLE COMPONENT 79941 Surgical Installation of Implant. Per Implant Surgical Re-entry. Removal of Healing Screw and Placement of Final Standard Transmucosal Element. Per Implant Surgical Installation of Implant with Final Transmucusal Element. Per Implant Surgical Installation of Implant with Healing Transmucosal Element. ROOT FORM. OSSEOINTEGRATED. per appointment REPAIRS TO REMOVABLE OR FIXED APPLIANCES (NOT INCLUDING REMOVAL AND RECEMENTATION) 80631 One Unit of Time 80632 Two Units of Time 80639 Each Additional Unit Over Two 60. Unilateral Appliance: Maxillary. FOR TOOTH GUIDANCE OR MINOR TOOTH MOVEMENT 81100 APPLIANCES: REMOVABLE A maximum of eight observation or adjustment appointments may be charged for these appliances.90 305.90 +L 305. serial extraction supervision. CROSS-BITE CORRECTION 81121 Appliance: Maxillary.90 305. Unilateral Appliance: Mandibular. Bilateral Appliance: Mandibular.90 305.10 80630 80640 80641 80642 80649 ALTERATIONS TO REMOVABLE OR FIXED APPLIANCES One Unit of Time Two Units of Time Each Additional Unit Over Two 80650 RECEMENTATION OF FIXED APPLIANCES 80651 One Unit of Time 80659 Each Additional Unit of Time SEPARATION (EXCEPT WHERE INCLUDED IN THE FABRICATION OF AN APPLIANCE) 80661 One Unit of Time 80669 Each Additional Unit of Time 69.50 80670 69.To Orthodontic Appliances and/or the Reduction of Proximal Surfaces of Teeth. SPACE REGAINING Appliance: Maxillary.e.50 +L 139.).50 69. tooth position.50 69.50 81000 APPLIANCES: ACTIVE.90 +L +L +L +L 305. 81110 81111 81112 81113 81114 APPLIANCES: REMOVABLE. per appointment 80602 Orthodontic Observation and Adjustment . Bilateral 81120 APPLIANCES: REMOVABLE.50 69. Simple 81122 Appliance: Mandibular. etc.90 +L 77 . eruption sequence.00 +L 69.2013 Alberta Blue Cross Dental Schedule General Practitioner • ORTHODONTICS ORTHODONTICS 80000 ORTHODONTIC SERVICES: MISCELLANEOUS 80600 ORTHODONTIC: OBSERVATIONS AND ADJUSTMENTS 80601 Orthodontic Observation .30 66.50 80660 REMOVAL OF FIXED ORTHODONTIC APPLIANCES (BY A PRACTITIONER OTHER THAN THE ORIGINAL TREATING PRACTICE OR PRACTITIONER) 80671 One Unit of Time 80679 Each Additional Unit of Time 69.00 +L 69.for Tooth Guidance (i. Simple 305.50 69.50 69.50 +L 139. 90 +L 81220 APPLIANCES: FIXED.90 +L 305. LIGATURES 81281 Grassline or Elastic Ligatures. Per Visit 81290 81291 81292 81293 81294 78 APPLIANCES: FIXED.90 +L +L +L +L .90 +L 447.90 +L 305.90 +L 81240 81241 81242 81243 APPLIANCES: FIXED.90 +L 305. Simple 81142 Appliance: Mandibular. Simple 305.90 +L 81280 APPLIANCES: FIXED. SPACE REGAINING. LINGUAL OR LABIAL ARCH WITH MOLAR BANDS. Erupted 66. Simple 81272 Appliance: Mandibular.POSTERIOR Appliance: Maxillary Appliance: Mandibular Appliance: Two-Molar Band. Rapid Expansion 447. ALIGNMENT OF INCISOR TEETH 81271 Appliance: Maxillary. Simple 81132 Appliance: Mandibular. TUBES.90 +L 81260 APPLIANCES: FIXED.ANTERIOR 81231 Appliance: Maxillary 81232 Appliance: Mandibular 305. MECHANICAL ERUPTION OF TOOTH/TEETH Appliance: Maxillary.90 +L 305. 81210 APPLIANCES: FIXED. Simple 447.90 +L 81200 APPLIANCES: FIXED OR CEMENTED A maximum of eight observation or adjustment appointments may be charged for these appliances. Simple 81262 Appliance: Mandibular.90 +L 447.60 +L 229. Hooked and Elastics 305. LOCKS) 81211 Appliance: Maxillary 81212 Appliance: Mandibular 305.60 305.90 +L 305. DENTAL ARCH EXPANSION 81131 Appliance: Maxillary.60 355. CROSS-BITE CORRECTION . Simple 305. Simple 305. Impaction Appliance: Maxillary.90 +L 229.90 +L 81270 APPLIANCES: FIXED.2013 Alberta Blue Cross Dental Schedule General Practitioner • ORTHODONTICS 81130 APPLIANCES: REMOVABLE. ALIGNMENT OF ANTERIOR TEETH 81151 Appliance: Maxillary.60 +L 81230 APPLIANCES: FIXED.90 +L 447.G.10 +L 355. Simple 305. SPACE REGAINING (E. DENTAL ARCH EXPANSION Appliance: Maxillary Appliance: Mandibular Appliance: Maxillary.90 +L 305.90 305.90 +L 81140 APPLIANCES: REMOVABLE. Impaction Appliance: Mandibular.90 +L 305.60 +L 81250 81251 81252 81253 APPLIANCES: FIXED. Erupted Appliance: Mandibular. CLOSURE OF DIASTEMAS 81141 Appliance: Maxillary. CLOSURE OF DIASTEMAS 81261 Appliance: Maxillary. Simple 81152 Appliance: Mandibular. UNILATERAL 81221 Appliance: Maxillary 81222 Appliance: Mandibular 229. CROSS-BITE CORRECTION .90 +L 81150 APPLIANCES: REMOVABLE. Case Type: Fixed Appliance (includes formal full banding treatment and retention) 84000 PERMANENT DENTITION 84101 Class I Malocclusion 84201 Class II Malocclusion 84301 Class III Malocclusion 84401 Malocclusions Not Requiring Complete Banding BR BR BR BR 85000 MIXED DENTITION 85101 Class I Malocclusion 85201 Class II Malocclusion 85301 Class III Malocclusion BR BR BR Case Type: Removable Appliance (includes removable appliance therapy and retention. degree of difficulty.90 +L COMPREHENSIVE ORTHODONTIC TREATMENT The range of fees with these procedure codes reflects such variables as length of time required to complete the treatment.2013 Alberta Blue Cross Dental Schedule General Practitioner • ORTHODONTICS 83000 APPLIANCES: RETENTION. ORTHODONTIC RETAINING APPLIANCES 83100 APPLIANCES: REMOVABLE.60 +L 229.90 +L 305. functional appliances) 87000 PERMANENT DENTITION 87101 Class I Malocclusion 87201 Class II Malocclusion 87301 Class III Malocclusion BR BR BR 88000 MIXED DENTITION 88101 Class I Malocclusion 88201 Class II Malocclusion 88301 Class III Malocclusion BR BR BR 79 . RETENTION 83101 Appliance: Maxillary 83102 Appliance: Mandibular 83103 Appliance: Tooth Positioner 229. co-operation of the patient. etc.60 +L 83200 APPLIANCES: FIXED/CEMENTED. e. and the fee charged should be determined accordingly. RETENTION 83201 Appliance: Maxillary 83202 Appliance: Mandibular 305.g.60 +L 229. 2013 Alberta Blue Cross Dental Schedule General Practitioner • ORTHODONTICS 89500 NEONATAL DENTO-FACIAL ORTHOPEDICS (COMPREHENSIVE TREATMENT FOR FIRST SIX MONTHS OF LIFE) (1) Diagnostic procedures (includes radiographs and/or photographs); (2) Parent consultation; (3) Impression and appliance construction; (4) Insertion and parent instruction; (5) Post treatment evaluation; (6) Adjustment of appliances (includes soft relines); (7) Reconstruction and/or reevaluation (may include up to two remakes). 89501 89502 89503 89504 89505 89506 80 Expansion Appliance for Infants With Cleft Palate Extraoral Retraction Appliance for Infants With Cleft Palate Stage I - Initial Expansion Stage II - Anterior Alignment Stage III - Final Alignment (Complete Banding) Stage III - Where Stage I and II Were Not Provided for BR BR BR BR BR BR 2013 Alberta Blue Cross Dental Schedule General Practitioner • ADJUNCTIVE GENERAL SERVICES ADJUNCTIVE GENERAL SERVICES 91000 UNCLASSIFIED TREATMENTS 91100 UNCLASSIFIED TREATMENT: DENTAL PAIN 91110 91111 91112 91113 91119 91120 91121 91122 91123 91129 PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN: MINOR PROCEDURE One Unit of Time Two Units of Time Three Units of Time Each Additional Unit Over Three 48.10 96.20 144.30 48.10 EMERGENCY SERVICES: NOT OTHERWISE SPECIFIED IN GUIDE One Unit of Time Two Units of Time Three Units of Time Each Additional Unit Over Three 48.10 96.20 144.30 48.10 91200 UNCLASSIFIED TREATMENT: UNUSUAL TIME AND RESPONSIBILITIES 91210 UNUSUAL TIME AND RESPONSIBILITY REQUIREMENT: IN ADDITION TO USUAL PROCEDURES IN GUIDE One Unit of Time Two Units of Time Three Units of Time Each Additional Unit Over Three 53.50 107.00 160.50 53.50 91220 91221 91222 91223 91224 91225 91226 91227 91228 91229 SECOND SURGEON (TEAM APPROACH) 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 Additional Unit Over Eight 55.40 110.80 166.20 221.60 277.00 332.40 387.80 443.20 55.40 91230 91231 91232 91233 91234 91239 MANAGEMENT OF EXCEPTIONAL PATIENT One Unit of Time Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 53.50 107.00 160.50 214.00 53.50 91211 91212 91213 91219 92000 ANAESTHESIA 92100 ANAESTHESIA: LOCAL (NOT IN CONJUNCTION WITH OPERATIVE OR SURGICAL PROCEDURES, INCLUDES PRE-ANAESTHETIC EVALUATION AND POST-ANAESTHETIC FOLLOW-UP) 92101 Regional Block Anaesthesia 92102 Trigeminal Division Block 55.80 55.80 81 2013 Alberta Blue Cross Dental Schedule General Practitioner • ADJUNCTIVE GENERAL SERVICES 92200 ANAESTHESIA: GENERAL (INCLUDES PRE-ANAESTHETIC EVALUATION AND POST-ANAESTHETIC FOLLOW-UP) 92210 92212 92213 92214 92215 92216 92217 92218 92219 GENERAL ANAESTHESIA 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 Additional Unit Over Eight 118.80 178.20 237.60 297.00 356.40 415.80 475.20 59.40 92220 PROVISION OF FACILITIES, EQUIPMENT AND SUPPORT SERVICES FOR GENERAL ANAESTHESIA WHEN PROVIDED BY A SEPARATE PRACTITIONER 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 Additional Unit Over Eight 118.80 178.20 237.60 297.00 356.40 415.80 475.20 59.40 92222 92223 92224 92225 92226 92227 92228 92229 92300 ANAESTHESIA: DEEP SEDATION Anaesthesia, 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 anaesthesia. Any intravenous 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-anaesthetic evaluation and post anaesthetic follow-up) 92302 92303 92304 92305 92306 92307 92308 92309 92320 92322 92323 92324 92325 92326 92327 92328 92329 82 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 Additional Unit Over Eight 107.40 161.10 214.80 268.50 322.20 375.90 429.60 53.70 PROVISION OF FACILITIES, EQUIPMENT AND SUPPORT SERVICES FOR DEEP SEDATION WHEN PROVIDED BY A SEPARATE PRACTITIONER 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 Additional Unit Over Eight 107.40 161.10 214.80 268.50 322.20 375.90 429.60 53.70 20 193.20 90.80 226.40 68.60 242.20 48. 92421 One Unit of Time 20.20 204..60 83 .40 92500 NON PHARMACOLOGICAL PAIN CONTROL AND PATIENT MANAGEMENT 92510 92511 92512 92513 92514 92519 HYPNOSIS One Unit of Time Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 68. (Includes pre-anaesthetic evaluation and post anaesthetic follow-up. 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 Additional Unit Over Eight 45. Conscious sedation is a varied technique which can require different levels of monitoring.) Any technique leading to these conditions in a patient would fall within this category of service.00 290.g.20 316.90 92411 92412 92413 92414 92415 92416 92417 92418 92419 92420 92440 92441 92442 92443 92444 92445 92446 92447 92448 92449 PARENTERAL CONSCIOUS SEDATION (regardless of method .a medically controlled state of depressed consciousness that allows protective reflexes to be maintained. Time is measured from the start of patient monitoring to release from treatment/recovery room.20 ORAL SEDATION .80 114.10 92520 92521 92522 92523 92524 92529 ACUPUNCTURE One Unit of Time Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 28.60 180.20 85.40 135. “open your eyes”. 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.40 96.10 136. 92410 NITROUS OXIDE .40 361.Sedation sufficient to require monitored care.40 28.IM or IV) 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 Additional Unit Over Eight 48.00 271. in accordance with the Regulatory Authority Guidelines for the Use of Sedation and General Anaesthesia in Dental Practice.60 57.40 338.80 145.Time is measured from the placement of the inhalation device and terminates with the removal of the inhalation device. The Guidelines should be consulted and observed.2013 Alberta Blue Cross Dental Schedule General Practitioner • ADJUNCTIVE GENERAL SERVICES 92400 ANAESTHESIA: CONSCIOUS SEDATION Anaesthesia: Conscious Sedation .80 387.30 272. e.60 45. lawyer.a short factually written or verbal communication given to any lay person (e.40 to 112.60 +E 119.60 93300 CLAIM FORMS AND TREATMENT FORMS 93301 Completing CDA "Blank" Approved Standard Claim Forms 93302 Upon Request. insurance representative.50 93122 Dental-Legal Report .g.60 93310 84 59.60 156. with possible long term consequences and complications in the development of the conditions. results and present condition. REPORTS AND OPINIONS 93121 Dental-Legal Report .40 117. 52.60 +E 55. etc. The report will require expert knowledge and judgement with respect to the facts leading to a detailed prognosis.20 78.20 +E 59. The report may be an opinion regarding the possible course of events (when these cannot be determined factually). BR 93123 Dental-Legal Opinion .) in relation to the patient with prior patient approval.80 39.20 +E 118. municipal or government agency.60 +E 237.a comprehensive written report primarily in the field of expert opinion. 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 FOR EXTRAORDINARY TIME SPENT. BR 93130 CONSULTATION AND/OR PARTICIPATION DURING AUTOPSY (OTHER THAN FORENSIC) 93131 One Unit of Time 93132 Two Units of Time 93139 Each Additional Unit Over Two 118. history and records giving diagnosis. on symptoms.60 +E 105.60 .2013 Alberta Blue Cross Dental Schedule 92530 92531 92532 92533 92534 92539 General Practitioner • ADJUNCTIVE GENERAL SERVICES ELECTRONIC DENTAL ANAESTHESIA One Unit of Time Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 39. The report is factual summary of all information available on the case and could contain prognostic information regarding patient response.a comprehensive written report with patient approval. Providing a Written Treatment Plan/Outline for a Patient. local. ON THE TELEPHONE WITH THIRD PARTY ADMINISTRATORS OR THEIR AGENTS. IN RELATION TO CLAIM/TREATMENT PLAN FORMS OR THE CLAIM PROBLEM OF THE PATIENT (PLUS LONG DISTANCE CHARGES) 93311 One Unit of Time 93312 Two Units of Time 93319 Each Additional Unit Over Two NO FEE NO FEE 59. treatment. IN OR OUT OF THE OFFICE 93111 One Unit of Time 93112 Two Units of Time 93119 Each Additional Unit Over Two 93120 DENTAL LEGAL LETTERS.20 93000 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.20 +E 52. After Regular Scheduled Office Hours (In Addition to Services Performed) 94303 Missed or Cancelled Appointment. POSTAGE.70 +L 85 .20 +E 124.50 83.70 +E BR BR BR 60.E. IN PREDETERMINATION SITUATIONS. With Insufficient Notice. REGISTRATION. 65.20 94000 PROFESSIONAL VISITS 94100 HOUSE CALLS 94101 House Call: Non Emergency Visit (In Addition To Procedures Performed) 94102 House Call: Emergency Visit. Out of Pocket Expenses. When One Must Immediately Leave Home.00 73.2013 Alberta Blue Cross Dental Schedule General Practitioner • ADJUNCTIVE GENERAL SERVICES 93320 FOR EXTRAORDINARY OFFICE TIME SPENT. During Regular Scheduled Office Hours (in addition to services performed) 94302 Office or Institutional Visit Unscheduled.20 65. With Insufficient Notice. IN FORWARDING PREDETERMINATION RECORDS.) 93321 One Unit of Time 93322 Two Units 93329 Each Additional Unit Over Two 62.00 119.30 BR 228. ETC. TO THIRD PARTIES PLUS EXPENSES (I.Opinion as an Expert Assisting in Civil or Criminal Cases 95102 Full or Part Time Participation in Civil Disaster 95104 Written Odontology Report 95105 Post Mortem Examination of Tissues In Forensic Cases (non-identification) 95106 Management of Oral Disease or Abnormality 95200 IDENTIFICATION SYSTEMS 95201 Identification Disk System: Acid Etch/Bonded 228.70 +E 94400 COURT APPEARANCES AND/OR PREPARATION 94410 94411 94412 94413 94414 94419 PREPARATION AS AN EXPERT WITNESS One Unit of Time Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 94420 COURT APPEARANCE AS AN EXPERT WITNESS 94421 One Half Day 94422 Full Day BR BR BR BR BR BR BR 95000 FORENSIC DENTAL SERVICES 95100 FORENSIC SERVICES: MISCELLANEOUS 95101 Identification . Plus Actual Services Performed.40 +E 62. During Regular Scheduled Office Hours 94304 Missed or Cancelled Appointment.10 to 119.30 64. etc.10 64. Being a Special Appointment Outside Regular Scheduled Office Hours 94305 Traveling Expenses 94306 Professional Visits Out of Office. Office or Hospital (In Addition To Procedures Performed) 94300 OFFICE OR INSTITUTIONAL VISITS 94301 Office (of another professional) or Institutional Visit. 80 63.30 +E 96200 INJECTIONS: THERAPEUTIC 96201 Intramuscular Drug Injection 96202 Intravenous Drug Injection 96203 Intralesional Delivery .50 +E 29.90 +E and/or +L 53.10 +E 17.Intra-articular Injections .90 +E and/or +L 244. Vitamins.60 97120 97122 Mandibular Arch 97130 97131 97132 97133 97134 97139 MICRO-ABRASION One Unit of Time Two Units of Time Three Units of Time Four Units of Time Each Additional Unit Over Four 244.10 214. Other Drugs/Medications) 35.20 +E 30. informing patients of oral health consequences associated with tobacco. advising tobacco users to quit. IN OFFICE One Unit of Time Two Units of Time Three Units of Time Each Additional Unit Over Three BLEACHING: VITAL. Fluorides.40 97000 BLEACHING: VITAL 97110 97111 97112 97113 97119 BLEACHING: VITAL.50 +E 48. provide apropriate self-help material.see 78600 48. Plus Giving a Written Prescription 96103 Dispensing : Non Emergency (e.50 +E 67.g. DISPENSING THE SYSTEM AND FOLLOW-UP CARE) 97121 Maxillary Arch 63.70 98000 COUNSELING 98100 TOBACCO-USE CESSATION SERVICES .70 +E 135.40 161. HOME (INCLUDES THE FABRICATION OF BLEACHING TRAYS.70 107.2013 Alberta Blue Cross Dental Schedule General Practitioner • ADJUNCTIVE GENERAL SERVICES 96000 DRUGS/MEDICATION: DISPENSING 96100 PRESCRIPTIONS 96101 Prescription: Emergency 96102 Emergency Dispensing of One or Two Doses of a Therapeutic Drug.20 190.To include: Identifying patients who use tobacco.80 53. and discuss treatment options.70 +E . 98101 One Unit of Time 98102 Two Units of Time 98109 Each additional Unit Over Two 86 67.60 127. ) When filling out the third party claim forms.2013 Alberta Blue Cross Dental Schedule General Practitioner • ADJUNCTIVE GENERAL SERVICES 99000 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. Or 70000 Code Services 99333 “+L” In-Office Laboratory Procedures (An in-office laboratory is defined as a laboratory service(s) performed within the same business entity). personal records and statistics. 99555 “+E” Additional Expenses of Materials BR BR BR BR 87 . 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. providing one description for a specific procedure code. 40000. 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) 99222 “+L” For Oral Pathology Biopsy Services When Provided In Relation To Surgical Services From The 30000.