This consolidation is unofficial and is for reference only. For the official version of the regulations, consult the original documents on file with the Registry of Regulations, or refer to the Royal Gazette Part II. Regulations are amended frequently. Please check the list of Regulations by Act to see if there are any recent amendments to these regulations filed with the Registry that are not yet included in this consolidation. Although every effort has been made to ensure the accuracy of this electronic version, the Registry of Regulations assumes no responsibility for any discrepancies that may have resulted from reformatting. This electronic version is copyright © 2009, Province of Nova Scotia, all rights reserved. It is for your personal use and may not be copied for the purposes of resale in this or any other form.
Insured Dental Services Tariff Regulations
made under Section 13 and subsection 17(2) of the
Health Services and Insurance Act
R.S.N.S. 1989, c. 197
O.I.C. 2001-327 (July 5, 2001), N.S. Reg. 87/2001
as amended up to O.I.C. 2010-278 (July 13, 2010), N.S. Reg. 106/2010
Table of Contents
Insured dental services tariff
Children’s Oral Health Program - limited coverage
Cleft Palate/Craniofacial Program - limited coverage
Mentally Challenged Program - limited coverage
Schedule “A” - Cleft Palate/Craniofacial Program
Part 1 - Diagnostic - 01000-09999
Tests and Laboratory Examinations
Part 2 - Endodontics - 30000-39999
Endodontic, Procedures, Miscellaneous
Part 3 - Oral and Maxillofacial Surgery - 70000-79999
Removals (Extractions), Erupted Teeth
Removals (Extractions), Surgical
Part 4 - Orthodontics - 80000-89999
Orthodontic Services, Observations and Adjustments
Appliances, Active, for Tooth Guidance or Minor Tooth Movement
Comprehensive Orthodontic Treatment
Part 5 - Periodontics - 40000- 49999
Periodontal Services, Surgical
Periodontal Procedures, Adjunctive
Chemotherapeutic and/or Antimicrobial Agents
Periodontal Services, Miscellaneous
Part 6 - Preventive - 10000-19999
Part 7- Prosthetics - Removable - 50000-59999
Dentures, Partial, Cast with Acrylic Base
Dentures, Duplication, Relining, Rebasing, and Remaking
Dentures, Miscellaneous Services
Part 8 - Prosthodontics - Fixed - 60000 - 69999
Fixed Prosthodontics, Abutments/Retainers, Miscellaneous Services
Fixed Prosthetics, Other Services
Part 9 - Restorative Services - 20000- 29999
Caries, Trauma and Pain Control
Restorations, Prefabricated, Full Coverage
Copings, Metal/Plastic, Transfer (thimble type)
Restorative Procedures, Overdentures
Schedule “B” - Children’s Oral Health Program
Part 1 - Diagnostic - 01000-09999
Tests and Laboratory Examinations
Part 2 - Preventive - 10000-19999
Part 3 - Restorative Services - 20000- 29999
Caries, Trauma and Pain Control
Restorations, Prefabricated, Full Coverage
Part 4 - Periodontics - 40000- 49999
Periodontal Procedures, Adjunctive
Part 5 - Prosthetics - Removable - 50000-59999
Part 6 - Oral and Maxillofacial Surgery - 70000-79999
Removals (Extractions), Erupted Teeth
Removals (Extractions), Surgical
Schedule “C” - Dental Surgical Program
Part 1 - Diagnostic - 01000-09999
Part 2 - Oral and Maxillofacial Surgery - 70000-79999
Removals, (Extractions), Surgical
Remodelling and Recontouring Oral Tissues
Sequestrectomy (for Osteomyelitis
Maxillofacial Deformities, Treatment of
Temporomandibular Joint Dysfunctions, Treatment of
Oral Surgery Procedures, Other
Schedule “D” - Maxillofacial Prosthodontics Program
Part 1 - Examination and Diagnosis, Prosthodontic, Specific - 01702
Part 2 - Prosthetics - Removable - 50000-59999
Dentures, Partial, Cast with Acrylic Base
Dentures, Duplication, Relining and Rebasing
Dentures, Miscellaneous Services
Schedule “E” - Mentally Challenged Program
1 These regulations may be cited as the Insured Dental Services Tariff Regulations.
Insured dental services tariff
2 (1) The tariff of fees for insured dental services is as set out in the following schedules:
(a) Schedule “A” - Cleft Palate/Craniofacial Program;
(b) Schedule “B” - Children’s Oral Health Program;
(c) Schedule “C” - Dental Surgical Program;
(d)Schedule “D” - Maxillofacial Prosthodontics Program;
(e)Schedule “E” - Mentally Challenged Program; and
(f) Schedule “F” - Atlantic Provinces Special Education Authority Dental Program.
Section 2 renumbered 2(1): O.I.C. 2002-382, N.S. Reg. 109/2002.
(2) The tariff of fees referred to in subsection (1) shall be increased effective April 1 of each year from 2001 to 2003, as follows:
(a) effective on and after April 1, 2001, an increase of 3.97%;
(b) effective on and after April 1, 2002, a further increase of 3.97%; and
(c) effective on and after April 1, 2003, a further increase of 3.97%.
Subsection 2(2) added: O.I.C. 2002-382, N.S. Reg. 109/2002.
(3) The tariff of fees referred to in subsection (1) for insured dental services set out in Schedules “A”, “B”, “C”, “E”, and “F” shall be increased effective April 1 of each year from 2004 to 2006, as follows:
(a) effective on and after April 1, 2004, an increase of 2%;
(b) effective on and after April 1, 2005, a further increase of 2%; and
(c) effective on and after April 1, 2006, a further increase of 2%.
Subsection 2(3) added: O.I.C. 2004-158, N.S. Reg. 128/2004.
(4) The tariff of fees referred to in subsection (1) for insured dental services set out in Schedule “D” shall be increased effective April 1 of each year from 2004 to 2006, as follows:
(a) effective on and after April 1, 2004, an increase of 6%;
(b) effective on and after April 1, 2005, a further increase of 6%; and
Clause 2(4)(b) amended: O.I.C. 2004-231, N.S. Reg. 166/2004.
(c) effective on and after April 1, 2006, a further increase of 2%.
Subsection 2(4) added: O.I.C. 2004-158, N.S. Reg. 128/2004.
(5) The tariff of fees referred to in subsection (1) shall be increased effective April 1 of each year from 2007 to 2010, as follows:
(a) effective on and after April 1, 2007, an increase of 5%, except for the Schedule “B” Children’s Oral Health Plan Restorative Fee Codes 20111 to 23515 inclusive which increase by 10%;
(b) effective on and after April 1, 2008, a further increase of 5%, except for the Schedule “B” Children’s Oral Health Plan Restorative Fee Codes 20111 to 23515 inclusive which increase by 10%;
(c) effective on and after April 1, 2009, a further increase of 5%, except for the Schedule “B” Children’s Oral Health Plan Restorative Fee Codes 20111 to 23515 inclusive which increase by 10%.
Subsection 2(5) added: O.I.C. 2007-282, N.S. Reg. 277/2007.
(6) The tariff of fees referred to in subsection (1) shall be increased effective on and after the date this subsection comes into force by 1%.
Subsection 2(6) added: O.I.C. 2010-278, N.S. Reg. 106/2010.
3 (1) The tariff of fees for insured optometric services is as follows:
(a) effective April 1, 2004, the Medical Service Unit (MSU) is $2.17;
(b) effective April 1, 2005, the MSU is increased to $2.22; and
(c) effective April 1, 2006, the MSU is increased to $2.26.
(2) The tariff of fees for insured optometric services is in effect from April 1, 2004, to March 31, 2007.
Children’s Oral Health Program - limited coverage
4 (1) Effective May 1, 2002, no amount shall be paid for services rendered to a resident in accordance with Schedule “B” to whom or for whom a benefit in respect of those services has been paid or would be payable if claimed under any contract or plan of insurance that applies to that resident.
(2) For further clarification, where a partial benefit for services rendered to a resident in accordance with Schedule “B” has been paid or would be payable if claimed under any contract or plan of insurance that applies to that resident, any outstanding costs shall be billed directly to the Province and will be paid for by the Province.
Section 4 added: O.I.C. 2002-168, N.S. Reg. 55/2002; amended: O.I.C. 2002-460, N.S. Reg. 126/2002.
Cleft Palate/Craniofacial Program - limited coverage
5 (1) Effective April 1, 2004, no amount shall be paid for services rendered to a resident in accordance with Schedule “A” that are services rendered pursuant to the Children’s Oral Health Program to whom or for whom a benefit in respect of those services has been paid or would be payable if claimed under any contract or plan of insurance that applies to that resident.
(2) For further clarification, where a partial benefit for services rendered to a resident in accordance with Schedule “A” has been paid or would be payable if claimed under any contract or plan of insurance that applies to that resident, any outstanding costs shall be billed directly to the Province and will be paid for by the Province.
Section 5 added: O.I.C. 2004-158, N.S. Reg. 128/2004.
Mentally Challenged Program - limited coverage
6 (1) Effective April 1, 2004, no amount shall be paid for services rendered to a resident in accordance with Schedule “E” to whom or for whom a benefit in respect of those services has been paid or would be payable if claimed under any contract or plan of insurance that applies to that resident.
(2) For further clarification, where a partial benefit for services rendered to a resident in accordance with Schedule “E” has been paid or would be payable if claimed under any contract or plan of insurance that applies to that resident, any outstanding costs shall be billed directly to the Province and will be paid for by the Province.
Section 6 added: O.I.C. 2004-158, N.S. Reg. 128/2004.
Tariff of Fees for Insured Dental Services
Cleft Palate/Craniofacial Program
The Cleft Palate/Craniofacial Program provides insured services for residents (as defined in the M.S.I. Regulations) with craniofacial anomalies which directly influence the growth and development of the dentoalveolar and craniofacial structures.
From birth to age 10, these residents will be eligible for insured coverage for basic dental services through the Children’s Oral Health Program (Schedule “B”) and other services under this Schedule as deemed necessary as a result of the anomaly.
From age 10 to 23 years, additional services are insured under this Schedule on a pre-authorization basis depending on the treatment required. Specifically, treatment made necessary as a result of the anomaly will be considered for coverage.
There will be no coverage for retreatment under this program. Under extenuating circumstances only, where the Department’s Cleft Palate/Craniofacial Team has determined that a condition requiring retreatment has resulted directly from the progression of the congenital/developmental craniofacial anomaly, will additional funding be considered.
There is no coverage for services outlined in this Schedule which are performed outside of the Province.
Fee Code G.P. Specialist
Fee ($) Fee ($)
Part 1 - Diagnostic - 01000-09999
1 Examinations and diagnosis, complete oral, to include:
- History, medical and dental
- Clinical examination and diagnosis of hard and soft tissues, including: carious lesions, missing teeth, determination of pocket depth and location of periodontal pockets, gingival contours, mobility of teeth, interproximal tooth contact relationships, occlusion of teeth, pulp vitality tests, where necessary, and any other pertinent factors.
- Radiographs extra, as required
01101 Examination and diagnosis, complete, primary dentition,
to include: extended examination and diagnosis on primary
dentition, recording history, charting, treatment planning
and case presentation, including above description.........................27.6234.47
This service (01101) is allowed once in a patient’s lifetime, when continuity of treatment is maintained. If there is a gap in treatment of 2 years or more, a further complete oral examination is warranted and is covered under the Plan.
A complete oral examination performed by another dentist is permitted under the Plan, unless performed by a dentist who is established in a group practice with the dentist who performed the first examination. (A group practice in this case means a mode of practice where patient records are available to all dentists.)
In cases where a patient has been referred to a specialist in the same group practice, complete oral examinations by both dentist and dental specialist are allowed.
01102 Examination and diagnosis, complete, mixed dentition,
to include: extended examination and diagnosis on mixed
dentition, recording history, charting, treatment
planning and case presentation, including above
description; and eruption sequence, tooth size -
jaw size assessment ......................................................................45.7050.00
01103 Examination and diagnosis, complete, permanent dentition
to include: extended examination and diagnosis on permanent
dentition, recording history, charting, treatment planning and
case presentation, including above description ..............................45.7050.00
2 Examinations and diagnosis, limited oral
01201 Examination and diagnosis, limited, oral, new patient:
examination with mirror and explorer of hard and soft
tissues, including checking of occlusion and appliances,
but not including specific tests as for 01100...................................20.1824.30
01202 Examination and diagnosis, limited oral, previous patient
(recall): examination and diagnosis with mirror and
explorer of hard and soft tissues, including checking of
occlusion and appliances, but not including specific
tests, as for 01100..........................................................................15.4219.16
This service (01202) is allowed after a 335 day period has elapsed from the previous complete or recall examination. A recall will be accepted if rendered more than 335 days following the complete or previous recall examination, but will be rejected if the service is rendered any time within the 335 days.
If procedures or treatment services are provided during the same appointment, the fees for both the examination and procedure(s) are allowed.
01204 Examination and diagnosis, specific:
examination, diagnosis and evaluation of a specific
situation in a localized area (MSI - includes x-rays).......................24.0932.12
01205 Examination and diagnosis, emergency:
examination for the investigation of discomfort and/or
infection in a localized area (MSI - includes x-rays).......................24.0932.12
The fee for either of specific (01204) or emergency (01205) oral examination is applicable only when no treatment is rendered during the appointment. If a procedure or treatment service is provided, the fee for the procedure, only, is allowed (unless otherwise specified).
05201 Consultation, MSI - specialist - In office ..........................................NA 4.39
(including radiographic examination and interpretation)
The fees are intended to include both the technical and professional components of an x-ray service, however, non readable films are not insured.
Procedural x-rays in connection with root canal therapy are not allowed separately as the fees for root canal therapy include procedural x-rays.
All x-rays are to be made available to the Plan upon request and therefore should be retained for 18 months following the service.
1 Radiographs, intra oral
02101 Radiographs, intra oral, pedodontic, complete series
(minimum of 12 films incl. bitewings)...........................................69.8069.80
02102 Radiographs, intra oral, adult, complete series
(minimum of 16 films incl. bitewings)...........................................69.80 69.80
2 Radiographs, intra oral, periapical
02111 Single film8.56...............................................................................8.56
02112 Two films ....................................................................................11.24 11.24
02113 Three films16.54...........................................................................16.54
02114 Four films ....................................................................................19.75 19.75
02115 Five films ....................................................................................22.96 22.96
02116 Six films ....................................................................................26.28 26.28
02117 Seven films....................................................................................29.44 29.44
02118 Eight films32.71...........................................................................32.71
02119 Nine films ....................................................................................35.92 35.92
02120 Ten films ....................................................................................39.18 39.18
02121 Eleven films..................................................................................42.70 42.70
02122 Twelve films.................................................................................46.54 46.54
02123 Thirteen film..................................................................................50.73 50.73
02124 Fourteen films...............................................................................55.30 55.30
02125 Fifteen films..................................................................................58.61 58.61
3 Radiographs, intra oral, occlusal
02131 Single film20.93...........................................................................20.93
02132 Two films ....................................................................................32.71 32.71
02133 Three films44.48...........................................................................44.48
02134 Four films ....................................................................................56.21 56.21
4 Radiographs, intra oral, bitewing
02141 Single film8.56...............................................................................8.56
02142 Two films ....................................................................................11.24 11.24
02143 Three films16.54...........................................................................16.54
02144 Four films ....................................................................................19.75 19.75
5 Radiographs, extra oral
02201 Single film20.93...........................................................................20.93
02202 Two films ....................................................................................32.71 32.71
02203 Three films44.48...........................................................................44.48
02204 Four films ....................................................................................56.21 56.21
6 Radiographs, postero-anterior and lateral
skull and facial bone
02301 Single filmPA...............................................................................20.93
02302 Two films .......................................................................................PA 32.71
02303 Three filmsPA...............................................................................44.48
02304 Sinus examination - minimum four films identified as:
(1) Waters (2) Calwell (3) Lateral Skull (4) Basal........................PA 56.21
7 Radiographs, sialography
02401 Single filmPA..................................................................................PA
02402 Two films .......................................................................................PA PA
02409 Each additional film over two............................................................PA PA
8 Radiopaque dyes, use of, to demonstrate lesions
02411 One unit of time................................................................................PA PA
02412 Two units of time..............................................................................PA PA
02419 Each additional unit over two............................................................PA PA
9 Radiographs, temporomandibular joint
02501 Single filmPA...............................................................................20.93
02502 Two films .......................................................................................PA 32.71
02503 Three filmsPA...............................................................................44.48
02504 Four films (minimum examination
closed and open each side)................................................................PA56.21
02509 Each additional film over four...........................................................PA PA
10 Radiographs, panoramic
02601 Single film35.97...........................................................................35.97
11 Radiographs, cephalometric
02701 Single film35.97...........................................................................35.97
02702 Two films ....................................................................................58.56 58.56
12 Radiographs, cephalometric, tracing and interpretation
02751 One unit of time................................................................................PA PA
02752 Two units .......................................................................................PA PA
02759 Each additional unit over two............................................................PA PA
13 Radiographs, interpretation (received from another
source, or for MSI - exposed on hospital equipment)
02801 MSI - paid at one-half regular fee
14 Radiographs, hand and wrist
02921 Radiographs, hand and wrist (as a duplicate aid for dental
treatment) per case............................................................................PAPA
15 Radiographs, tomography
02931 Single view.......................................................................................PA PA
02932 Two view .......................................................................................PA PA
02933 Three viewPA..................................................................................PA
02934 Four view .......................................................................................PA PA
02939 Each additional view over four..........................................................PA PA
Tests and Laboratory Examinations
Pulp vitality tests (general and specific) are intended to be included in the fee for an initial examination; therefore, no additional allowance will be made for these tests when performed in conjunction with an initial examination.
Fees for all tests and laboratory examinations, other than pulp vitality tests (general and specific), are payable in addition to the fee for an initial examination when such applies.
Diagnostic casts are to be available to the Plan upon request and accordingly, should be retained for a period of 18 months following the service.
1 Tests, microbiological
04101 Microbiological test for the determination of
pathological agents + L..................................................................21.63 21.63
2 Tests, caries susceptibility
04201 Bacteriological test for the determination of dental caries
susceptibility + L...........................................................................21.1421.14
3 Tests, histological
Test, histological, soft tissue
04311 Biopsy, soft oral tissue - by puncture + L.......................................50.53 50.53
04312 Biopsy, soft oral tissue - by incision + L.........................................50.53 50.53
04313 Biopsy, soft oral tissue - by aspiration + L......................................50.53 50.53
Tests, histological, hard tissue
04321 Biopsy, hard oral tissue - by puncture + L......................................58.19 58.19
04322 Biopsy, hard oral tissue - by incision + L.......................................58.19 58.19
04323 Biopsy, hard oral tissue - by aspiration + L.....................................58.19 58.19
4 Tests, cytological
04401 Cytological smear from the oral cavity + L....................................21.14 21.14
04402 Vital staining of oral mucosal tissues
(+ E - not payable by MSI)............................................................21.1421.14
5 Tests, pulp vitality
04501 One unit of time.............................................................................17.88 17.88
6 Reports, laboratory
04601 Report, microbiological by oral microbiologist..................................PA PA
04602 Report, histological by oral pathologist..............................................PA PA
04603 Report, cytological by oral pathologist...............................................PA PA
04604 Reports, other....................................................................................PA PA
7 Tests and laboratory examinations, miscellaneous
(All available by preauthorization)
Equilibration, casts, diagnostic (pilot equilibration) for extensive or
complicated restorative dentistry + L
04711 One unit of time................................................................................PA PA
04712 Two units .......................................................................................PA PA
04713 Three unitsPA..................................................................................PA
04714 Four units .......................................................................................PA PA
04719 Each additional unit over four............................................................PA PA
Wax-up, diagnostic (to evaluate cosmetic and/or preparation
design and/or occlusal considerations) (gnathological
wax-up) + L
04721 One unit of time................................................................................PA PA
04722 Two units PA..................................................................................PA
04723 Three unitsPA..................................................................................PA
04724 Four units PA..................................................................................PA
04729 Each additional unit over four............................................................PA PA
Split cast mounting, diagnostic + L
04731 One unit of time................................................................................PA PA
04732 Two units PA..................................................................................PA
04733 Three unitsPA..................................................................................PA
04734 Four units PA..................................................................................PA
04739 Each additional unit over four............................................................PA PA
Interpretation of models from another source
04741 First unit of time................................................................................PA PA
04749 Each additional unit of time...............................................................PA PA
04801 Single photograph..........................................................................11.08 11.08
04802 Two photographs...........................................................................22.16 22.16
04803 Three photographs.........................................................................33.24 33.24
04809 Each additional photograph over three...........................................11.08 11.08
1 Cast, diagnostic, unmounted
04911 Cast, diagnostic, unmounted + L....................................................21.63 29.76
04912 Cast, diagnostic, unmounted, duplicate + L........................................PA PA
2 Cast, diagnostic, mounted
04921 Cast, diagnostic, mounted + L........................................................33.62 PA
04922 Cast, diagnostic, mounted using face bow
transfer + L60.86...............................................................................PA
04923 Cast, diagnostic, mounted, using face bow +
occlusal records + L.......................................................................60.86PA
04924 Cast, diagnostic, mounted using fully adjustable
articulator + L (used with 04942).......................................................PAPA
3 Casts, diagnostic, orthodontic
04931 Cast, diagnostic, orthodontic (unmounted, angle
trimmed and soaped) + L...................................................................PA29.76
Part 2 - Endodontics - 30000-39999
(excluding final restoration)
1 Pulpotomy
Pulpotomy vital, permanent teeth (as a separate
emergency procedure)
32221 Anterior and bicuspid teeth............................................................50.10 60.06
32222 Molar teeth50.10...........................................................................60.06
Pulpotomy, vital, primary teeth
32231 Primary tooth as a separate procedure ...........................................40.25 50.05
32232 Primary tooth, concurrent with restorations (but
excluding final restoration)............................................................40.2550.05
2 Pulpectomy (as a separate emergency procedure)
Pulpectomy, permanent teeth/retained primary teeth
32311 One canal ....................................................................................57.70 57.70
32312 Two canals89.40...........................................................................89.40
32313 Three canals......................................................................................PA PA
32314 Four canals or more...........................................................................PA PA
Pulpectomy, primary teeth
32321 Anterior tooth................................................................................57.70 57.70
32322 Posterior tooth...............................................................................85.44 85.44
To include: treatment plan, clinical procedures (i.e. pulpectomy, biomechanical preparation, chemotherapeutic treatment and obturation), with appropriate radiographs and follow-up care, excluding final restoration.
1 Root canals, permanent teeth, retained primary
teeth (includes: clinical procedures with appropriate
radiographs, excluding final restoration)
33111 One canal ..................................................................................227.93 273.53
33121 Two canals333.86.......................................................................393.86
33131 Three canals.................................................................................448.41 538.07
33141 Four or more canals.....................................................................556.70 644.38
2 Root canals, primary teeth
33401 One canal ....................................................................................85.97 108.07
33402 Two canals118.14.......................................................................143.19
33403 Three canals or more...................................................................117.98 141.69
3 Apexification/apical closure/induction of hard tissue
repair (to include biomechanical preparation and
placement of dentogenic media)
33601 One canal ....................................................................................86.82 104.17
33602 Two canals114.95.......................................................................150.31
33603 Three canals.................................................................................146.38 197.10
33604 Four canals or more.....................................................................262.99 297.07
4 Re-insertion of dentogenic media per visit
33611 One canal ....................................................................................38.70 44.72
33612 Two canals38.70...........................................................................44.72
33613 Three canals..................................................................................38.70 44.72
33614 Four canals or more.......................................................................38.70 44.72
1 Apicoectomy/apical curettage
Maxillary anterior
34111 One root ..................................................................................119.05 142.87
34112 Two roots ..................................................................................170.09 185.18
Maxillary bicuspid
34121 One root ..................................................................................169.15 202.93
34122 Two roots ..................................................................................223.86 242.26
34123 Three roots or more.....................................................................267.17 281.53
Maxillary molar
34131 One root ..................................................................................169.15 202.93
34132 Two roots ..................................................................................223.86 242.26
34133 Three roots267.17.......................................................................281.53
34134 Four or more roots.......................................................................300.83 314.75
Mandibular anterior
34141 One root ..................................................................................119.05 142.87
34142 Two or more roots.......................................................................170.09 185.18
Mandibular bicuspid
34151 One root .................................................................................`169.15 202.93
34152 Two roots ..................................................................................223.86 242.26
34153 Three or more roots.....................................................................267.17 281.53
Mandibular molar
34161 One root ..................................................................................169.15 202.93
34162 Two roots ..................................................................................223.86 242.26
34163 Three roots267.17.......................................................................281.53
34164 Four or more roots.......................................................................300.83 314.75
2 Retrofilling
Maxillary anterior
34211 One canal ....................................................................................47.32 56.79
34212 Two or more canals.......................................................................57.35 70.81
Maxillary bicuspid
34221 One canal ....................................................................................47.32 56.79
34222 Two canals57.35...........................................................................70.81
34223 Three canals..................................................................................69.39 88.51
34224 Four or more canals.......................................................................77.79 99.57
Maxillary molar
34231 One canal ....................................................................................47.32 56.79
34232 Two canals57.35...........................................................................70.81
34233 Three canals..................................................................................69.39 88.51
34234 Four or more canals.......................................................................77.79 99.57
Mandibular anterior
34241 One canal ....................................................................................47.32 56.79
34242 Two or more canals.......................................................................57.35 70.81
Mandibular bicuspid
34251 One canal ....................................................................................47.32 56.79
34252 Two canals57.35...........................................................................70.81
34253 Three canals..................................................................................69.39 88.51
34254 Four canals77.79...........................................................................99.57
Mandibular molar
34261 One canal ....................................................................................47.32 56.79
34262 Two canals57.35...........................................................................70.81
34263 Three canals..................................................................................69.39 88.51
34264 Four or more canals.......................................................................77.79 99.57
3 Enlargement, canal and/or pulp chamber
(preparation of post space)
34601 In Previously filled tooth when root canal treatment
done by another practitioner..............................................................PAPA
34602 In calcified canals..............................................................................PA PA
Endodontic, Procedures, Miscellaneous
1 Isolation of endodontic tooth/teeth for asepsis
39101 Banding of tooth/teeth and/or contouring of tissue surrounding
teeth to maintain aseptic operating field (per tooth)........................57.4968.94
2 Bleaching, non vital
Bleaching endodontically treated tooth/teeth
39311 One unit of time............................................................................ 37.58 37.58
39319 Each additional unit over one - MSI -
to a maximum of three...................................................................27.0927.09
Part 3 - Oral and Maxillofacial Surgery - 70000-79999
Certain procedures included in this Part are also contained in the list of MSI Dental Surgical Procedures covering all eligible residents of the Province. These services continue as benefits of MSI, and accordingly, when dental surgical procedures are performed in hospital, care should be taken to ensure that claims for those services which are included on the list of insured dental surgical procedures are submitted with fee code and fee as shown in the Dental Surgical Procedures section.
Bilateral procedures done under the same general anaesthetic, other than uncomplicated extractions, will be entitled to 50% of unilateral procedures.
Bilateral procedures done under local anaesthetic or conscious sedation will be entitled to a fee equivalent to 100% of unilateral procedures.
When more than 2 quadrants are involved, the first 2 procedures will be paid at 100% and subsequent procedures at 50%.
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 considered to include a full quadrant, sextant or group of several teeth, or in some cases a single tooth, which can be practically and conveniently combined for a single surgical sitting.
Removals (Extractions), Erupted Teeth
1 Removals, erupted teeth, uncomplicated
Unless directly related to the developmental anomaly (supply details
with claim) uncomplicated extractions are insured only in the case of
1) pain, infection, trauma 2) ankylosis and 3) supernumerary teeth.
71101 Single tooth, uncomplicated...........................................................35.81 42.98
71109 Each additional tooth, same quadrant, same
appointment...................................................................................18.7922.59
2 Removals, erupted teeth, complicated
71201 Odontectomy, (extraction), erupted tooth, surgical approach,
requiring surgical flap and/or sectioning of tooth............................97.53116.37
Removals (Extractions), Surgical
1 Removals, impactions, soft tissue coverage
Removals, impaction, requiring incision of overlying
soft tissue and removal of the tooth
72111 Single tooth...................................................................................97.53 116.37
2 Removals, impactions, involving tissue and/or bone coverage
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.................................................................................118.14 PA
Removals, impaction, requiring incision of overlying soft
tissue, elevation of a flap, removal of bone AND sectioning
of tooth for removal
72221 Single tooth.................................................................................161.98 PA
Removals, impaction, requiring incision of overlying
soft tissue, elevation of a flap, removal of bone,
sectioning of the tooth for removal AND/OR presents
unusual difficulties and circumstances
72231 Single tooth.......................................................................................PA PA
3 Removals (Extractions), Residual Roots
Removals, residual roots, erupted
72311 First tooth ....................................................................................35.81 PA
Removals, residual roots, soft tissue coverage
72321 First tooth ...................................................................................67.12 80.56
Removals, residual roots, bone tissue coverage
72331 First tooth ..................................................................................139.60 167.49
4 Post extraction bone preservation
Simple ridge preservation, alloplastic material
(+ E - not payable by MSI)
72411 First tooth .......................................................................................PA PA
5 Surgical exposure of teeth
Surgical exposure, unerupted, uncomplicated, soft tissue
coverage (includes operculectomy)
72511 Single tooth.................................................................................123.49 154.54
Surgical exposure, complex, hard tissue coverage
72521 Single tooth.......................................................................................PA PA
Surgical exposure, unerupted tooth, with orthodontic
attachment
72531 Single tooth.................................................................................136.02 163.32
Surgical exposure, unerupted tooth, soft tissue coverage
with positioning of attached gingivae
72541 Single tooth.......................................................................................PA PA
Surgical exposure, unerupted tooth, hard tissue coverage with
positioning of attached gingivae
72551 Single tooth.......................................................................................PA PA
6 Surgical movement of teeth
Transplantation of erupted tooth
72611 First tooth .......................................................................................PA PA
Transplantation of unerupted tooth
72621 First tooth .......................................................................................PA PA
Repositioning, surgical
72631 First tooth .......................................................................................PA PA
Surgical incision and drainage and/or exploration,
intra-oral soft tissue
75111 Intra-oral, surgical exploration, soft tissue..........................................PA PA
75112 Intra-oral, abscess, soft tissue.........................................................50.10 66.27
75113 Intra-oral, abscess, in major anatomical
area with drain...................................................................................PAPA
Surgical incision and drainage and/or exploration,
intra-oral hard tissue
75121 Intra-oral, abscess, hard tissue, trephination and
drainage.......................................................................................PAPA
75122 Intra-oral, surgical exploration, hard tissue.........................................PA PA
75123 Intra-oral, abscess, hard tissue, trephination and
drainage in major anatomical area......................................................PAPA
It is understood that the majority of fractures will be treated in hospital and covered under the MSI Dental Surgical Benefit. However, independent consideration will be given for fractures treated in a dental office. Explanation should be included on the claim form.
Fracture, alveolar, debridement, teeth removed
76911 3 cm or less.......................................................................................PA PA
76912 3-6 cm .......................................................................................PA PA
76913 6 cm and over....................................................................................PA PA
Reduction, alveolar, closed, with teeth (fixation extra)
76921 3 cm or less.......................................................................................PA PA
76922 3-6 cm .......................................................................................PA PA
76923 6-9 cm .......................................................................................PA PA
76924 9 cm and over....................................................................................PA PA
Reduction, alveolar, open, with teeth (fixation extra)
76931 3 cm and less.....................................................................................PA PA
76932 3-6 cm .......................................................................................PA PA
76933 6-9 cm .......................................................................................PA PA
76934 9 cm and over....................................................................................PA PA
Replantation, avulsed tooth/teeth (including splinting)
76941 Replantation, first tooth.....................................................................PA PA
76949 Each additional tooth.........................................................................PA PA
Repositioning of traumatically displaced teeth
76951 One unit of time................................................................................PA PA
76952 Two units of time..............................................................................PA PA
76959 Each additional unit over two............................................................PA PA
77801 Frenectomy, upper labial (office only)..........................................111.82 111.82
77801 Frenectomy, upper labial (hospital only)........................................83.50 83.50
77802 Frenectomy, lower labial (office only)..........................................111.82 111.82
77802 Frenectomy, lower labial (hospital only)........................................83.50 83.50
79401 Primary hemorrhage, control.............................................................PA PA
79402 Secondary hemorrhage, control..........................................................PA PA
79403 Hemorrhage control, using compression
and hemostatic agent......................................................................34.9041.91
79404 Hemorrhage control, using hemostatic substance
and sutures (including removal of bony tissue,
if necessary)...................................................................................34.9041.91
(Required by complications and unusual circumstances, refer to comment at beginning of Part 3.)
79605 Post surgical care, alveolitis, treatment of
(without anaesthesia)....................................................................29.5535.54
79606 Post surgical care, alveolitis, treatment of
(with anaesthesia)..........................................................................29.5535.54
(Includes placement of implant, post-surgical care, uncovering and placement of attachment but not prosthesis.)
1 Implants, Endosseous, Integrated Cylindrical
79951 First stage surgical placement, maxilla per implant
(+ E - not payable by MSI)................................................................PAPA
79952 First stage surgical placement, mandible per implant
(+ E - not payable by MSI)................................................................PAPA
79953 Second stage exposure and temporization, maxilla
per implant (+ E - not payable by MSI)..............................................PAPA
79954 Second stage exposure and temporization, mandible
per implant (+ E - not payable by MSI).............................................PA PA
2 Implants, removal of
79991 First implant (uncomplicated)............................................................PA PA
79992 First implant (complicated)................................................................PA PA
Part 4 - Orthodontics - 80000-89999
Orthodontic Services, Observations and Adjustments
Recementation of fixed appliances - msi - not including
brackets
80651 One unit of time.............................................................................31.37 37.47
Appliances, Active, for Tooth Guidance or Minor Tooth Movement
1 Appliances, Removable
Appliances, removable, space regaining
81113 Appliance, maxillary, bilateral + L...............................................344.14 440.59
81114 Appliance, mandibular, bilateral + L............................................344.14 440.59
Appliances, removable, cross-bite correction
81121 Appliance, maxillary, simple + L.......................................................PA 808.02
81122 Appliance, mandibular, simple + L....................................................PA 808.02
Appliances, removable, dental arch expansion
81131 Appliance, maxillary, simple + L.......................................................PA PA
81132 Appliance, mandibular, simple + L....................................................PA PA
Appliances, removal, closure of diastemas
81141 Appliance, maxillary, simple + L.......................................................PA PA
81142 Appliance, mandibular, simple + L....................................................PA PA
Appliances, removable, alignment of anterior teeth
81151 Appliance, maxillary, simple + L.......................................................PA PA
81152 Appliance, mandibular, simple + L....................................................PA PA
2 Appliances, fixed or cemented
Appliance, fixed, space regaining (e.g. lingual or labial arch
with molar bands, tubes, locks)
81211 Appliance, maxillary + L...................................................................PA 440.59
81212 Appliance, mandibular + L................................................................PA 440.59
Appliance, fixed, space regaining, unilateral
81221 Appliance, maxillary + L...................................................................PA 307.47
81222 Appliance, mandibular + L................................................................PA 307.47
Appliance, fixed, cross-bite correction - anterior
MSI - as Phase I treatment
81231 Appliance, maxillary + L...................................................................PA 808.02
81232 Appliance, mandibular + L................................................................PA 808.02
Appliance, fixed, cross-bite correction - posterior
MSI - as Phase I treatment
81241 Appliance, maxillary + L...................................................................PA 808.02
81242 Appliance, mandibular + L................................................................PA 808.02
81243 Appliance, two-molar band, hooked and elastics + L.........................PA 808.02
Appliance, fixed, dental arch expansion
81251 Appliance, maxillary + L...................................................................PA PA
81253 Appliance, maxillary, rapid expansion + L.........................................PA PA
Appliance, fixed, closure of diastemas
81261 Appliance, maxillary, simple + L.......................................................PA PA
81262 Appliance, mandibular, simple + L....................................................PA PA
Appliance, fixed, alignment of incisor teeth
81271 Appliance, maxillary, simple + L.......................................................PA PA
81272 Appliance, mandibular, simple + L....................................................PA PA
Appliances, fixed, mechanical eruption tooth/teeth
81291 Appliance, maxillary + L...................................................................PA PA
81292 Appliance, mandibular + L................................................................PA PA
3 Appliances, retention, orthodontic retaining appliances
Appliances, removable, retention
83101 Appliance, maxillary + L (MSI - $60.00 lab maximum)....................PA 214.00
83102 Appliance, mandibular + L (MSI - $60.00 lab maximum)..................PA 214.00
83103 Appliance, tooth positioner + L (MSI - $60.00
lab maximum)...................................................................................PA214.00
Appliances, fixed/cemented, retention
83201 Appliance, maxillary + L (MSI - $60.00 lab maximum)....................PA 214.00
83202 Appliance, mandibular + L (MSI - $60.00 lab maximum)..................PA 214.00
Comprehensive Orthodontic Treatment
1 Fixed appliance (includes formal full banded treatment and retention)
Permanent dentition
84101 Class I malocclusion (MSI - non-surgical case)..................................PA 3519.00
84101 Class I malocclusion (MSI - surgical case).........................................PA 3867.00
84201 Class II malocclusion (MSI - non-surgical case)................................PA 4111.00
84201 Class II malocclusion (MSI - surgical case).......................................PA 4355.00
84301 Class III malocclusion (MSI - non-surgical case)...............................PA 5052.00
84301 Class III malocclusion (MSI - surgical case)......................................PA 5958.00
84401 Malocclusions not requiring complete banding..................................PA PA
2 Removable appliance (includes removable appliance therapy and
retention; e.g. functional appliances for mixed and primary dentition)
Permanent dentition
87101 Class I malocclusion + L...................................................................PA PA
87201 Class II malocclusion + L..................................................................PA PA
87301 Class III malocclusion + L.................................................................PA PA
Mixed dentition
88101 Class I malocclusion + L...................................................................PA PA
88201 Class II malocclusion + L..................................................................PA PA
88301 Class III malocclusion + L.................................................................PA PA
Part 5 - Periodontics - 40000- 49999
(This may involve application and burnishing of medicinal aids on the root or the use of a variety of therapeutic procedures. More than one appointment may be necessary.)
(MSI - details as to rationale must accompany claim.)
41301 One unit of time.............................................................................22.00 22.00
41302 Two units ....................................................................................44.00 44.00
41309 Each additional unit over two.........................................................22.00 22.00
Periodontal Services, Surgical
(Includes local anesthetic, suturing and the placement and removal of initial surgical dressing. A surgical site is an area that lends itself to one or more procedures. It is considered to include a full quadrant, sextant or a group of teeth or in some cases a single tooth which can be practically and conveniently combined for a single surgical sitting.)
1 Periodontal surgery, gingival curettage
Surgical curettage, to include definitive root planing
42111 Per sextant77.83...........................................................................93.53
2 Periodontal surgery, gingivoplasty
42201 Per sextantPA.............................................................................133.75
3 Periodontal surgery, gingivectomy
(The procedure by which gingival deformities are reshaped and reduced to create normal and functional form, when the pocket is uncomplicated by extension into the underlying bone.)
Gingivectomy, uncomplicated
42311 Per sextantPA...............................................................................95.98
Gingivectomy, with curettage
42321 Per sextantPA.............................................................................105.58
Gingival fiber incision (supra crestal fibrotomy)
42331 Per tooth .......................................................................................PA 17.85
42339 Each additional tooth.........................................................................PA 17.85
Soft tissue recontouring for crown lengthening
42341 Limited recontouring of tissue, per tooth............................................PA 49.90
4 Periodontal surgery, flap approach
Flap approach, with osteoplasty/ostectomy
42411 Per sextantPA.............................................................................196.08
Flap approach, with curettage of osseous defect
42421 Per sextantPA.............................................................................196.08
Flap approach, with curettage of osseous defect and osteoplasty
42431 Per sextantPA.............................................................................219.56
Flap approach, exploratory (for diagnosis)
42441 Per site .......................................................................................PA 48.30
Flap approach, with osteoplasty/ostoectomy for crown
lengthening
42451 Per site .......................................................................................PA 196.08
5 Periodontal surgery, grafts
Grafts, soft tissue, pedicle (including apically or coronally
positioned, lateral sliding and rotated flaps)
42511 Per site .......................................................................................PA 217.92
42512 Periosteal stimulation in addition to 42511........................................PA 239.71
Grafts, soft tissue, pedicle (coronally positioned)
42521 Per site .......................................................................................PA 217.92
42522 Periosteal stimulation in addition to 42521........................................PA 239.71
Grafts, free soft tissue
42531 Per site .......................................................................................PA 217.92
Grafts, soft tissue, pedicle, with free graft placed in pedicle
Donar site
42541 Per site .......................................................................................PA 217.92
Grafts, free connective tissue (for root coverage)
42551 Per site .......................................................................................PA 217.92
Grafts, free connective tissue (for ridge augmentation)
42561 Per site .......................................................................................PA 217.92
Grafts, connective tissue, pedicle with free graft for root
coverage
42571 Per site .......................................................................................PA 217.92
Grafts, gingival onlay, for ridge augmentation
42581 Per site .......................................................................................PA 217.92
6 Periodontal surgery, grafts, osseous tissue
Grafts, osseous, autograft (including flap entry and closure)
42611 Per site .......................................................................................PA 188.15
Grafts, osseous, allograft (including flap entry and closure)
42621 Per site (+ E - not payable by MSI)....................................................PA PA
7 Periodontal surgery, miscellaneous procedures
Guided tissue regeneration (including re-entry)
42711 Per site (+ E - not payable by MSI)....................................................PA PA
8 Periodontal surgery, miscellaneous procedures
Proximal wedge procedure (as a separate procedure)
42811 With flap curettage, per site...............................................................PA PA
42819 With flap curettage and ostectomy/ostoplasty, per site........................PA PA
Post surgical periodontal treatment visit per dressing change
42821 One unit of time................................................................................PA PA
42822 Two units of time..............................................................................PA PA
42823 Three units of time............................................................................PA PA
42829 Each additional unit over three..........................................................PA PA
Periodontal abscess or pericoronitis, may include one or more
of the following procedures: lancing, scaling, curettage,
surgery or medication
42831 One unit of time................................................................................PA PA
42832 Two units .......................................................................................PA PA
42833 Three unitsPA..................................................................................PA
42834 Four units .......................................................................................PA PA
42839 Each additional unit over four............................................................PA PA
Periodontal Procedures, Adjunctive
(When per joint is designated, the corresponding tooth code is represented by the mesial of the tooth involved, except at the midline, where the tooth to the right of the joint is utilized.)
1 Periodontal splinting or ligation, provisional, intra coronal
“A” splint (acrylic, composite or amalgam, plus knurled wire)
43111 Per joint .......................................................................................PA 31.58
2 Periodontal splinting or ligation, provisional, extra coronal
Acid etch joint restorations (per joint)
43211 Per joint .......................................................................................PA 41.38
Acid etch, interproximal enamel splint
43221 Per joint .......................................................................................PA 41.38
Wire ligation
43231 Per joint .......................................................................................PA 41.38
Wire ligation, acrylic covered
43241 Per joint .......................................................................................PA 41.38
Dental floss ligation
43251 Per joint .......................................................................................PA 41.38
Orthodontic band splint
43261 Per band .......................................................................................PA 41.38
Cast/soldered splint acid etch/resin bonded
43271 Per abutment + L...............................................................................PA 41.38
Removal of fixed periodontal splints
43281 One unit of time................................................................................PA PA
43289 Each additional unit of time...............................................................PA PA
Occlusal adjustment/equilibration:
(a) may require several sessions;
(b) may be used in conjunction with basic restorative treatment
only when occlusal adjustment/equilibration is not required
as a result of that restoration;
(c) is not to be used in conjunction with the delivery and post-insertion
care of fixed or removable prosthesis (5000+6000 code series)
by the same dentist for a period of 3 months.
43311 One unit of time.............................................................................34.53 41.38
43312 Two units ....................................................................................69.06 82.76
43313 Three units103.59.......................................................................124.14
43314 Four units ..................................................................................138.12 165.52
43317 One half unit..................................................................................17.27 20.69
43319 Each additional unit over four........................................................34.53 41.38
43421 One unit of time.............................................................................34.53 41.38
43422 Two units ....................................................................................69.06 82.76
43423 Three units103.59.......................................................................124.14
43424 Four units ..................................................................................138.12 165.52
43425 Five units ..................................................................................172.65 206.90
43426 Six units ..................................................................................207.18 248.28
Chemotherapeutic and/or Antimicrobial Agents
1 Chemotherapeutic and/or antimicrobial agents, topical application
43511 One unit of time................................................................................PA PA
43519 Each additional unit of time...............................................................PA PA
2 Chemotherapeutic and/or antimicrobial agents, intra-sulcular
43521 One unit of time................................................................................PA PA
43529 Each additional unit of time...............................................................PA PA
1 Appliances, periodontal
(See separate codes for TMJ (43700) and TMJ appliances (78700).)
Appliances, periodontal (including bruxism appliance):
includes impression, insertion and adjustment
43611 Maxillary appliance + L....................................................................PA PA
43612 Mandibular appliance + L..................................................................PA PA
Appliances, maintenance, adjustments, repair (including
bruxism appliances)
43621 One unit of time + L..........................................................................PA PA
43622 Two units of time + L........................................................................PA PA
43623 Three units of time + L......................................................................PA PA
43629 Each additional unit over three..........................................................PA PA
Appliances, reline (including bruxism appliances)
43631 Reline, direct.....................................................................................PA PA
43632 Reline, processed + L........................................................................PA PA
2 Appliances, temporomandibular joint
Appliance, TMJ, diagnostic
43711 Maxillary appliance + L....................................................................PA PA
43712 Mandibular appliance + L..................................................................PA PA
Appliance, TMJ intra-oral repositioning
43721 Maxillary appliance + L...............................................................185.96 222.95
43722 Mandibular appliance + L............................................................185.96 222.95
Appliance, TMJ, periodic maintenance, adjustments, repairs
43731 One unit of time + L......................................................................31.34 37.63
43732 Two units of time + L....................................................................62.68 75.26
43733 Three units of time + L..................................................................94.02 112.89
43739 Each additional unit over three.......................................................31.34 37.63
Appliance, TMJ, relines
43741 Reline, direct.....................................................................................PA PA
43742 Reline, processed + L........................................................................PA PA
3 Appliances, myofacial pain syndrome
(Conditions that originate outside the temporomandibular joint, to include: models, gnathological determinants, adjustments and three post insertion adjustments.)
43801 Maxillary appliance + L....................................................................PA PA
43802 Mandibular appliance + L..................................................................PA PA
Appliance, myofacial pain syndrome, periodic maintenance,
adjustment and repairs
43811 One unit of time + L..........................................................................PA PA
43812 Two units of time + L........................................................................PA PA
43813 Three units of time + L......................................................................PA PA
43819 Each additional unit over three..........................................................PA PA
Periodontal Services, Miscellaneous
1 Periodontal re-evaluation
49101 One unit of time................................................................................PA PA
49102 Two units of time..............................................................................PA PA
49109 Each additional unit over two............................................................PA PA
2 Periodontal irrigation, subgingival
49211 One unit of time................................................................................PA PA
49219 Each additional unit of time...............................................................PA PA
3 Provisional non-coded services
Root separation.................................................................................PAPA
Forced eruption - one tooth................................................................PAPA
Forced eruption - more than one tooth...............................................PAPA
Rapid extrusion - one tooth...............................................................PAPA
Rapid extrusion - more than one tooth...............................................PAPA
Part 6 - Preventive - 10000-19999
1 Polishing - See below “Caries prevention service”
2 Scaling
11111 One unit of time.............................................................................21.14 21.14
11112 Two units of time..........................................................................42.28 42.28
11113 Three units of time.........................................................................63.42 63.42
11114 Four units of time..........................................................................84.56 84.56
11115 Five units of time.........................................................................105.76 105.76
3 Fluoride treatments
12101 Fluoride treatment, topical application...........................................11.03 11.03
1 Nutritional dietary counselling
Including: recording and analysis of 7-day dietary intake and consultation (MAXIMUM OF 4 PAYABLE PER LIFETIME - MSI)
13101 One unit of time.............................................................................21.14 21.14
2 Caries prevention service - MSI (previously MSI fee code 220)
Oral hygiene instruction/plaque control, to include: brushing and/or flossing and/or embrasure cleaning, includes for MSI Programs rubber cup polishing and minor scaling procedures.
13211 One unit of time.............................................................................21.14 21.14
3 Sealants, pit and fissure (acid etch preparation included)
(MSI - limited to 6-year molars that meet guidelines - one
application per tooth.)
13401 Each tooth19.27...........................................................................19.27
4 Disking of teeth, interproximal (MSI - MAXIMUM 3 UNITS
PER LIFETIME)
13701 One unit ....................................................................................37.58 37.58
13702 Two units ....................................................................................75.16 75.16
13703 Three units112.74.......................................................................112.74
5 Recontouring of teeth for functional reasons (not associated
with delivery of a single or multiple prosthesis)
13901 One unit of time................................................................................PA PA
13909 Each additional unit of time...............................................................PA PA
(Includes the design, separation, fabrication, insertion and where applicable initial cementation and removal.)
1 Space maintainers, band type
15101 Space maintainer, band type, fixed, unilateral + L..........................86.82 116.10
15103 Space maintainer, band type, fixed, bilateral
(soldered lingual arch) + L...........................................................109.47176.64
15105 Space maintainer, band type, fixed, bilateral tubes
and locking wires + L..................................................................148.65193.19
2 Space maintainers, stainless steel crown type
15201 Space maintainer, stainless steel crown type,
fixed + L..................................................................................112.04134.46
3 Space maintainers, maintenance of
15601 Maintenance, space maintainer appliance, to include
adjustment and/or recementation after 30 days
from insertion................................................................................40.5740.57
Part 7- Prosthetics - Removable - 50000-59999
Dentures, complete (includes: impressions, initial and final jaw relation records, try-in evaluation and check records, insertion and adjustments, including 3 months post insertion care)
1 Dentures, complete, equilibrated (involves remounted
equilibration on a semi adjustable articulator)
51201 Maxillary + L....................................................................................PA 851.27
51202 Mandibular + L.................................................................................PA 887.34
51204 Liners, resilient in addition to above + L............................................PA 42.00
2 Dentures, surgical, standard (immediate) (includes tissue
conditioner, but does not include hard reline, but does include
3 months post insertion care)
51301 Maxillary + L..............................................................................392.90 PA
51302 Mandibular + L............................................................................392.90 PA
3 Dentures, complete, transitional (temporary)
51601 Maxillary + L....................................................................................PA 584.32
51602 Mandibular + L.................................................................................PA 584.32
4 Dentures, complete, overdenture
51701 Maxillary + L....................................................................................PA PA
51702 Mandibular + L.................................................................................PA PA
5 Dentures, complete, overdentures (immediate)
51801 Maxillary + L....................................................................................PA PA
51802 Mandibular + L.................................................................................PA PA
6 Dentures, complete, attached to implants
Dentures, removable, tissue bone, with independent
attachments secured to implants
51921 Maxillary + L....................................................................................PA PA
51922 Mandibular + L.................................................................................PA PA
1 Dentures, partial, acrylic base (transitional)
(with or without clasps)
52101 Maxillary + L..............................................................................121.88 PA
52102 Mandibular + L............................................................................121.88 PA
2 Dentures, partial, acrylic base (immediate)
52111 Maxillary + L....................................................................................PA PA
52112 Mandibular + L.................................................................................PA PA
3 Dentures, partial, acrylic, with metal wrought/cast
clasps and/or rests
52301 Maxillary + L..............................................................................239.43 294.62
52302 Mandibular + L............................................................................239.43 294.62
4 Dentures, partial, acrylic, with metal wrought/cast
clasps and/or rests (immediate)
52311 Maxillary + L..............................................................................239.43 294.62
52312 Mandibular + L............................................................................239.43 294.62
5 Dentures, partial, overdenture, acrylic, with
cast/wrought clasps and/or rests
52501 Maxillary + L....................................................................................PA PA
52502 Mandibular + L.................................................................................PA PA
6 Dentures, partial, overdenture, acrylic, with cast/wrought
clasps and/or rests (immediate)
52511 Maxillary + L....................................................................................PA PA
52512 Mandibular + L.................................................................................PA PA
Dentures, Partial, Cast with Acrylic Base
1 Dentures, partial, free end, cast frame/connector,
clasps and rests
53101 Maxillary + L....................................................................................PA PA
53102 Mandibular + L.................................................................................PA PA
53104 Altered cast impression technique in conjunction
with 53101, 53102, 53103 + L...........................................................PAPA
2 Dentures, partial, tooth borne, cast frame/
connector, clasps and rests
53201 Maxillary + L..............................................................................341.78 PA
53202 Mandibular + L............................................................................341.78 PA
3 Dentures, partial, cast, precision attachments
53401 Maxillary + L..............................................................................484.97 PA
53402 Mandibular + L............................................................................484.97 PA
4 Dentures, partial, cast, semi-precision attachments
53501 Maxillary + L....................................................................................PA PA
53502 Mandibular + L.................................................................................PA PA
5 Dentures, partial, cast, overdenture, removable
53701 Maxillary + L....................................................................................PA PA
53702 Mandibular + L.................................................................................PA PA
53704 Altered cast impression technique done in
conjunction with 53701, 53702 and 53703 + L..................................PAPA
(after 3 months insertion or by other than the dentist providing prosthesis)
1 Denture adjustments, partial or complete denture, minor
54201 One unit of time + L......................................................................31.37 37.52
2 Denture adjustments, partial or complete
denture, remount and occlusal equilibration
54301 Maxillary + L....................................................................................PA 198.91
54302 Mandibular + L.................................................................................PA 207.37
1 Denture, repair, complete denture, no impression required
55101 Maxillary + L................................................................................28.26 34.10
55102 Mandibular + L..............................................................................28.26 34.10
2 Denture, repair, complete denture, impression required
55201 Maxillary + L................................................................................57.06 68.36
55202 Mandibular + L..............................................................................57.06 68.36
3 Denture, repairs/additions, partial denture, no impression required
55301 Maxillary + L................................................................................28.26 37.63
55302 Mandibular + L..............................................................................28.26 37.63
4 Denture, repairs/additions, partial denture, impression required
55401 Maxillary + L................................................................................57.06 68.36
55402 Mandibular + L..............................................................................57.06 68.36
5 Dentures, implant retained prosthesis, prophylaxis and polishing
55501 One unit of time + L..........................................................................PA PA
55509 Each additional unit of time...............................................................PA PA
Dentures, Duplication, Relining, Rebasing, and Remaking
1 Dentures, duplication
Denture, duplication, complete denture
56111 Maxillary + L....................................................................................PA PA
56112 Mandibular + L.................................................................................PA PA
2 Dentures, relining
Denture, reline, direct, complete denture
56211 Maxillary ..................................................................................100.85 100.85
56212 Mandibular100.85.......................................................................100.85
Denture, reline, direct, partial denture
56221 Maxillary ....................................................................................96.73 96.73
56222 Mandibular96.73...........................................................................96.73
Denture, reline, processed, complete denture
56231 Maxillary + L..............................................................................125.47 125.47
56232 Mandibular + L............................................................................125.47 125.47
Denture, reline, processed, partial denture
56241 Maxillary + L................................................................................73.92 73.92
56242 Mandibular + L..............................................................................73.92 73.92
Denture, reline, processed, functional impression
requiring 3 appointments, partial denture
56261 Maxillary + L..............................................................................125.47 125.47
56262 Mandibular + L............................................................................125.47 125.47
3 Dentures, remake
Denture, remake, using existing framework, partial denture
56411 Maxillary + L....................................................................................PA PA
56412 Mandibular + L.................................................................................PA PA
1 Denture, tissue conditioning, per appointment, complete denture
56511 Maxillary + L................................................................................61.40 61.40
56512 Mandibular + L..............................................................................61.40 61.40
2 Denture, tissue conditioning, per appointment, partial denture
56521 Maxillary + L................................................................................71.03 71.03
56522 Mandibular + L..............................................................................71.03 71.03
Dentures, Miscellaneous Services
56601 Resilient liner, in relined or rebased denture (in addition
to reline or rebase of denture) + L..................................................61.4061.40
56602 Resetting of teeth (not including reline or rebase
of denture) + L..................................................................................PAPA
Part 8 - Prosthodontics - Fixed - 60000 - 69999
Fixed bridges (each abutment, each retainer and each pontic constitutes a separate unit in a bridge, with a separate code number).
1 Pontics, bridge
Pontics, cast
62101 Pontics, cast metal + L......................................................................PA 166.80
62102 Pontics, cast metal core with separate porcelain
jacket pontic + L...............................................................................PA166.80
Pontics, porcelain/polymer glass
62501 Pontics, porcelain fused to metal + L.................................................PA 187.30
62502 Pontics, porcelain, aluminous + L......................................................PA 187.30
Pontics, acrylic/plastic/composite
62702 Pontics, acrylic/plastic/composite, processed indirect
(transitional) + L...............................................................................PAPA
62703 Pontics, acrylic/plastic/composite, transitional direct..........................PA PA
2 Recontouring of retainers/pontics, per tooth
(of existing bridgework)
63001 One unit of time................................................................................PA PA
63009 Each additional unit of time...............................................................PA PA
3 Master cast, facebow mounting
64101 Master cast, facebow mounting + L...................................................PA PA
4 Repairs, removal
Removal, fixed bridge
66211 One unit of time.............................................................................36.72 44.05
5 Repairs, recementation (+L where laboratory charges are
incurred during repair of bridge)
66301 One unit of time + L......................................................................42.23 50.53
6 Repairs, fixed bridge
Repairs, porcelain/ceramic/plastic/composite, direct
66711 First tooth PA..................................................................................PA
66719 Each additional tooth.........................................................................PA PA
Repairs, solder indexing to repair broken solder joint
66721 One unit of time + L..........................................................................PA PA
66729 Each additional unit of time...............................................................PA PA
1 Retainers, plastic/acrylic
67101 Retainer, plastic/acrylic, processed + L...........................................37.74 46.73
67102 Retainer, plastic processed to metal + L.........................................37.74 46.73
Retainers, plastic/acrylic, direct (transitional during healing,
done at chairside)
67121 First tooth .......................................................................................PA PA
67129 Each additional tooth.........................................................................PA PA
Retainers, plastic/acrylic, indirect, processed (transitional
during healing)
67131 First tooth + L...................................................................................PA PA
67139 Each additional tooth + L..................................................................PA PA
Retainers, plastic/acrylic, indirect, processed, attached
to implants
67141 First implant + L...............................................................................PA PA
67149 Each additional implant + L..............................................................PA PA
2 Retainers, porcelain/ceramic/polymer glass
67201 Retainer, porcelain/ceramic + L.........................................................PA PA
Retainers, porcelain fused to metal
67211 Retainers, porcelain/ceramic fused to metal + L.................................PA 407.25
67212 Stress breaker and/or precision attachments, in
addition to above + L........................................................................PA116.26
Retainers, porcelain/ceramic fused to metal, attached to implant
67221 First implant + L...............................................................................PA PA
67229 Each additional implant + L..............................................................PA PA
3 Retainers, metal, cast
Retainers, metal full cast
67301 Retainers, metal full cast + L.............................................................PA 407.25
67302 Stress breaker and/or precision attachments, in
addition to above + L........................................................................PA116.26
Retainers, metal 3/4 cast
67311 Retainers, metal 3/4 cast + L.............................................................PA 407.25
67312 Stress breakers and/or precision attachments, in
addition to above + L........................................................................PA116.26
Retainers, metal inlay (used with broken stress technique)
67321 Retainer, metal inlay, two surfaces + L..............................................PA 309.77
67322 Retainer, metal inlay, three or more surfaces + L...............................PA 388.62
Retainers, metal, onlay (internal retention type)
67331 Retainer, metal, onlay + L.................................................................PA 388.62
Retainers, metal, onlay (external retention type)
67341 Retainer, metal, onlay, acid etch and/or perforated, bonded
to abutment tooth, (pontic extra) + L.................................................PA PA
Retainers, metal, prefabricated or custom cast, attached to
transmucosal component (25761) used with 67503
67351 Retainer + L and/or (+ E - not payable by MSI).................................PA PA
67359 Each additional retainer + L and/or (+ E - not
payable by MSI)................................................................................PAPA
Fixed Prosthodontics, Abutments/Retainers, Miscellaneous Services
67501 Abutment preparation under existing partial denture
clasp, in addition to retainer codes + L...............................................PAPA
67502 Telescoping crown unit + L...............................................................PA 540.69
67503 Implant, each retentive bar attached by screws to
implant (67351) to retain removable prosthesis (see
51920 for prosthesis).........................................................................PAPA
Fixed Prosthetics, Other Services
1 Fixed prosthetics, miscellaneous services
69101 Fixed prosthesis, porcelain, to replace a substantial
portion of the alveolar process (in addition to retainer
and pontics) + L................................................................................PAPA
2 Fixed prosthetics, splinting
69201 Splinting for extensive or complicated restorative
dentistry(per tooth) + L......................................................................PAPA
3 Fixed prosthetics, retentive pins (for retainers in
addition to restoration)
69301 One pin/restoration + L..................................................................18.84 18.84
69302 Two pins/restoration + L................................................................27.69 27.69
69303 Three pins/restoration + L..............................................................37.38 37.38
69304 Four pins/restoration + L................................................................49.71 49.71
69305 Five pins or more/restoration + L...................................................70.10 70.10
4 Fixed prosthetics, provisional coverage (in
extensive or complicated restorative dentistry)
69701 Abutment tooth + L.......................................................................39.18 46.78
69702 Pontic + L .......................................................................................PA PA
5 Fixed prosthetic framework, attached to
endosseous integrated implants
Fixed framework attached with screws and incorporated teeth
(denture teeth and acrylic)
69811 Maxillary + L....................................................................................PA PA
69812 Mandibular + L.................................................................................PA PA
Fixed framework attached with screws and incorporating teeth
(full metal and porcelain bonded to metal crowns)
69821 Maxillary + L....................................................................................PA PA
69822 Mandibular + L.................................................................................PA PA
Removal of implant screw - retained prosthesis for cleaning
or repair
69831 One unit of time................................................................................PA PA
69839 Each additional unit of time...............................................................PA PA
Reinsertion of implant screw - retained prosthesis
69841 One unit of time + E and/or + L........................................................PA PA
69849 Each additional unit of time...............................................................PA PA
Part 9 - Restorative Services - 20000- 29999
Caries, Trauma and Pain Control
(MSI - permanent teeth only)
Removal of carious lesions or existing restorations and
placement of sedative/protective dressings, includes pulp
caps when necessary, as a separate procedure)
20111 First tooth ....................................................................................37.58 45.12
Removal of carious lesions or existing restorations and
placement of sedative/protective dressings, includes pulp
caps when necessary and the use of a band for retention
and support, as a separate procedure)
20121 First tooth ....................................................................................51.01 58.24
Trauma control, smoothing of fractured surfaces per tooth
20131 First tooth .......................................................................................PA PA
1 Restorations, amalgam, primary teeth
Restorations, amalgam, non-bonded, primary teeth
21111 One surface...................................................................................24.89 29.82
21112 Two surfaces.................................................................................35.81 43.20
21113 Three surfaces................................................................................41.16 49.41
21114 Four surfaces.................................................................................51.92 62.20
21115 Five surfaces or maximum surfaces per tooth.................................65.36 78.42
Restorations, amalgam, bonded, primary teeth
21121 One surface...................................................................................24.89 29.82
21122 Two surfaces.................................................................................35.81 43.20
21123 Three surfaces................................................................................41.16 49.41
21124 Four surfaces.................................................................................51.92 62.20
21125 Five surfaces or maximum surfaces per tooth.................................65.36 78.42
2 Restorations, amalgam, permanent teeth
Restorations, amalgam, non-bonded, permanent bicuspids
and anteriors
21211 One surface...................................................................................32.22 38.59
21212 Two surfaces.................................................................................48.34 57.65
21213 Three surfaces................................................................................60.86 72.75
21214 Four surfaces.................................................................................78.74 98.01
21215 Five surfaces or maximum surfaces per tooth.................................96.67 115.41
Restorations, amalgam, non-bonded, permanent molars
21221 One surface...................................................................................35.33 42.23
21222 Two surfaces.................................................................................52.57 62.90
21223 Three surfaces................................................................................68.89 82.17
21224 Four surfaces.................................................................................94.85 113.91
21225 Five surfaces or maximum surfaces per tooth...............................126.22 150.74
Restorations, amalgam, bonded, permanent bicuspids
and anteriors
21231 One surface...................................................................................32.22 38.59
21232 Two surfaces.................................................................................48.34 57.65
21233 Three surfaces................................................................................60.86 72.75
21234 Four surfaces.................................................................................78.74 98.01
21235 Five surfaces or maximum surfaces per tooth.................................96.67 115.41
Restorations, amalgam, bonded, permanent molars
21241 One surface...................................................................................35.33 42.23
21242 Two surfaces.................................................................................52.57 62.90
21243 Three surfaces................................................................................68.89 82.17
21244 Four surfaces.................................................................................94.85 113.91
21245 Five surfaces or maximum surfaces per tooth...............................126.22 150.74
3 Restorations, amalgam cores
21301 Restorations, amalgam core, in conjunction
with crownPA..................................................................................PA
21302 Restorations, amalgam core, bonded, in conjunction
with crownPA..................................................................................PA
4 Pins, retentive per restoration (for amalgams and tooth
coloured restorations)
21401 One pin ......................................................................................9.69 9.69
21402 Two pins ....................................................................................16.97 16.97
21403 Three pins ....................................................................................21.47 21.47
21404 Four pins ....................................................................................26.55 26.55
21405 Five pins or more...........................................................................30.83 30.83
5 Restorations made to a tooth supporting an existing
partial denture clasp (additional to restoration)
21501 Per restoration...................................................................................PA PA
Restorations, Prefabricated, Full Coverage
1 Restorations, prefabricated, metal, primary dentition
22201 Primary anterior.............................................................................74.40 92.77
22211 Primary posterior...........................................................................74.40 92.77
22212 Primary anterior - open face...........................................................71.89 86.18
2 Restorations, prefabricated, metal, permanent dentition
22301 Permanent anterior.........................................................................74.40 92.77
22302 Permanent anterior - open face.......................................................71.89 86.18
22311 Permanent posterior.......................................................................74.40 92.77
22312 Permanent posterior - open face.....................................................71.89 86.18
3 Restorations, prefabricated, plastic, permanent dentition
22501 Permanent anterior.......................................................................108.29 131.47
22511 Permanent posterior.....................................................................108.29 131.47
1 Restorations, tooth coloured, permanent
anteriors, acid etch/bond technique (not to be used
for veneer applications or diastema closures)
23111 One surface...................................................................................44.75 53.42
23112 Two surfaces (continuous).............................................................58.40 69.91
23113 Three surfaces (continuous)...........................................................68.03 81.68
23114 Four surfaces (continuous)...........................................................108.29 131.47
23115 Five surfaces (continuous, maximum surfaces
per tooth)..................................................................................108.29131.47
2 Restorations, tooth coloured, veneer applications
23121 Tooth coloured veneer application - direct chairside
prefabricated - acid etch/bond......................................................108.29131.47
23122 Tooth coloured veneer application - non prefabricated
direct buildup-acid etch/bond.......................................................108.29131.47
3 Restorations, tooth coloured, permanent posteriors
- acid etch/bond technique
Tooth coloured, permanent bicuspids
23311 One surface...................................................................................32.22 38.59
23312 Two surfaces.................................................................................48.34 57.65
23313 Three surfaces................................................................................60.86 72.75
23314 Four surfaces.................................................................................78.74 98.01
23315 Five surfaces or maximum surfaces per tooth.................................96.67 115.41
Tooth coloured, permanent molars
23321 One surface...................................................................................35.33 42.23
23322 Two surfaces.................................................................................52.57 62.90
23323 Three surfaces................................................................................68.89 82.17
23324 Four surfaces.................................................................................94.85 113.91
23325 Five surfaces................................................................................126.22 150.74
4 Restorations, tooth coloured, primary,
anterior, acid etch/bond technique
23411 One surface...................................................................................41.59 49.89
23412 Two surfaces (continuous).............................................................41.59 49.89
23413 Three surfaces (continuous)...........................................................58.40 69.91
23414 Four surfaces (continuous).............................................................90.30 98.00
23415 Five surfaces (continuous or maximum surfaces
per tooth)....................................................................................90.3098.00
5 Restorations, tooth coloured, primary,
posterior, acid etch/bond technique
23511 One surface...................................................................................24.89 29.87
23512 Two surfaces.................................................................................35.81 43.20
23513 Three surfaces................................................................................41.16 49.41
23514 Four surfaces.................................................................................51.92 62.20
23515 Five surfaces or maximum surfaces per tooth.................................65.36 78.42
6 Restorations, tooth coloured/plastic with
silver filings, cores
23601 Restoration, tooth coloured, core, in conjunction
with crown90.30...........................................................................98.00
23602 Restoration, tooth coloured, acid etch/bonded, core,
in conjunction with crown.............................................................90.3098.00
Note: Please see prosthodontics section for inlays, onlays and pins.
Posts, cast metal (including core) as a separate procedure
25711 Single section + L........................................................................120.33 167.33
25712 Two sections + L.........................................................................120.33 167.33
25713 Three sections + L.............................................................................PA 321.39
Posts, cast metal (including core) concurrent with impression
for crown
25721 Single section + L........................................................................120.33 167.33
25722 Two sections + L.........................................................................120.33 167.33
25723 Three sections + L.............................................................................PA 321.39
Posts, prefabricated retentive (separate procedure)
25731 One post ....................................................................................76.28 91.27
25732 Two posts same tooth....................................................................76.28 91.27
27533 Three posts same tooth..................................................................76.28 91.27
Posts, prefabricated, retentive and cast core
25741 One post and cast core + L...........................................................120.33 167.33
25742 Two posts (same tooth) and cast core + L....................................120.33 167.33
25743 Three posts (same tooth) and cast core + L........................................PA 321.39
Posts, prefabricated, with core for crown restoration (when pins
are applicable, refer to 21401-21405 for additional fee)
25751 One post, with amalgam core + pins..................................................PA PA
25752 Two posts (same tooth) with amalgam core + pins............................PA PA
25753 Three posts (same tooth) with amalgam core + pins...........................PA PA
25754 One post, with composite core + pins................................................PA PA
25755 Two posts (same tooth) with composite core + pins...........................PA PA
25756 Three posts (same tooth) with composite core + pins.........................PA PA
Post removal
25781 One unit of time................................................................................PA PA
Stainless steel crowns - 100% of the dental tariff applies to each of the first 3 stainless steel crowns done at one sitting for a patient under general anaesthesia; and 50% of the dental tariff applies to each additional stainless steel crown done at the same sitting.
Notwithstanding, a dentist may, when submitting a claim, request independent consideration for payment of 100% of the dental tariff for 4 or more stainless steel crowns done at the same sitting for a patient under general anaesthesia. Such requests must be substantiated. Under normal circumstances, should be accompanied by necessary x-rays.
Permanent crowns - pre-determination of benefits is necessary prior to rendering services for permanent crowns. X-rays and/or study models should accompany the request for pre-determination.
MSI Note: Gold, butt margins (including collarless veneers), custom shading or any esthetics included in the lab fees are uninsured.
1 Crowns, plastic (single units only)
Crowns, plastic, processed
27111 Crown, plastic, processed + L......................................................276.64 276.64
27112 Crown, plastic, processed complicated (restorative,
positional and/or aesthetic) + L..........................................................PAPA
27113 Crown, plastic, transitional, indirect + L............................................PA PA
27114 Crown, plastic/metal base, processed + L.....................................339.69 407.62
Crowns, plastic, direct
27121 Crown, plastic, direct, transitional (chairside).................................80.56 80.56
27122 Crown, transitional restoration of fractured anterior...........................PA PA
2 Crowns, porcelain/ceramic/polymer glass
27201 Crown, porcelain/ceramic jacket + L.................................................PA PA
27202 Crown, porcelain/ceramic jacket complicated + L..............................PA PA
Crowns, porcelain/ceramic fused to metal
27211 Crown, porcelain/ceramic fused to metal base + L.......................337.39 337.39
27212 Crown, porcelain/ceramic fused to metal base,
complicated (restorative, positional and/or
aesthetic) + L.....................................................................................PA PA
27213 Crown, porcelain/ceramic fused to metal base,
screwed directly to an implant without the intervening
post (not using 25761) (+L and/or + E)..............................................PA PA
Crown, porcelain/ceramic, 3/4 partial veneer
27221 Crown, porcelain/ceramic, 3/4 partial veneer + L...............................PA PA
27222 Crown, porcelain/ceramic, 3/4 partial veneer
complicated + L................................................................................PAPA
3 Crowns, metal, cast
27301 Crown, metal, full cast, uncomplicated + L..................................308.38 370.04
27302 Crown, metal, full cast, complicated (restorative,
positional) + L.............................................................................308.38370.04
Crowns, metal 3/4 partial veneer
27311 Crowns, metal 3/4 partial veneer + L...........................................339.69 407.62
27312 Crowns, metal 3/4 partial veneer, complicated + L.......................339.69 407.62
27313 Crowns, metal 3/4 partial veneer, with direct tooth
coloured corner + L.....................................................................339.69407.62
4 Crowns made to an existing partial denture clasp
(additional to crown)
27401 One crown38.87...........................................................................38.87
Copings, Metal/Plastic, Transfer (thimble type)
27501 coping, metal/plastic, transfer (thimble) as a separate
procedure + L....................................................................................PAPA
27502 Coping, metal/plastic, transfer (thimble) each additional
coping as a separate procedure + L....................................................PA PA
27503 Copings, metal/plastic, transfer (thimble) concurrent with
impression for crown + L..................................................................PAPA
27504 Coping, metal/plastic, transfer (thimble), each
additional coping concurrent with impression for
additional crown + L.........................................................................PAPA
27602 Veneers, porcelain/ceramic, acid etch/bonded + L..............................PA PA
(single units only, does not include removal and recementation)
Repairs, inlays, onlays or crowns, plastic (single units)
27711 Repairs, plastic direct........................................................................PA PA
Repairs, inlays, onlays or crowns, porcelain/ceramic
(single units)
27721 Repairs, porcelain/ceramic, direct......................................................PA PA
27722 Repairs, porcelain/ceramic indirect + L..............................................PA PA
MSI Note: gold, butt margins (including collarless veneers), custom shading or any esthetics included in the lab fees are uninsured.
Restorative Procedures, Overdentures
1 Restorative procedures, overdentures, direct
28101 Natural tooth preparation, placement of pulp chamber
restoration (amalgam or composite) and fluoride
applicationPA..................................................................................PA
28102 Prefabricated attachment, as an internal or external
overdenture retentive device, direct chairside + E..............................PAPA
28103 Natural tooth preparation and fluoride application,
vital tooth.......................................................................................PAPA
2 Restorative procedures, overdentures, indirect
Coping crowns, metal cast
28211 Coping crown, metal cast - no attachment
indirect + L.......................................................................................PAPA
28212 Coping crown, metal cast - with attachment
indirect + L.......................................................................................PAPA
1 Recementation/rebonding, inlays/onlays/
crowns/veneers/posts/natural tooth fragments
(single units only)(+L where laboratory charges are incurred
during repair of the unit) MSI - maximum of 2 services
29101 One unit of time.............................................................................40.57 40.57
2 Staining, porcelain (chairside)
29401 One unit of time................................................................................PA PA
29402 Two units .......................................................................................PA PA
29403 Three unitsPA..................................................................................PA
29404 Four units .......................................................................................PA PA
29409 Each additional unit over four............................................................PA PA
Tariff of Fees for Insured Dental Services
Children’s Oral Health Program
The Children’s Oral Health Program provides insured diagnostic, preventive, and treatment services for residents (as defined in the M.S.I. Regulations) until the end of the month in which the resident turns 10 years of age.
Part 1 - Diagnostic - 01000-09999
1 Examinations and diagnosis, complete oral, to include:
- History, medical and dental
- Clinical examination and diagnosis of hard and soft tissues, including: carious lesions, missing teeth, determination of pocket depth and location of periodontal pockets, gingival contours, mobility of teeth, interproximal tooth contact relationships, occlusion of teeth, pulp vitality tests, where necessary, and any other pertinent factors.
- Radiographs extra, as required
01101 Examination and diagnosis, complete, primary
dentition, to include: extended examination and
diagnosis on primary dentition, recording history,
charting, treatment planning and case presentation,
including above description ...........................................................27.6234.47
This service (01101) is allowed once in a patient’s lifetime, when continuity of treatment is maintained. If there is a gap in treatment of 2 years or more, a further complete oral examination is warranted and is covered under the Plan.
A complete oral examination performed by another dentist is permitted under the Plan, unless performed by a dentist who is established in a group practice with the dentist who performed the first examination. (A group practice in this case means a mode of practice where patient records are available to all dentists.)
In cases where a patient has been referred to a specialist in the same group practice, complete oral examinations by both dentist and dental specialist are allowed.
2 Examinations and diagnosis, limited oral
01202 Examination and diagnosis, limited oral, previous patient
(recall): examination and diagnosis with mirror and explorer of
hard and soft tissues, including checking of occlusion
and appliances, but not including specific tests,
as for 01100...................................................................................15.4219.16
This service (01202) is allowed after a 335 day period has elapsed from the previous complete or recall examination. A recall will be accepted if rendered more than 335 days following the complete or previous recall examination, but will be rejected if the service is rendered any time within the 335 days.
If procedures or treatment services are provided during the same appointment, the fees for both the examination and procedure(s) are allowed.
01204 Examination and diagnosis, specific: examination, diagnosis
and evaluation of a specific situation in a localized
area (MSI - details must accompany claim)....................................24.0932.12
01205 Examination and diagnosis, emergency: examination
for the investigation of discomfort and/or infection in
a localized area (MSI - details must accompany claim)..................24.09 32.12
The fee for either specific (01204) or emergency (01205) oral examination is applicable only when no treatment is rendered during the appointment. If a procedure or treatment service, payable by MSI, is provided, the fee for the procedure, only, is allowed (unless otherwise specified).
05201 Consultation (in office), MSI - specialist other than
orthodontist .....................................................................................NA54.39
(including radiographic examinations and interpretation)
The fees are intended to include both the technical and professional components of an x-ray service, however, non readable films are not insured.
Fees for diagnostic x-rays should not exceed $11.24 per child per year (whether same or different dentist), excluding panoramic or cephalometric films.
Procedural x-rays in connection with root canal therapy are not allowed separately as the fees for root canal therapy include procedural x-rays.
All x-rays are to be made available to the Plan upon request and therefore should be retained for 18 months following the service.
1 Radiographs, intra oral, periapical
02111 Single film8.56...............................................................................8.56
02112 Two films ....................................................................................11.24 11.24
2 Radiographs, intra oral, bitewing
02141 Single film8.56...............................................................................8.56
02142 Two films ....................................................................................11.24 11.24
3 Radiographs, panoramic
02601 Single film (MSI - once per lifetime, only in
connection with a specific request for a consultation
with a specialist other than an orthodontist)....................................35.9735.97
4 Radiographs, cephalometric
02701 Single film (MSI - once per lifetime, only in connection
with a specific request for a consultation with a
specialist other than an orthodontist)..............................................35.9735.97
5 Radiographs, interpretation (received from another
source, or for MSI - exposed on hospital equipment)
02801 MSI - paid at one-half regular fee
Tests and Laboratory Examinations
Pulp vitality tests (general and specific) are intended to be included in the fee for an initial examination; therefore, no additional allowance will be made for these tests when performed in conjunction with an initial examination.
Fees for all tests and laboratory examinations, other than pulp vitality tests (general and specific), are payable in addition to the fee for an initial examination when such applies.
When diagnostic casts are prepared, an explanation as to the necessity should be included on the claim.
Diagnostic casts are to be available to the Plan upon request and accordingly, should be retained for a period of 18 months following the service.
1 Tests, microbiological
04101 Microbiological test for the determination of
pathological agents + L..................................................................21.6321.63
2 Tests, caries susceptibility
04201 Bacteriological test for the determination of
dental caries susceptibility + L.......................................................21.14 21.14
3 Tests, histological
Test, histological, soft tissue
04311 Biopsy, soft oral tissue - by puncture + L.......................................50.53 50.53
04312 Biopsy, soft oral tissue - by incision + L.........................................50.53 50.53
04313 Biopsy, soft oral tissue - by aspiration + L......................................50.53 50.53
Tests, histological, hard tissue
04321 Biopsy, hard oral tissue - by puncture + L......................................58.19 58.19
04322 Biopsy, hard oral tissue - by incision + L.......................................58.19 58.19
04323 Biopsy, hard oral tissue - by aspiration + L.....................................58.19 58.19
4 Tests, cytological
04401 Cytological smear from the oral cavity + L....................................21.14 21.14
04402 Vital staining of oral mucosal tissues
(+E - not payable by MSI).............................................................21.1421.14
5 Tests, pulp vitality
04501 One unit ....................................................................................17.88 17.88
(MSI - Not payable in conjunction with orthodontic cases and preventive orthodontic services. Each claim is to be supported by a detailed explanation.)
1 Cast, diagnostic, unmounted
04911 Cast, diagnostic, unmounted + L....................................................21.63 29.76
04912 Cast, diagnostic, unmounted, duplicate + L........................................PA PA
2 Cast, diagnostic, mounted
04921 Cast, diagnostic, mounted + L........................................................33.62 PA
04922 Cast, diagnostic, mounted using face bow transfer + L...................60.86 PA
04923 Cast, diagnostic, mounted, using face bow +
occlusal records + L.......................................................................60.86PA
Part 2 - Preventive - 10000-19999
12101 Fluoride treatment, topical application...........................................11.03 11.03
1 Nutritional dietary counselling
Including: recording and analysis of 7-day dietary intake and consultation (MAXIMUM OF 4 PAYABLE PER LIFETIME - MSI)
13101 One unit of time.............................................................................21.14 21.14
2 Caries prevention service - MSI (previously MSI fee code 220)
allowed once every 335 days
Oral hygiene instruction/plaque control to include: brushing and/or flossing and/or embrasure cleaning, includes for MSI programs rubber cup polishing and minor scaling procedures.
13211 One unit of time.............................................................................21.14 21.14
3 Sealants, pit and fissure (acid etch preparation included)
(MSI - Limited to 6-year molars that meet guidelines - one application
per tooth)
13401 Each tooth19.27...........................................................................19.27
4 Disking of teeth, interproximal (MSI - MAXIMUM 3 UNITS PER LIFETIME)
13701 One unit ....................................................................................37.58 37.58
13702 Two units ....................................................................................75.16 75.16
13703 Three units112.74.......................................................................112.74
(includes the design, separation,fabrication, insertion and
where applicable initial cementation and removal)
1 Space maintainers, band type
15101 Space maintainer, band type, fixed, unilateral + L..........................86.82 116.10
15103 Space maintainer, band type, fixed, bilateral (soldered
lingual arch) + L..........................................................................109.47176.64
15105 Space maintainer, band type, fixed, bilateral tubes and
locking wires + L.........................................................................148.65193.19
2 Space maintainers, stainless steel crown type
15201 Space maintainer, stainless steel crown type,
fixed + L..................................................................................112.04134.46
3 Space maintainers, maintenance of
15601 Maintenance, space maintainer appliance, to include
adjustment and/or recementation after 30 day
from insertion................................................................................40.5740.57
Part 3 - Restorative Services - 20000- 29999
Caries, Trauma and Pain Control
(MSI - permanent teeth only)
Caries/trauma/pain control (removal of carious lesions or
existing restorations and placement of sedative/protective
dressings, includes pulp caps when necessary, as a separate
procedure)
20111 First tooth ....................................................................................37.58 45.12
Caries/trauma/pain control (removal of carious lesions or
existing restorations and placement of sedative/protective
dressings, includes pulp caps when necessary and the use
of a band for retention and support, as a separate procedure)
20121 First tooth ....................................................................................51.01 58.24
1 Restorations, amalgam, primary teeth
Restorations, amalgam, non-bonded, primary teeth
21111 One surface...................................................................................24.89 29.82
21112 Two surfaces.................................................................................35.81 43.20
21113 Three surfaces................................................................................41.16 49.41
21114 Four surfaces.................................................................................51.92 62.20
21115 Five surfaces or maximum surfaces per tooth.................................65.36 78.42
Restorations, amalgam, bonded, primary teeth
21121 One surface...................................................................................24.89 29.82
21122 Two surfaces.................................................................................35.81 43.20
21123 Three surfaces................................................................................41.16 49.41
21124 Four surfaces.................................................................................51.92 62.20
21125 Five surfaces or maximum surfaces per tooth.................................65.36 78.42
2 Restorations, amalgam, permanent teeth
Restorations, amalgam, non-bonded, permanent bicuspids
and anteriors
21211 One surface...................................................................................32.22 38.59
21212 Two surfaces.................................................................................48.34 57.65
21213 Three surfaces................................................................................60.86 72.75
21214 Four surfaces.................................................................................78.74 98.01
21215 Five surfaces or maximum surfaces per tooth.................................96.67 115.41
Restorations, amalgam, non-bonded, permanent molars
21221 One surface...................................................................................35.33 42.23
21222 Two surfaces.................................................................................52.57 62.90
21223 Three surfaces................................................................................68.89 82.17
21224 Four surfaces.................................................................................94.85 113.91
21225 Five surfaces or maximum surfaces per tooth...............................126.22 150.74
Restorations, amalgam, bonded, permanent bicuspids_and anteriors
21231 One surface...................................................................................32.22 38.59
21232 Two surfaces.................................................................................48.34 57.65
21233 Three surfaces................................................................................60.86 72.75
21234 Four surfaces.................................................................................78.74 98.01
21235 Five surfaces or maximum surfaces per tooth.................................96.67 115.41
Restorations, amalgam, bonded, permanent molars
21241 One surface...................................................................................35.33 42.23
21242 Two surfaces.................................................................................52.57 62.90
21243 Three surfaces................................................................................68.89 82.17
21244 Four surfaces.................................................................................94.85 113.91
21245 Five surfaces or maximum surfaces per tooth...............................126.22 150.74
3 Pins, retentive per restoration (for amalgams and tooth
coloured restorations)
21401 One pin ......................................................................................9.69 9.69
21402 Two pins ....................................................................................16.97 16.97
21403 Three pins ....................................................................................21.47 21.47
21404 Four pins ....................................................................................26.55 26.55
21405 Five pins or more...........................................................................30.83 30.83
Restorations, Prefabricated, Full Coverage
1 Restorations, prefabricated, metal, primary dentition
22201 Primary anterior.............................................................................74.40 92.77
22211 Primary posterior...........................................................................74.40 92.77
22212 Primary anterior - open face...........................................................71.89 86.18
2 Restorations, prefabricated, metal, permanent dentition
22301 Permanent anterior.........................................................................74.40 92.77
22302 Permanent anterior - open face.......................................................71.89 86.18
22311 Permanent posterior.......................................................................74.40 92.77
22312 Permanent posterior - open face.....................................................71.89 86.18
3 Restorations, prefabricated, plastic, permanent dentition
22501 Permanent anterior.......................................................................108.29 131.47
22511 Permanent posterior.....................................................................108.29 131.47
1 Restorations, tooth coloured, permanent
anteriors, acid etch/bond technique (not to be used
for veneer applications or diastema closures)
23111 One surface...................................................................................44.75 53.42
23112 Two surfaces (continuous).............................................................58.40 69.91
23113 Three surfaces (continuous)...........................................................68.03 81.68
23114 Four surfaces (continuous)...........................................................108.29 131.47
23115 Five surfaces (continuous, maximum surfaces
per tooth)..................................................................................108.29131.47
2 Restorations, tooth coloured, permanent
posteriors - acid etch/bond technique
Tooth coloured, permanent bicuspids
23311 One surface...................................................................................32.22 38.59
23312 Two surfaces.................................................................................48.34 57.65
23313 Three surfaces................................................................................60.86 72.75
23314 Four surfaces.................................................................................78.74 98.01
23315 Five surfaces or maximum surfaces per tooth.................................96.67 115.41
Tooth coloured, permanent molars
23321 One surface...................................................................................35.33 42.23
23322 Two surfaces.................................................................................52.57 62.90
23323 Three surfaces................................................................................68.89 82.17
23324 Four surfaces.................................................................................94.85 113.91
23325 Five surfaces................................................................................126.22 150.74
3 Restorations, tooth coloured, primary,
anterior, acid etch/bond technique
23411 One surface...................................................................................41.59 49.89
23412 Two surfaces (continuous).............................................................41.59 49.89
23413 Three surfaces (continuous)...........................................................58.40 69.91
23414 Four surfaces (continuous).............................................................90.30 98.00
23415 Five surfaces (continuous or maximum surfaces
per tooth)....................................................................................90.3098.00
4 Restorations, tooth coloured, primary,
posterior, acid etch/bond technique
23511 One surface...................................................................................24.89 29.87
23512 Two surfaces.................................................................................35.81 43.20
23513 Three surfaces................................................................................41.16 49.41
23514 Four surfaces.................................................................................51.92 62.20
23515 Five surfaces or maximum surfaces per tooth.................................65.36 78.42
Note: please see prosthodontics section for inlays, onlays and pins.
5 Posts
Posts, cast metal (including core) as a separate procedure
25711 Single section + L........................................................................120.33 167.33
25712 Two sections + L.........................................................................120.33 167.33
25713 Three sections + L.............................................................................PA 321.39
Posts, cast metal (including core) concurrent with impression
for crown
25721 Single section + L........................................................................120.33 167.33
25722 Two sections + L.........................................................................120.33 167.33
25723 Three sections + L.............................................................................PA 321.39
Posts, prefabricated retentive (separate procedure)
25731 One post 76.28...........................................................................91.27
25732 Two posts same tooth....................................................................76.28 91.27
27533 Three posts same tooth..................................................................76.28 91.27
Posts, prefabricated, retentive and cast core
25741 One post and cast core + L...........................................................120.33 167.33
25742 Two posts (same tooth) and cast core + L....................................120.33 167.33
25743 Three posts (same tooth) and cast core + L........................................PA 321.39
Stainless steel crowns - 100% of the dental tariff applies to each of the first 3 stainless steel crowns done at one sitting for a patient under general anaesthesia; and 50% of the dental tariff applies to each additional stainless steel crown done at the same sitting.
Notwithstanding, a dentist may, when submitting a claim, request independent consideration for payment of 100% of the dental tariff for 4 or more stainless steel crowns done at the same sitting for a patient under general anaesthesia. Such requests must be substantiated. Under normal circumstances, should be accompanied by necessary x-rays.
Permanent anterior crowns - it is recommended that pre-determination of benefits be requested prior to rendering services for permanent anterior crowns, along with x-rays and/or study models.
MSI Note: gold, butt margins (including collarless veneers), custom shading or any esthetics included in the lab fees are uninsured.
1 Crowns, plastic (single units only)
Crowns, plastic, processed
27111 Crown, plastic, processed + L......................................................276.64 276.64
27112 Crown, plastic, processed complicated (restorative,
positional and/or aesthetic) + L..........................................................PA PA
27113 Crown, plastic, transitional, indirect + L............................................PA PA
27114 Crown, plastic/metal base, processed + L.....................................339.69 407.62
Crowns, plastic, direct, MSI - not payable in addition to
permanent crowns
27121 Crown, plastic, direct, transitional (chairside).................................80.56 80.56
27122 Crown, transitional restoration of fractured anterior...........................PA PA
2 Crowns, porcelain/ceramic/polymer glass
27201 Crown, porcelain/ceramic jacket + L.................................................PA PA
27202 Crown, porcelain/ceramic jacket complicated + L..............................PA PA
3 Crowns, porcelain/ceramic fused to metal
27211 Crown, porcelain/ceramic fused to metal base + L.......................337.39 337.39
27212 Crown, porcelain/ceramic fused to metal base,
complicated (restorative, positional and/or
aesthetic) + L.....................................................................................PAPA
4 Restorative services - other
29101 Recementation (MSI - crown)........................................................40.57 40.57
(MSI - after 120 days of original placement by same or different dentist)
Part 4 - Periodontics - 40000- 49999
This may involve application and burnishing of medicinal aids on the root or the use of a variety of therapeutic procedures. More than one appointment may be necessary.
41301 One unit of time.............................................................................22.00 22.00
41302 Two units ....................................................................................44.00 44.00
41309 Each additional unit over two.........................................................22.00 22.00
Periodontal Procedures, Adjunctive
(When per joint is designated, the corresponding tooth code is represented by the mesial of the tooth involved, except at the midline, where the tooth to the right of the joint is utilized.)
1 Periodontal splinting or ligation, provisional,
intra coronal
“A” splint (acrylic, composite or amalgam, plus knurled wire)
43111 Per joint ....................................................................................24.00 31.58
2 Periodontal splinting or ligation, provisional,
extra coronal
Acid etch joint restorations (per joint)
43211 Per joint ....................................................................................31.45 41.38
Acid etch, interproximal enamel splint
43221 Per joint ....................................................................................31.45 41.38
Wire ligation
43231 Per joint ....................................................................................31.45 41.38
Wire ligation, acrylic covered
43241 Per joint ....................................................................................31.45 41.38
Dental floss ligation
43251 Per joint ....................................................................................31.45 41.38
Orthodontic band splint
43261 Per band ....................................................................................31.45 41.38
Cast/soldered splint acid etch/resin bonded
43271 Per abutment + L...........................................................................31.45 41.38
Part 5 - Prosthetics - Removable - 50000-59999
Cast partials are not insured services.
Dentures, partial, acrylic, with metal wrought/cast
clasps and/or rests, msi - payable only when due to
congenital condition or accident
52301 Maxillary + L..............................................................................239.43 294.62
52302 Mandibular + L............................................................................239.43 294.62
Part 6 - Oral and Maxillofacial Surgery - 70000-79999
Bilateral procedures done under the same general anaesthetic, other than uncomplicated extractions, will be entitled to 50% of unilateral procedures.
Bilateral procedures done under local anaesthetic or conscious sedation will be entitled to a fee equivalent to 100% of unilateral procedures.
When more than 2 quadrants are involved, the first 2 procedures will be paid at 100% and subsequent procedures at 50%.
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 considered to include a full quadrant, sextant or group of several teeth, or in some cases a single tooth, which can be practically and conveniently combined for a single surgical sitting.
Removals (Extractions), Erupted Teeth
1 Removals, erupted teeth, uncomplicated
MSI: Extractions are insured only in the case of:
1) pain, infection, trauma
2) ankylosis
3) supernumerary teeth
71101 Single tooth, uncomplicated...........................................................35.81 42.98
71109 Each additional tooth, same quadrant, same
appointment...................................................................................18.7922.59
2 Removals, erupted teeth, complicated
71201 Odontectomy, (extraction), erupted tooth, surgical approach,
requiring surgical flap and/or sectioning of tooth............................97.53116.37
71209 Each addition tooth, same quadrant................................................48.77 58.19
Removals (Extractions), Surgical
1 Removals, impactions, soft tissue coverage
Removals, impaction, requiring incision of overlying soft
tissue and removal of the tooth
72111 Single tooth...................................................................................97.53 116.37
72119 Each additional tooth, same quadrant.............................................48.77 58.19
2 Removals, impactions, involving tissue and/or bone coverage
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.................................................................................118.14 191.73
72219 Each additional tooth, same quadrant.............................................59.07 95.87
Removals, impaction, requiring incision of overlying soft
tissue, elevation of a flap, removal of bone AND sectioning
of tooth for removal
72221 Single tooth.................................................................................161.98 213.23
72229 Each additional tooth, same quadrant.............................................81.00 106.62
3 Removals (extractions), residual roots
Removals, residual roots, erupted
72311 First tooth ....................................................................................35.81 42.98
72319 Each additional tooth, same quadrant.............................................17.91 21.49
Removals, residual roots, soft tissue coverage
72321 First tooth ....................................................................................67.12 80.56
72329 Each additional tooth, same quadrant.............................................33.56 40.28
Removals, residual roots, bone tissue coverage
72331 First tooth ..................................................................................139.60 167.49
72339 Each additional tooth, same quadrant.............................................69.80 83.75
4 Surgical exposure of teeth
Surgical exposure, unerupted, uncomplicated, soft tissue
coverage (includes operculectomy)
72511 Single tooth.................................................................................123.49 154.54
72519 Each additional tooth, same quadrant.............................................61.75 77.27
Surgical exposure, complex, hard tissue coverage
72521 Single tooth.................................................................................123.49 154.54
72529 Each additional tooth, same quadrant.............................................61.75 77.27
Surgical exposure, unerupted tooth, with orthodontic
attachment
72531 Single tooth.................................................................................136.02 163.32
72539 Each additional tooth, same quadrant.............................................68.01 81.66
Surgical incision and drainage and/or exploration,
intra-oral soft tissue
75111 Intra-oral, surgical exploration, soft tissue......................................50.10 66.27
75112 Intra-oral, abscess, soft tissue.........................................................50.10 66.27
75113 Intra-oral, abscess, in major anatomical area with drain..................50.10 66.27
Replantation, avulsed tooth/teeth (including splinting)
76941 Replantation, first tooth................................................................131.63 147.43
76949 Each additional tooth.....................................................................65.82 73.72
Repositioning of traumatically displaced teeth
76951 One unit of time.............................................................................26.98 32.33
76952 Two units of time..........................................................................53.90 64.66
76959 Each additional unit over two.........................................................26.98 32.33
77801 Frenectomy, upper labial (office fee only)....................................111.82 111.82
77801 Frenectomy, upper labial (hospital fee only)...................................83.50 83.50
77802 Frenectomy, lower labial (office fee only)....................................111.82 111.82
77802 Frenectomy, lower labial (hospital fee only)...................................83.50 83.50
(MSI - payable only if procedures rendered by a
dentist other than the provider of the original service.)
79403 Hemorrhage control, using compression and
hemostatic agent............................................................................34.9041.91
79404 Hemorrhage control, using hemostatic substance
and sutures (including removal of bony tissue,
if necessary)...................................................................................34.9041.91
Post Surgical Care
(MSI - excludes alveolitis, details must accompany claim.)
Required by complications and unusual circumstances, refer to comment at beginning of Part 6.
79605 Post surgical care, alveolitis, treatment of
(without anaesthesia).....................................................................29.5535.54
79606 Post surgical care, alveolitis, treatment of
(with anaesthesia)..........................................................................29.5535.54
Insured Dental Services Tariff
Dental Surgical Program
The Dental Surgical Program provides insured dental surgical services for residents as defined in the M.S.I. Regulations where the condition of the resident is such that the services are medically required to be rendered in hospital.
Part 1 - Diagnostic - 01000-09999
01601 Examination and diagnosis, surgical, general, includes:
(a)History, medical and dental; and
(b)Clinical examinations as above, may include in-depth
analysis of medical status, medication, anesthetic and surgical risk,
initial consultation with referring dentist or physician, parent or
guardian, evaluation of source of chief complaint, evaluation of
pulpal vitality, mobility of teeth, occlusal factors or where the
patient is to be admitted to hospital for dental procedures.................................41.86
(MSI - Payable only on hospital in-patients, when requested by a physician or dentist.)
Part 2 - Oral and Maxillofacial Surgery - 70000-79999
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 considered to include a full quadrant, sextant or group of several teeth, or in some cases a single tooth, which can be practically and conveniently combined for a single surgical sitting.
1 Removals, erupted teeth, complicated
71201 Odontectomy, (extraction), erupted tooth, surgical approach,
requiring surgical flap and/or sectioning of tooth..............................................61.18
71209 Each additional tooth, same quadrant...............................................................30.59
Removals, (Extractions), Surgical
2 Removals, impactions, soft tissue coverage
Removals, impaction, requiring incision of overlying soft tissue
and removal of the tooth
72111 Single tooth...................................................................................................110.64
72119 Each additional tooth, same quadrant...............................................................55.32
3 Removals, impactions, involving tissue and/or
bone coverage
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...................................................................................................110.64
72219 Each additional tooth, same quadrant...............................................................55.32
Removals, impaction, requiring incision of overlying soft tissue,
elevation of a flap, removal of bone AND sectioning of tooth
for removal
72221 Single tooth...................................................................................................110.64
72229 Each additional tooth, same quadrant...............................................................55.32
Removals, impaction, requiring incision of overlying soft tissue,
elevation of a flap, removal of bone, sectioning of the tooth for
removal AND/OR presents unusual difficulties and circumstances
72231 Single tooth...................................................................................................110.64
72239 Each additional tooth, same quadrant...............................................................55.32
4 Removals (extractions), residual roots
Removals, residual roots, erupted
72311 First tooth ......................................................................................................65.41
72319 Each additional tooth, same quadrant...............................................................32.71
Removals, residual roots, soft tissue coverage
72321 First tooth ......................................................................................................65.41
72329 Each additional tooth, same quadrant...............................................................32.71
Removals, residual roots, bone tissue coverage
72331 First tooth ......................................................................................................65.41
72339 Each additional tooth, same quadrant...............................................................32.71
Remodelling and Recontouring Oral Tissues
1 Alveoloplasty (bone remodelling of ridge with soft tissue revisions)
Alveoloplasty, in conjunction with extractions
73111 Per sextant69.62
Remodelling of bone
73141 Mylohyoid ridge remodelling...........................................................................69.62
73142 Genial tubercles remodelling............................................................................69.62
Excision of bone
73151 Nasal spine, excision......................................................................................104.43
73152 Torus palatinus, excision................................................................................200.84
73153 Torus mandibularis, unilateral, excision.........................................................148.97
73154 Torus mandibularis, bilateral, excision...........................................................240.45
Removal of bone, exostosis, multiple
73161 Per quadrant..................................................................................................104.43
Reduction of bone, tuberosity
73171 Unilateral, reduction......................................................................................104.43
73172 Bilateral, reduction...................................................................................................
Augmentation of bone
73181 Unilateral, pterygomaxillary tuberosity, augmentation + E..............................641.81
73182 Bilateral, pterygomaxillary tuberosity, augmentation + E................................962.72
73183 Unilateral, mandibular ridge, augmentation + E.............................................641.81
73184 Bilateral, mandibular ridge, augmentation + E................................................962.72
2 Gingivoplasty and/or stomatoplasty, oral surgery
Independent procedure
73211 Per sextant63.91
Miscellaneous procedures
73222 Excision of vestibular hyperplasia (per sextant)................................................95.87
73223 Surgical shaving of papillary hyperplasia of the palate....................................143.81
73224 Excision of pericoronal gingiva (for retained teeth)
per tooth/implant.............................................................................................95.87
Removals, tissue, hyperplastic (includes the incision of the
mucous membrane, the dissection and removal of hyperplastic
tissue, the replacing and adapting of the mucous membrane)
73231 Per sextant63.91
Removal, mucosa, excess (complete removal without dissection)
73241 Per sextant63.91
3 Remodelling, floor of the mouth
73301 Full arch lowering of the floor of the mouth...................................................392.20
73302 Partial arch lowering of the floor of the mouth...............................................392.20
73303 Reinsertion of the mylohyoid muscle.............................................................392.20
4 Vestibuloplasty
Vestibuloplasty, sub-mucous
73411 Per sextant103.74
Sulcus deepening and ridge reconstruction
73421 Per sextant103.74
Vestibuloplasty, with secondary epithelization
73431 Per sextant103.74
Vestibuloplasty, with labial inverted flap
73441 Per sextant130.74
Vestibuloplasty, with skin graft
73451 Per sextant130.74
Vestibuloplasty, with mucosal graft
73461 Per sextant130.74
5 Reconstruction, alveolar ridge
Reconstruction, alveolar ridge, with autogenous bone
73511 Per sextant + E..............................................................................................213.94
Reconstruction, alveolar ridge, with alloplastic material
73521 Per sextant + E..............................................................................................106.98
6 Extensions, Mucous Folds
Extensions, mucous folds with secondary epithelization
73611 Per sextant130.74
Extensions, mucous folds, with skin grafts
73621 Per sextant130.74
Extensions, mucous folds, with mucous graft
73631 Per sextant130.74
(not in conjunction with tooth removal, including biopsy)
1 Surgical excision, tumors, benign
Tumors, benign, scar tissue, inflammatory or congenital
lesions of soft tissue of the oral cavity
74111 1 cm and under................................................................................................89.29
74112 1-2 cm.............................................................................................................89.29
74113 2-3 cm...........................................................................................................223.05
74114 3-4 cm...........................................................................................................223.05
74115 4-6 cm...........................................................................................................223.05
74116 6-9 cm...........................................................................................................223.05
74117 9-15 cm.........................................................................................................350.18
74118 15 cm and over..............................................................................................350.18
Tumors, benign, bone tissue
74121 1 cm and under..............................................................................................108.04
74122 1-2 cm...........................................................................................................108.04
74123 2-3 cm...........................................................................................................108.04
74124 3-4 cm...........................................................................................................270.40
74125 4-6 cm...........................................................................................................270.40
74126 6-9 cm...........................................................................................................270.40
74127 9-15 cm.........................................................................................................424.53
74128 15 cm and over..............................................................................................424.53
2 Surgical excision, tumors, malignant
Tumors, malignant, soft tissue, oral cavity
74211 1 cm and under................................................................................................89.29
74212 1-2 cm.............................................................................................................89.29
74213 2-3 cm.............................................................................................................89.29
74214 3-4 cm...........................................................................................................223.05
74215 4-6 cm...........................................................................................................223.05
74216 6-9 cm...........................................................................................................223.05
74217 9-15 cm.........................................................................................................350.18
74218 15 cm and over..............................................................................................350.18
Tumors, malignant, bone tissue
74221 1 cm and under..............................................................................................108.04
74222 1-2 cm...........................................................................................................108.04
74223 2-3 cm...........................................................................................................108.04
74224 3-4 cm...........................................................................................................270.40
74225 4-6 cm...........................................................................................................270.40
74226 6-9 cm...........................................................................................................270.40
74227 9-15 cm.........................................................................................................424.53
74228 15 cm and over..............................................................................................424.53
3 Cheiloplasty (lip shave)
74301 Cheiloplasty, partial.........................................................................................36.80
74302 Cheiloplasty, total..........................................................................................110.40
4 Surgical excision, cysts/granulomas
Enucleation of cyst/granuloma, odontogenic and non-odontogenic,
requiring prior removal of bony tissue and subsequent suture(s)
74611 1 cm and under..............................................................................................102.83
74612 1-2 cm...........................................................................................................102.83
74613 2-3 cm...........................................................................................................102.83
74614 3-4 cm...........................................................................................................102.83
74615 4-6 cm...........................................................................................................128.47
74616 6-9 cm...........................................................................................................128.47
74617 9-15 cm.........................................................................................................128.47
74618 15 cm and over..............................................................................................201.70
Marsupialization
74621 Cyst, marsupialization....................................................................................110.40
Excision of cyst
74631 1 cm and under..............................................................................................102.83
74632 1-2 cm...........................................................................................................102.83
74633 2-3 cm...........................................................................................................102.83
74634 3-4 cm...........................................................................................................102.83
74635 4-6 cm...........................................................................................................128.47
74636 6-9 cm...........................................................................................................128.47
74637 9-15 cm.........................................................................................................128.47
74638 15 cm and over..............................................................................................201.70
1 Surgical incision and drainage and/or exploration, intra-oral
Surgical incision and drainage and/or exploration, intra-oral soft tissue
75111 Intra-oral, surgical exploration, soft tissue........................................................43.09
75112 Intra-oral, abscess, soft tissue...........................................................................43.09
75113 Intra-oral, abscess, in major anatomical area with drain....................................43.09
Surgical incision and drainage and/or exploration, intra-oral hard tissue
75121 Intra-oral, abscess, hard tissue, trephination and drainage.................................55.82
75122 Intra-oral, surgical exploration, hard tissue.......................................................55.82
75123 Intra-oral, abscess, hard tissue, trephination and drainage in
major anatomical area......................................................................................55.82
2 Surgical incision and drainage and/or exploration, extra-oral
Surgical incision and drainage and/or exploration, extra-oral, soft tissue
75211 Extra-oral, abscess, superficial.........................................................................86.07
75212 Extra-oral, abscess, deep..................................................................................86.07
Surgical incision and drainage and/or exploration, extra-oral, hard tissue
75221 Extra-oral, surgical exploration, hard tissue....................................................104.14
3 Surgical incision for removal of foreign bodies
75301 Removal, from skin or subcutaneous areolar tissue..........................................95.87
75302 Removal, of reaction producing foreign bodies................................................95.87
75303 Removal, of needle from musculoskeletal system..........................................104.43
Sequestrectomy (for Osteomyelitis)
75401 Intra-oral sequestrotomy.................................................................................161.66
75402 Saucerization.................................................................................................161.66
75403 Osteomyelitis, non-surgical treatment of..........................................................59.03
Extra-oral sequestrotomy
75411 3 cm and less.................................................................................................215.51
75412 3-4 cm...........................................................................................................215.51
75413 4-6 cm...........................................................................................................323.31
75414 6-9 cm...........................................................................................................323.31
75415 9 cm and over................................................................................................323.31
75511 3 cm or less...................................................................................................421.35
75512 3-4 cm...........................................................................................................421.35
75513 4-6 cm...........................................................................................................421.35
75514 6-9 cm...........................................................................................................421.35
75515 9-12 cm.........................................................................................................421.35
75516 12-15 cm.......................................................................................................421.35
75517 15 cm and over..............................................................................................661.51
75518 Total mandibulectomy.................................................................................1095.89
75611 3 cm or less...................................................................................................421.35
75612 3-4 cm...........................................................................................................421.35
75613 4-6 cm...........................................................................................................421.35
75614 6-9 cm...........................................................................................................421.35
75615 9-12 cm.........................................................................................................421.35
75616 12-15 cm.......................................................................................................421.35
75617 15 cm and over..............................................................................................661.51
75618 Total maxillectomy......................................................................................1095.89
1 Fractures, reductions, mandibular
76201 Reduction, mandibular, closed.......................................................................215.51
76202 Reduction, mandibular, open, simple.............................................................377.11
76203 Reduction, mandibular, open, double.............................................................565.67
76204 Reduction, mandibular, open, multiple...........................................................754.22
2 Fractures, reductions, maxillary, horizontal Le Fort’s I
76301 Reduction, maxillary, closed..........................................................................215.51
76302 Reduction, maxillary, open, simple................................................................377.11
76303 Reduction, mandibular, open, double.............................................................565.67
76304 Reduction, maxillary, open, multiple..............................................................754.22
76305 Reduction, compound fracture or maxilla (requiring reduction
and soft tissue repair).....................................................................................431.07
3 Fractures, reductions, maxilla, pyramidal Le Fort’s II
76401 Reduction, maxillary, closed..........................................................................215.51
76402 Reduction, maxillary, open, unilateral............................................................431.07
76403 Reduction, maxillary, open, bilateral..............................................................431.07
4 Fractures, reductions, naso-orbital
76501 Reduction, unilateral......................................................................................646.57
76502 Reduction, bilateral........................................................................................646.57
76503 Reduction, naso-orbital, open, external approach............................................646.57
76504 Reduction, naso-orbital, open, sinusal approach.............................................646.57
76505 Reduction, naso-orbital, open, orbital approach
with insertion of subperiosteal implant...........................................................646.57
76506 Exploration, of Orbital blowout fracture.........................................................646.57
76507 Exploration, of orbital blowout fracture and reconstruction with
insertion of a subperiosteal implant................................................................646.57
5 Fractures, reductions, malar bone
76601 Reduction, malar bone, closed.......................................................................107.81
76602 Reduction, malar bone, open, by simple elevation..........................................107.81
76603 Reduction, malar bone, open, by osteosynthesis.............................................215.51
76604 Reduction, malar bone, open, by sinus approach............................................323.31
76605 Reduction, malar bone, simple fracture, (open
reduction with antrostomy and packing).........................................................323.31
6 Fractures, reductions, zygomatic arch
76701 Reduction, zygomatic arch, intra oral approach..............................................107.81
76702 Reduction, zygomatic arch, temporal approach..............................................107.81
76703 Reduction, zygomatico-maxillary fracture dislocation,
complex, closed reduction..............................................................................215.51
76704 Reduction, zygomatico-maxillary fracture dislocation,
open reduction...............................................................................................323.31
7 Fractures, reductions, craniofacial dysfunction,
Le Fort’s III transverse (specify type of procedure according to
previous code used for fracture)
76801 Reduction, craniofacial dysfunction, closed....................................................646.57
76802 Reduction, craniofacial dysfunction, open......................................................646.57
8 Fractures, reductions alveolar
Fracture, alveolar, debridement, teeth removed
76911 3 cm or less...................................................................................................120.12
76912 3-6 cm...........................................................................................................120.12
76913 6 cm and over................................................................................................215.51
Reduction, alveolar, closed, with teeth (fixation extra)
76921 3 cm or less...................................................................................................120.12
76922 3-6 cm...........................................................................................................120.12
76923 6-9 cm...........................................................................................................215.51
76924 9 cm and over................................................................................................215.51
Reduction, alveolar, open, with teeth (fixation extra)
76931 3 cm and less.................................................................................................215.51
76932 3-6 cm...........................................................................................................215.51
76933 6-9 cm...........................................................................................................377.11
76934 9 cm and over................................................................................................377.11
Replantation, avulsed tooth/teeth (including splinting)
76941 Replantation, first tooth....................................................................................61.18
76949 Each additional tooth.......................................................................................30.59
Repositioning of traumatically displaced teeth
76951 One unit of time...............................................................................................32.33
76952 Two units of time............................................................................................64.66
76959 Each additional unit over two...........................................................................32.33
Repairs, lacerations, uncomplicated, intra-oral or extra-oral
76961 2 cm or less.....................................................................................................43.09
76962 2-4 cm.............................................................................................................43.09
76963 4-6 cm.............................................................................................................43.09
76964 6-9 cm.............................................................................................................43.09
76965 9-12 cm...........................................................................................................43.09
76966 12-16 cm.......................................................................................................105.00
76967 16-20 cm.......................................................................................................105.00
76968 20-25 cm.......................................................................................................105.00
76969 25 cm and over..............................................................................................105.00
Repairs, lacerations, through and through
76971 2 cm or less...................................................................................................107.81
76972 2-4 cm...........................................................................................................107.81
76973 4-6 cm...........................................................................................................107.81
76974 6-9 cm...........................................................................................................176.64
76975 9-12 cm.........................................................................................................176.64
76976 12-16 cm.......................................................................................................176.64
76977 16-20 cm.......................................................................................................176.64
76978 20-25 cm.......................................................................................................176.64
76979 25 cm and over..............................................................................................176.64
Repairs, lacerations, complicated (local tissue shifts)
76981 2 cm or less...................................................................................................107.81
76982 2-4 cm...........................................................................................................107.81
76983 4-6 cm...........................................................................................................107.81
76984 6-9 cm...........................................................................................................176.64
76985 9-12 cm.........................................................................................................176.64
76986 12-16 cm.......................................................................................................176.64
76987 16-20 cm.......................................................................................................176.64
76988 20-25 cm.......................................................................................................176.64
76989 25 cm and over..............................................................................................176.64
Maxillofacial Deformities, Treatment of
1 Osteotomy/ostectomy, ramus of the mandible
77101 Osteotomy, subcondylar, closed.....................................................................377.22
77102 Osteotomy, subcondylar, open.......................................................................913.15
77103 Osteotomy, ramus of the mandibule, oblique, extra-oral.................................913.15
77104 Osteotomy, ramus of the mandible, oblique, intra-oral....................................913.15
77105 Osteotomy/ostectomy, body of the mandible..................................................913.15
77106 Osteotomy, coronoidectomy...........................................................................913.15
77107 Osteotomy, condylar neck..............................................................................913.15
77108 Osteotomy, sagittal split.................................................................................913.15
2 Osteotomy, miscellaneous
77201 Osteotomy, oblique with bone graft..............................................................1095.89
77202 Osteotomy, inverted “L”................................................................................913.15
77203 Osteotomy, “C”.............................................................................................913.15
3 Osteotomy, maxilla
77301 Osteotomy, maxilla, total...............................................................................913.15
77302 Osteotomy, maxilla, total with bone graft.....................................................1095.89
77303 Osteotomy, maxilla, Le Forte II with bone graft.............................................913.15
77304 Osteotomy, maxilla, Le Forte III..................................................................1095.89
77305 Additional to the above osteotomy requiring three segments............................50.00
77306 Additional to the above osteotomy requiring four segments..............................75.00
77307 Additional to the above osteotomy requiring a cranial flap.............................100.00
77308 Closure of cleft fistula (alveolar)....................................................................328.50
77309 Closure of cleft fistula (palatal)......................................................................438.25
77311 Pharyngoplasty..............................................................................................263.00
77312 Submucous resection.....................................................................................175.30
4 Osteotomy, maxillary/mandibular, segmental
Osteotomy, segmental, maxilla
77411 Osteotomy, segmental, anterior......................................................................663.27
77412 Osteotomy, segmental, posterior....................................................................663.27
77413 Osteotomy, midpalatal split, anterio...............................................................663.27
77414 Osteotomy, midpalatal split, complete............................................................663.27
Osteotomy, segmental, mandible
77421 Osteotomy, segmental, anterior with transfer of mental eminence...................663.27
77422 Osteotomy, segmental, anterior, without the transfer
of mental eminence........................................................................................663.27
77423 Osteotomy, segmental, posterior....................................................................663.27
77424 Osteotomy, lower border, mandible...............................................................663.27
77425 Osteotomy, total dento-alveolar, mandible.....................................................663.27
5 Genioplasty
77501 Genioplasty, sliding, reduction or augmentation.............................................663.27
77502 Genioplasty, reduction (vertical)....................................................................663.27
77503 Genioplasty, augmentation with graft (see grafting codes)..............................663.27
77504 Myotomy, suprahyoid....................................................................................663.27
6 Miscellaneous treatment of maxillofacial deformities
77601 Corticotomy...................................................................................................104.43
77602 Interdental septotomy.....................................................................................104.43
77603 Surgical expansion of the palate.....................................................................663.27
7 Palatorrhaphy
77701 Palatorrhaphy, anterior (closure of palatine fissure)........................................663.27
77702 Palatorrhaphy, posterior.................................................................................663.27
77703 Palatorrhaphy, total........................................................................................663.27
77704 Palatorrhaphy, with bone graft.......................................................................663.27
77705 Palatorrhaphy, bone graft to anterior alveolar ridge.........................................663.27
8 Glossectomy
77901 Glossectomy, partial, anterior wedge..............................................................223.05
77902 Glossectomy, partial, for orthodontic purposes...............................................223.05
77903 Glossectomy, full posterior-anterior wedge....................................................223.05
9 Cleft surgery
77911 Primary unilateral cleft lip repair....................................................................641.81
77912 Secondary unilateral cleft lip repair................................................................641.81
77913 Primary bilateral cleft lip repair......................................................................962.72
77914 Secondary bilateral cleft lip repair..................................................................962.72
77917 Closure of alveolar cleft (see grafting codes)..................................................641.81
10 Oral nasal fistula
77921 Primary closure at time of initial surgery........................................................427.91
77922 Secondary closure with palatal flap................................................................427.91
77923 Secondary closure with pharyngeal flap.........................................................427.91
77924 Secondary closure with tongue flap................................................................427.91
77925 Secondary closure with buccal flap................................................................427.91
Temporomandibular Joint Dysfunctions, Treatment of
1 Temporomandibular joint, dislocation, management of
78101 Dislocation, open reduction............................................................................269.46
78102 TMJ, dislocation, closed reduction, uncomplicated..........................................32.33
78103 TMJ, dislocation, closed reduction, under general anesthetic............................32.33
78104 TMJ, luxation, reduction without anesthesia....................................................32.33
78105 TMJ, luxation, reduction under anesthesia.......................................................32.33
78106 TMJ, manipulation, under anesthesia...............................................................32.33
2 Temporomandibular joint, capsule, management of
78201 Condyloplasty................................................................................................323.31
78202 Condylotomy.................................................................................................323.31
78203 Cyndylectomy................................................................................................323.31
78204 Eminoplasty...................................................................................................285.25
78205 Re-contour of glenoid fossa...........................................................................285.25
78206 Menisectomy.................................................................................................427.91
78207 Plication of meniscus.....................................................................................570.62
78208 Repair of meniscus........................................................................................570.62
78209 Replacement of meniscus...............................................................................570.62
3 Temporomandibular joint, arthrotomy for major reconstruction
78301 Fossa replacement (see grafting codes)...........................................................627.62
78302 Condylar replacement (see grafting codes).....................................................627.62
78303 Gap arthroplasty for ankylosis (see grafting codes).........................................627.62
4 Temporomandibular joint, arthrocentesis (puncture and aspiration)
78501 One unit of time...............................................................................................53.90
78502 Two units......................................................................................................107.80
78509 Each additional unit over two...........................................................................53.90
5 Temporomandibular joint, management by injections
78601 Injection, with anti-inflammatory drugs............................................................53.90
78602 Injection, with sclerosing agent........................................................................53.90
Oral Surgery Procedures, Other
1 Salivary glands, treatment of
79101 Salivary duct, dilation of..................................................................................18.40
79102 Salivary duct, insertion of polyethylene tube....................................................18.78
79103 Salivary duct, sialodochoplasty......................................................................220.80
79104 Salivary duct, reconstruction of......................................................................220.80
Salivary duct, sialolithotomy
79111 Sialolithotomy, anterior 1/3 of canal................................................................64.66
79112 Sialolithotomy, posterior 2/3 of canal.............................................................193.93
79113 Sialolithotomy, external approach..................................................................258.54
Salivary gland, excisions
79121 Excision of submaxillary gland......................................................................258.54
79122 Excision of sublingual gland..........................................................................258.54
79123 Excision of mucocele.......................................................................................99.44
79124 Excision of ranula..........................................................................................129.38
79125 Marsupialization of ranula.............................................................................129.38
Salivary gland, removal
79131 Salivary gland, removal, parotid (sub total)....................................................387.98
79132 Salivary gland, removal, parotid (radical, including facial nerve)....................517.30
2 Neurological disturbances, treatment of
Neurological disturbances, trigeminal nerve
79211 Trigeminal nerve, injection for destruction.......................................................53.90
79212 Trigeminal nerve, avulsion at periphery..........................................................214.11
79213 Trigeminal nerve, total avulsion of a branch...................................................214.11
79214 Trigeminal nerve, alcoholization of a branch....................................................53.90
79215 Trigeminal nerve, infiltration of a branch for diagnosis....................................53.90
79217 Trigeminal nerve, neurolysis or tumor excision of
trigeminal nerve branch in soft tissue.............................................................214.11
79218 Trigeminal nerve, neurolysis or tumor excision of
trigeminal nerve branch in bone (mandibule, maxilla
or orbit) (not to include osteotomy)................................................................214.11
Neurological disturbances, inferior dental nerve
79231 Inferior dental nerve, complete avulsion.........................................................214.11
79232 Inferior dental nerve, decompression in the canal...........................................214.11
Neurological disturbances, surgery
79246 Excision of tumor or neuroma........................................................................214.11
3 Antral surgery
Antral surgery, recovery, foreign bodies
79311 Antral surgery, immediate recovery of a dental root or
foreign body from the antrum........................................................................129.38
79312 Antral surgery, immediate closure of antrum by
another dental surgeon...................................................................................104.43
79313 Antral surgery, delayed recovery of a dental root
with oral antrostomy......................................................................................323.31
79314 Antral sugery with nasal antrostomy..............................................................323.31
Antral sugery, oro-antral fistula closure (same session)
79331 Oro-antral fistula closure with buccal flap......................................................323.31
79332 Oro-antral fistula closure with gold plate........................................................323.31
79333 Oro-antral fistula closure with palatal flap......................................................323.31
Antral surgery, oro-antral fistula closure (subsequent session)
79341 Oro-antral fistula closure with buccal flap......................................................323.31
79342 Oro-antral fistula closure with gold plate........................................................323.31
79343 Oro-antral fistula closure with palatal flap......................................................323.31
(MSI - Payable if procedures rendered by dentist
other than the provider of the original service.)
79403 Hemorrhage control, using compression and hemostatic agent.........................34.90
79404 Hemorrhage control, using hemostatic substance and sutures
(including removal of bony tissue, if necessary)...............................................34.90
(MSI - excludes alveolitis, details must accompany claim.)
Required by complications and unusual circumstances, refer to comment under section heading 70000.
79602 Post surgical care, minor, by other than treating dentist....................................34.90
79701 Emergency procedure, tracheotomy......................................................................IC
79702 Emergency procedure, crico-thyroidotomy............................................................IC
[“IC” means Independent Consideration]
Insured Dental Services Tariff
Maxillofacial Prosthodontics Program
The Maxillofacial Prosthodontics Program provides insured dental services for residents (as defined in the M.S.I. Regulations) whose maxillofacial prosthodontic needs are the result of congenital facial disorders, cancer, surgery, trauma, and neurological deficit.
The following services are payable on the basis of $37.20 per 15-minute unit:
Fee per 15-minute unit replaced: O.I.C. 2004-158, N.S. Reg. 128/2004.
Part 1 - Examination and Diagnosis, Prosthodontic, Specific - 01702
Part 2 - Prosthetics - Removable - 50000-59999
Includes: impressions, initial and final jaw relation records, try-in evaluation and check records, insertion and adjustments, including 3 months post insertion care.
1 Dentures, complete, equilibrated (involves remounted equilibration on a
semi adjustable articulator)
51201 Maxillary + L
51202 Mandibular + L
51204 Liners, resilient in addition to above
2 Dentures, surgical, standard (immediate) (includes tissue conditioner, but
does not include hard reline, but does include 3 months post insertion care)
51301 Maxillary + L
51302 Mandibular + L
3 Dentures, complete, transitional (temporary)
51601 Maxillary + L
51602 Mandibular + L
4 Dentures, complete, overdenture
51701 Maxillary + L
51702 Mandibular + L
5 Dentures, complete, overdentures (immediate)
51801 Maxillary + L
51802 Mandibular + L
6 Dentures, complete, attached to implants
Dentures, removable, tissue bone, with independent attachments
secured to implants
51921 Maxillary + L
51922 Mandibular + L
1 Dentures, partial, acrylic base (transitional) (with or without clasps)
52101 Maxillary + L
52102 Mandibular + L
2 Dentures, partial, acrylic base (immediate)
52111 Maxillary + L
52112 Mandibular + L
3 Dentures, partial, acrylic, with metal wrought/cast clasps and/or rests
52301 Maxillary + L
52302 Mandibular + L
4 Dentures, partial, acrylic, with metal wrought/cast clasps and/or rests
(immediate)
52311 Maxillary + L
52312 Mandibular + L
5 Dentures, partial, overdenture, acrylic, with cast/wrought clasps and/or
rests
52501 Maxillary + L
52502 Mandibular + L
6 Dentures, partial, overdenture, acrylic, with cast/wrought clasps and/or
rests (immediate)
52511 Maxillary + L
52512 Mandibular + L
Dentures, Partial, Cast with Acrylic Base
1 Dentures, partial, free end, cast frame/connector, clasps and rests
53101 Maxillary + L
53102 Mandibular + L
53104 Altered cast impression technique in conjunction with 53101, 53102, 53103 + L
2 Dentures, partial, tooth borne, cast frame/connector, clasps and rests
53201 Maxillary + L
53202 Mandibular + L
3 Dentures, partial, cast, precision attachments
53401 Maxillary + L
53402 Mandibular + L
4 Dentures, partial, cast, semi-precision attachments
53501 Maxillary + L
53502 Mandibular + L
5 Dentures, partial, cast, overdenture, removeable
53701 Maxillary + L
53702 Mandibular + L
53704 Altered cast impression technique done in conjunction with 53701, 53702 and 53703 + L
(After 3 months insertion or by other than the dentist providing prosthesis.)
1 Denture adjustments, partial or complete denture, minor
54201 One unit of time + L
2 Denture adjustments, partial or complete denture, remount and occlusal
equilibration
54301 Maxillary + L
54302 Mandibular + L
1 Denture, repair, complete denture, no impression required
55101 Maxillary + L
55102 Mandibular + L
2 Denture, repair, complete denture, impression required
55201 Maxillary + L
55202 Mandibular + L
3 Denture, repairs/additions, partial denture, no impression required
55301 Maxillary + L
55302 Mandibular + L
4 Denture, repairs/additions, partial denture, impression required
55401 Maxillary + L
55402 Mandibular + L
5 Dentures, implant retained prosthesis, prophylaxis and polishing
55501 One unit of time + L
55509 Each additional unit of time
Dentures, Duplication, Relining and Rebasing
1 Dentures, duplication
Denture, duplication, complete denture
56111 Maxillary + L
56112 Mandibular + L
2 Dentures, relining
Denture, reline, direct, complete denture
56211 Maxillary
56212 Mandibular
Denture, reline, direct, partial denture
56221 Maxillary
56222 Mandibular
Denture, reline, processed, complete denture
56231 Maxillary + L
56232 Mandibular + L
Denture, reline, processed, partial denture
56241 Maxillary + L
56242 Mandibular + L
Denture, reline, processed, functional impression requiring 3 appointments, partial denture
56261 Maxillary + L
56262 Mandibular + L
3 Dentures, remake
Denture, remake, using existing framework, partial denture
56411 Maxillary + L
56412 Mandibular + L
1 Denture, tissue conditioning, per appointment, complete denture
56511 Maxillary + L
56512 Mandibular + L
2 Denture, tissue conditioning, per appointment, partial denture
56521 Maxillary + L
56522 Mandibular + L
Dentures, Miscellaneous Services
56601 Resilient liner, in relined or rebased denture (in addition to reline or rebase of denture) + L
56602 Resetting of teeth (not including reline or rebase of denture) + L
1 Prosthesis, facial
57101 Orbital + L
57102 Nose + L
57103 Ear + L
57104 Patch + L
57105 Facial, complex + L
57106 Facial Moulage impression
57108 Ocular conformer prosthesis
57109 Ocular prosthesis
2 Prosthesis, maxillofacial, obturators
57202 Obturator (definitive) (prosthesis extra) + L
57203 Obturator (post-surgical) (prosthesis extra) + L
57204 Obturator (temporary) (prosthesis extra) + L
57208 Obturator prosthesis, modification (relines or repairs) + L
57209 Speech aid prosthesis
3 Prosthesis, maxillofacial, other
57301 Velar (speech) bulb (prosthesis and obturator extra) + L
57302 Velar lift button, mechanical (prosthesis and obturator extra) +L
(palatal lift prosthesis)
57304 Retention, magnetic (prosthesis extra) + L
57305 Guide plane, condylar (prosthesis extra) + L
57308 Skull plate, customized + L
57311 Feeding appliance (for infants with cleft palate) + L
57321 Lingual prosthesis
57341 Mandibular resection prosthesis with guide flange + L
57342 Mandibular resection prosthesis without guide flange + L
4 Prosthesis, temporomandibular joint
57401 Exerciser, trismus, therapy + L
5 Prosthesis, splints
57503 Gunning (upper and lower) + L
57504 Bar splint, labial and lingual + L
57505 Scaffolding, rhinoplastic (nasal stent) + L
57507 Template, surgical + L
57508 Commissure splint + L
6 Prosthesis, stents
57601 Ridge extension + L
57602 Maxillary and mandibular + L
57603 Skin grafts
57604 Mucous membrane grafts (mucosal guard)
7 Prosthesis, radiation appliances
57651 Radiation vehicle carrier + L
57652 Radiation protection shield (extra oral) + L
57653 Radiation protection shield (intra oral) + L
57660 Prosthesis, stents, decompression
Insured Dental Services Tariff
Mentally Challenged Program
The Mentally Challenged Program provides the insured dental services set out for the Children’s Oral Health Program in Schedule “B” for residents (as defined in the M.S.I Regulations) who are considered by a physician to be mentally handicapped.
The fee for an insured dental service provided under this Schedule to a mentally handicapped resident is the fee set out in the Nova Scotia Dental Association Schedule of Fees at the general practitioner rate, unless the service is provided in a hospital, in which case the fee is the fee set out in the Nova Scotia Dental Association Schedule of Fees at the general practitioner rate, plus 30%.
In order for an insured dental service to be provided in a hospital, a physician must indicate that a hospital setting is required to meet the resident’s dental needs.
Where major restorative treatment is required, pre-authorization must be obtained from the Corporation that administers the M.S.I. Plan for the Province prior to beginning treatment.
There is no coverage under the Mentally Challenged Program for services performed outside the Province.
Schedule “E” amended: O.I.C. 2004-158, N.S. Reg. 128/2004; O.I.C. 2007-282, N.S. Reg. 277/2007.
Schedule “F” repealed: O.I.C. 2007-282, N.S. Reg. 277/2007.