Read Schedule of Dental Procedures and Fees text version

SCHEDULE OF PROCEDURES AND FEES

The procedures and fees in this Schedule of Procedures are subject to change without prior notice at the sole discretion of Alberta Seniors. Procedures are available only to seniors who meet program eligibility requirements. Program eligibility requirements are subject to change without prior notice. An individual's program eligibility may change if there are changes to certain personal information, including but not limited to: income, marital status, and residency. Eligible procedures may be subject to maximum claimable amounts and/or frequency limitations. The provisions of this Schedule of Procedures do not constitute a contract, express or implied, between any applicant and Alberta Seniors or Alberta Blue Cross. While due caution has been exercised in the preparation and presentation of this information, it does not necessarily constitute the most up-to-date, accurate, or complete statement of program parameters and should be treated as informational only. For further information, contact the Alberta Supports Call Centre at 1-877-644-9992 or Alberta Blue Cross at 1-800-661-6995.

Dental Benefits Schedule- Coverage Group 101

Schedule of Covered Dental Procedures

Codes DAC Code Hygiene Procedure Descriptions Code General Pract. Specialist Denturists Limitation

DIAGNOSTIC

01000 Examination and Diagnosis, Clinical Oral Examination and Diagnosis, Complete, Permanent Dentition Not more than 1 exam per day per participant. 1 of any complete or general examination per participant in any 3 years per provider (applies to procedure codes 01103, 01601, 01701, 01801). 98.00 121.52 1 of any limited recall or specified examination per participant in any 12 month period per provider. (01201, 01202, 01204, 01602, 01702, 01802). Emergency exams are unlimited. (01205) 62.94 62.94 62.94 62.94 78.05 78.05 78.05 78.05 47.25 47.25

01103

00113

01200 Examination and diagnosis, limited oral Examination and Diagnosis Limited Oral, New Patient Limited oral, previous patient (recall) Specific examination Emergency

01201 10020 01202 10030 01204 01205 00121 00122 00123

01600 Examination and Diagnosis Surgical 01601 General Exam 01602 Specific Exam 01700 Examinations and Diagnosis Prosthodontic 01701 10010 00114 General Exam 01702 10104 Specific Exam 01800 Examination and Diagnosis Endodontic 01801 General Exam 01802 Specific Exam 02100 Radiographs, intraoral 02110 Periapical 02111 02112 02113 02114 02115 02116 00221 00222 00223 00224 00225 00226 Single film Two films Three films Four films Five films Six films

145.00 89.00

179.80 110.36

104.54 73.00

129.63 90.52

68.56 43.60

140.00 100.00

173.60 124.00 6 periapical radiographs per participant in any 12 month period (02111-02120).

26.00 43.00 58.04 75.00 90.03 106.30

32.24 53.32 71.97 93.00 111.64 131.81

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Dental Benefits Schedule- Coverage Group 101

Schedule of Covered Dental Procedures

Codes DAC Code Hygiene Procedure Descriptions Code General Pract. Specialist Denturists Limitation

DIAGNOSTIC

02140 Bitewing (single or two films) 02141 02142 02600 Radiographs, Panoramic 02601 00241 Single film 84.00 104.16 1 panoramic radiograph per participant in any 5 year period. 00211 00212 Single film Two films 26.00 43.00 32.24 53.32 2 bitewing radiographs per participant in any 12 month period (02141 - 02146).

PREVENTIVE

11100 Polishing 11107 11101 11110 Scaling 11117 11111 11112 11113 11114 11115 11116 00517 00511 00512 00513 00514 00515 00516 One half unit of time One unit of time Two units of time Three units of time Four units of time Five units of time Six units of time 31.67 63.34 126.68 190.02 253.36 316.70 380.04 39.27 78.54 157.08 235.62 314.16 392.70 471.24 00537 00531 One half unit of time One unit of time 30.00 60.00 37.20 74.40 1 time unit of polishing per participant in any 12 month period.

6 time units of scaling and root planing per participant in any 12 month period.

RESTORATIVE SERVICES

20100 Caries/Trauma/Pain Control 20110 Caries/Trauma/Pain Control 20111 00666 First tooth 20119 00667 Each additional tooth, same quadrant 20130 Trauma Control, smoothing of fractured surfaces (per tooth) 20131 20139 First tooth Each additional tooth, same quadrant 38.00 32.26 47.12 40.00 Not eligible in conjunction with filling restorations. 105.85 81.31 131.25 100.82

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Dental Benefits Schedule- Coverage Group 101

Schedule of Covered Dental Procedures

Codes DAC Code Hygiene Procedure Descriptions Code General Pract. Specialist Denturists Limitation

RESTORATIVE SERVICES

21000 Restorations, Amalgam 21200 Restorations, Amalgam, permanent teeth 21210 Restorations, Amalgam, non-bonded, permanent bicuspids & anteriors 21211 21212 21213 21214 21215 One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth 90.00 125.00 158.93 190.53 211.00 111.60 155.00 197.07 236.26 261.64 1 per surface in any 24 month period to the dollar maximum of a 5 surface restoration per tooth.

21220 Restorations, Amalgam, non-bonded, permanent molars 21221 One surface 21222 Two surfaces 21223 Three surfaces 21224 Four surfaces 21225 Five surfaces or maximum surfaces per tooth 21400 Pins, retentive per restoration 21401 21402 21403 21404 21405

93.54 129.00 160.65 197.50 228.00

115.99 159.96 199.21 244.90 282.72

One pin Two pins Three pins Four pins Five pins or more

27.00 39.50 51.00 65.84 77.00

33.48 48.98 63.24 81.64 95.48

23000 Restorations, Tooth Coloured/Plastic with/without silver filings 23100 Restorations, tooth coloured, permanent anteriors, non acid etch 23110 Restorations, permanent anteriors, bonded technique 23111 One surface 23112 Two surfaces (continuous) 23113 Three surfaces (continuous) 23114 Four surfaces (continuous) Five surfaces (continuous) or maximum surfaces 23115 per tooth 1 per surface in any 24 month period to the dollar maximum of a 5 surface restoration per tooth.

123.00 144.00 170.00 205.33 249.00

152.52 178.56 210.80 254.61 308.76

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Dental Benefits Schedule- Coverage Group 101

Schedule of Covered Dental Procedures

Codes DAC Code Hygiene Procedure Descriptions Code General Pract. Specialist Denturists Limitation

RESTORATIVE SERVICES

23300 Restorations, tooth coloured, permanent posteriors--bonded 23310 Permanent Bicuspids 23311 23312 23313 23314 23315 23320 Permanent molars 23321 23322 23323 23324 23325

One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth

129.00 180.00 212.20 247.26 280.16

159.96 223.20 263.13 306.60 347.40

One surface Two surfaces Three surfaces Four surfaces Five surfaces or maximum surfaces per tooth

135.24 190.00 226.00 260.00 299.00

167.70 235.60 280.24 322.40 370.76

ENDODONTICS

33000 Root Canal Therapy 33100 Root Canals, Permanent teeth, retained primary teeth 33110 Root Canals, Permanent teeth, retained primary teeth, one canal 33111 33112 33113 33114 One canal Difficult access Exceptional anatomy Calcified canal 599.00 762.89 762.89 762.89 742.76 945.98 945.98 945.98 1 per tooth in any 24 month period.

33120 Root Canals, Permanent teeth, retained primary teeth, two canals 33121 33122 33123 33124 Two canals Difficult access Exceptional anatomy Calcified canal 879.00 1,045.00 1,045.00 1,045.00 1,089.96 1,295.84 1,295.84 1,295.84

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Dental Benefits Schedule- Coverage Group 101

Schedule of Covered Dental Procedures

Codes DAC Code Hygiene Procedure Descriptions Code General Pract. Specialist Denturists Limitation

ENDODONTICS

33130 Root Canals, Permanent teeth, retained primary teeth, three canals 33131 33132 33133 33134 Three canals Difficult access Exceptional anatomy Calcified canal 1,027.00 1,182.33 1,182.33 1,182.33 1,273.48 1,466.09 1,466.09 1,466.09

33140 Root Canals, Permanent teeth, retained primary teeth, four or more canals 33141 33142 33143 33144 Four of more canals Difficult access Exceptional anatomy Calcified canal 1,229.00 1,348.00 1,348.00 1,348.00 1,523.96 1,671.52 1,671.52 1,671.52

PERIODONTICS

42000 Periodontal Services, Surgical 1 time unit of periodontal abscess or pericoronitis per participant per appointment to a maximum of 3 time units in any 12 month period.

42800 Periodontal Surgery, miscellaneous procedures

42830 Periodontal abscess or pericoronitis 42831 One unit of time 43000 Periodontal Procedures, Adjunctive 43400 Root planing, periodontal 43420 Root planing 43427 43421 43422 43423 43424 43425 43426

68.74

85.24

6 time units of scaling and root planing per participant in any 12 month period.

00527 00521 00522 00523 00524 00525 00526

One half unit of time one unit of time two units of time three units of time four units of time five units of time six units of time

34.02 68.04 136.08 204.12 272.16 340.20 408.24

42.19 84.38 168.76 253.14 337.52 421.90 506.28

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Dental Benefits Schedule- Coverage Group 101

Schedule of Covered Dental Procedures

Codes DAC Code Hygiene Procedure Descriptions Code General Pract. Specialist Denturists Limitation

PROSTHODONTICS - REMOVABLE

51000 Denture Complete Lab charges will be covered at the usual and customary charges. 1 upper and/or 1 lower denture per participant in any 5 year period. Maxillary Lab Mandibular Lab Resilient Liner Lab 51300 Dentures, surgical, standard 51301 31311 51302 31321 731.77 731.77 907.39 907.39 647.98 647.98 1 liner per denture per participant in any 5 year period.

51100 Denture Complete, Standard 51101 31310 51102 31320 51104 73008

No Fee

No Fee

No Fee

Maxillary Lab Mandibular Lab

800.00 800.00

992.00 992.00

744.61 744.61

53000 Dentures, Partial, Cast with Acrylic Base Dentures, Partial, Acrylic, Without Clasps - Standard 41612 Maxillary Lab 41622 Mandibular Lab Dentures, Partial, Acrylic, Surgical Without Clasps - Standard 41613 Maxillary Lab 41623 Mandibular Lab

215.80 215.80

215.80 215.80

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Dental Benefits Schedule- Coverage Group 101

Schedule of Covered Dental Procedures

Codes DAC Code Hygiene Procedure Descriptions Code General Pract. Specialist Denturists Limitation

PROSTHODONTICS - REMOVABLE

53101 41114 53102 41124 53111 41115 53112 41125 Maxillary Lab Mandibular Lab Maxillary Lab Mandibular Lab 750.00 750.00 741.17 741.17 930.00 930.00 919.50 919.50 604.15 604.15 597.50 597.50

53200 Dentures, partial, tooth-borne, Caste Frame, Connector, Clasps and Rests 53201 41254 Maxillary Lab 53202 41264 Mandibular Lab 53200 Dentures, partial, tooth-borne, Cast Frame, Connector, Clasps and Rests 53211 41215 Maxillary Lab 53212 41225 Mandibular Lab

752.00 752.00

932.48 932.48

605.64 605.64

777.00 777.00

963.48 963.48

623.54 623.54

54000 Dentures, Adjustment

1 denture repair or adjustment per denture in any 12 month period. Not allowed within 3 months of the placement of the denture. 61.00 75.64 47.54 1 denture repair or adjustment per denture in any 12 month period.

54200 Denture adjustments, partial or complete minor 54201 58110 55000 Dentures, Repairs/Additions 55100 Denture, repair, complete denture, no impression req'd 55101 36110 Maxillary Lab 55102 36120 Mandibular Lab one unit of time

65.00 65.00

80.60 80.60

55.87 55.87

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Dental Benefits Schedule- Coverage Group 101

Schedule of Covered Dental Procedures

Codes DAC Code Hygiene Procedure Descriptions Code General Pract. Specialist Denturists Limitation

PROSTHODONTICS - REMOVABLE

55201 36210 55202 36220 Maxillary Lab Mandibular Lab 130.00 130.00 161.20 161.20 114.06 114.06

55300 Denture, repairs/additions, partial denture, no impression req'd 55301 46110 Maxillary Lab 55302 46120 Mandibular Lab 55400 Denture, repairs/additions, partial denture, impression req'd 55401 46210 Maxillary Lab 55402 46220 Mandibular Lab 56000 Dentures, Replication, Relining and Rebasing

69.00 69.00

85.56 85.56

59.08 59.08

132.00 132.00

163.68 163.68

114.85 114.85

56200 Dentures, relining 56210 Denture, reline, direct complete denture 56211 32418 Maxillary 56212 32428 Mandibular 56220 Denture, reline, direct, partial denture 56221 42418 Maxillary 56222 42428 Mandibular 56230 Denture, reline, processed, complete denture 56231 32215 Maxillary Lab 56232 32225 Mandibular Lab

1 reline per denture in any 24 month period. (56200) Not allowed within 3 months of the placement of the denture. 190.00 190.00 235.60 235.60 164.08 164.08

195.00 195.00

241.80 241.80

167.60 167.60

207.00 207.00

256.68 256.68

193.94 193.94

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April 1, 2012

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Dental Benefits Schedule- Coverage Group 101

Schedule of Covered Dental Procedures

Codes DAC Code Hygiene Procedure Descriptions Code General Pract. Specialist Denturists Limitation

PROSTHODONTICS - REMOVABLE

56241 42210 56242 42220 Maxillary Lab Mandibular Lab 196.90 196.90 244.16 244.16 185.44 185.44

56500 Therapeutic Tissue Conditioning 56510 Denture: Therapeutic Tissue Conditioning, Per Appointment, Complete Dentures 56511 37110 Maxillary Lab 56512 37120 Mandibular Lab 56520 Denture: Therapeutic Tissue Conditioning, Per Appointment, Partial Denture

Not allowed within 3 months of the placement of the denture.

128.55 128.55

159.40 159.40

111.09 111.09

56521 47110 56522 47120

Maxillary Lab Mandibular

128.00 128.00

158.72 158.72

111.32 111.32

ORAL AND MAXILLOFACIAL SURGERY

71000 Removals, (extractions), Erupted Teeth 71100 Removals, erupted teeth, uncomplicated 71101 Single tooth Each additional tooth, same quadrant, same 71109 appointment 71200 Removals, erupted teeth, complicated Odontectomy, (extraction), erupted tooth, surgical 71201 approach, requiring surgical flap and/or resectioning 71209 Each additional tooth, same quadrant

117.00 109.20

145.08 135.41

213.00 202.80

264.12 251.47

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April 1, 2012

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Dental Benefits Schedule- Coverage Group 101

Schedule of Covered Dental Procedures

Codes DAC Code Hygiene Procedure Descriptions Code General Pract. Specialist Denturists Limitation

ORAL AND MAXILLOFACIAL SURGERY

72000 Removals, (Extractions), Surgical 72110 Removals, impaction, requiring incision of overlying soft tissue and removal of tooth 72111 Single tooth 72119 Each additional tooth, same quadrant

223.00 191.00

276.52 236.84

72200 Removals, impactions, involving tissue and/or bone coverage 72210 Removals, impaction, requiring incision of overlying soft tissue, elevation of flap and either removal of bone and tooth or sections 72211 72219 72220 Single tooth Each additional tooth, same quadrant 272.00 239.36 337.28 296.81

Removals, impaction, requiring incision of overlying soft tissue, elevation of flap and removal of bone 72221 Single tooth 72229 Each additional tooth, same quadrant Removals, impaction, requiring incision of overlying soft tissue, elevation of flap and removal of bone or presents unusual difficulties 72231 72239 Single tooth Each additional tooth, same quadrant

346.51 277.71

429.23 344.36

72230

410.00 360.80

508.40 447.40

ORAL AND MAXILLOFACIAL SURGERY

72300 Removals, (extractions), residual roots 72311 First tooth 72319 Each additional tooth, same quadrant 72320 Removals, residual roots, soft tissue coverage 72321 First tooth 72329 Each additional tooth, same quadrant 72330 Removals, residual roots, bone tissue coverage 72331 First tooth 72339 Each additional tooth, same quadrant 85.00 80.00 105.40 99.20

126.60 104.92

156.98 130.10

210.00 162.84

260.40 201.92

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April 1, 2012

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Dental Benefits Schedule- Coverage Group 101

Schedule of Covered Dental Procedures

Codes DAC Code Hygiene Procedure Descriptions Code General Pract. Specialist Denturists Limitation

ADJUNCTIVE GENERAL SERVICES

Only allowed in conjunction with 4 or more extractions (same appt) and/or if medically necessary and the reason is submitted to ABC in writing for approval 92200 Anesthesia: General (inlcudes pre-anesthesia, evaluation and postanesthesia follow-up) 92212 Two Units of Time 92213 Three Units of Time 92214 Four Units of Time 92220 Provision of Facilities, Equipment and Support Services for General Anesthesia when provided by a separate practitioner 92222 Two Units of Time 92223 Three Units of Time 92224 Four Units of Time 92300 Anaesthesia: Deep Sedation 92302 92303 92304

158.34 237.51 316.68

196.34 294.51 392.68

176.34 264.51 352.68

218.66 327.99 437.32

Two Units of Time Three Units of Time Four Units of Time

165.50 248.25 331.00

205.22 307.83 410.44

92320 Provision of Facilities, Equipment and Support Services for Deep Sedation when provided by a separate practitioner 92322 Two Units of Time 92323 Three Units of Time 92324 Four Units of Time

95.40 143.10 190.80

118.30 177.45 236.60

3/29/2012

This Schedule is effective

April 1, 2012

11

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