Species at Risk List Regulations (N.S. Reg. 82/2001) (just regulations rg2 2001 RG2 2001 07 27)

N.S. Reg. 82/2001

Nova Scotia — Gazette

Part II Regulations under the Regulations Act Printed by the Queen’s Printer Halifax, Nova Scotia Vol. 25, No. 15 July 27, 2001 Contents Act Reg. No.

Page Apprenticeship and Trades Qualifications Act T r a d e N a m e s E q u i v a l e n c y R e g u l a t i o n s - A m e n d m e n t ........................8 6 /2001 562 Dairy Industry Act B u l k M i l k T r a n s p o r t a t i o n R a t e s..........................................8 4 / 2001 555 Employment Support and Income Assistance Act A s s i s t a n c e A p p e a l R e g u l a t i o n s ..........................................9 0 / 2001 642 Employment Support and Income Assistance Regulations–Amendment ..........9 1 / 2001 646 Endangered Species Act S p e c i e s a t R i s k L i s t R e g u l a t i o n s – A m e n d m e n t ..............................8 2 /2001 553 Health Authorities Act D i s t r i c t H e a l t h A u t h o r i t i e s G e n e r a l R e g u l a t i o n s – A m e n d m e n t ..................8 3 /2001 554 Health Services and Insurance Act Insured Dental Services Tariff Regulations and MSI Regulations–Amendment .....8 7 / 2001 563 Municipal Government Act D e e d T r a n s f e r A f f i d a v i t o f V a l u e R e g u l a t i o n s ..............................8 8 /2001 634 Natural Products Act Nova Scotia Egg Producers: Marketing Plan–Amendment; Egg Regulations–Amendment; Pullet Regulations–Amendment; and C o m p o s i t i o n o f M a r k e t i n g B o a r d R e g u l a t i o n s – A m e n d m e n t ..................8 5 /2001 557

552 © NS Registry of Regulations. Web version. July 27, 2001 ROYAL GAZETTE

Part II Regulations Public Highways Act A d v e r t i s i n g S i g n s R e g u l a t i o n s...........................................8 9 / 2001 636 NOW AVAILABLE The second issue for the 2001 subscription year of the Folio®-based Nova Scotia Regulations CD-ROM, containing the consolidated regulations of Nova Scotia and the quarterly sectional index of regulations, is now available from the Office of the Registrar of Regulations. For information or subscriptions please call (902) 424-6723 or visit our website at <www.gov.ns.ca/just/regulations/cd>.

Part II Regulations N.S. Reg. 82/2001 Made: June 14, 2001 Filed: July 3, 2001 Species at Risk List Regulations Order dated June 14, 2001 Amendment to regulations made under Sections 10 and 12 of the Endangered Species Act THE SPECIES-AT-RISK WORKING GROUP, pursuant to Sections 10 and 12 of

Chapter 11 of the Acts of 1998, the Endangered Species Act, on 14 June, 2001, HEREBY lists by category species at risk in the Province of Nova Scotia, which are in addition to those listed in the Species at Risk List Regulations made by Order dated June 5, 2000, in N.S. Reg. 109/2000: American Marten Martes americana Endangered (Cape Breton population) Golden Crest Lophiola aurea Threatened Water Pennywort Hydrocotyle umbellata Endangered New Jersey Rush Juncus caesariensis Vulnerable Long’s Bulrush Scirpus longii Vulnerable Plymouth Gentian Sabatia kennedyana Endangered

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Part II Regulations N.S. Reg. 83/2001 Made: June 29, 2001 Filed: July 3, 2001 District Health Authorities General Regulations Order in Council 2001-306 made June 29, 2001 Amendment to regulations made by the Governor in Council pursuant to

Section 84 of the Health Authorities Act The Governor in Council, on the report and recommendation of the Minister of Health dated June 11, 2001, and pursuant to

Section 84 of

Chapter 6 of the Acts of 2000, the Health Authorities Act, is pleased to amend the District Health Authorities General Regulations made by the Governor in Council by Order in Council 2000-565 dated November 9, 2000, in the manner set forth in

Schedule “A” attached to and forming part of the report and recommendation, effective on and after June 29, 2001.

Schedule “A” Amendment to the District Health Authorities General Regulations made by the Governor in Council pursuant to

Section 84 of

Chapter 6 of the Acts of 2000, the Health Authorities Act

Section 4 of the District Health Authorities General Regulations made by the Governor in Council by Order in Council 2000-565 dated November 9, 2000, is amended by (

a) striking out “ District Health Authority 1” in clause (

a) and substituting “South Shore District Health Authority”; (

b) striking out “ District Health Authority 2” in clause (

b) and substituting “South West Nova District Health Authority”; (

c) striking out “ District Health Authority 3” in clause (

c) and substituting “Annapolis Valley District Health Authority”; (

d) striking out “ District Health Authority 4” in clause (

d) and substituting “Colchester East Hants District Health Authority”; (

e) striking out “ District Health Authority 5” in clause (

e) and substituting “Cumberland Health Authority”; (

f) striking out “ District Health Authority 6” in clause (

f) and substituting “Pictou County District Health”; (

g) striking out “ District Health Authority 7” in clause (

g) and substituting “Guysborough Antigonish-Strait Health Authority”; and (

h) striking out “ District Health Authority 8” in clause (

h) and substituting “Cape Breton District Health Authority”.

Part II Regulations N.S. Reg. 84/2001 Made: July 3, 2001 Filed: July 9, 2001 Bulk Milk Transportation Rates Order dated July 3, 2001 Amendment to regulations made under subclause 9(b)(

i) and clause 9(

q) of the Dairy Industry Act Nova Scotia Natural Products Marketing Council Bulk Milk Transportation Rates The Natural Products Marketing Council, pursuant to subclause 9(b)(iv) and clause 9(

q) of

Chapter 24 of the Acts of 2000, the Dairy Industry Act, effective on August 1, 2001: Hereby orders that the following transportation rates shall be the maximum rates which may be charged to processors by transporters and shall be applicable to all transporters in the Province: Maximum Rate Transporter Per 100 Litres Effective Date (

a) Bedford Transport Limited Farm Pick Up $2.22 August 1, 2001 (

b) E.D.F. Transport Limited Farm Pick Up $2.44 August 1, 2001 (

c) Fisher Transport Ltd. Farm Pick Up $2.04 August 1, 2001 (

d) Rudy Burghardt Farm Pick Up $2.47 August 1, 2001 (

e) Cook's Dairy Farm Ltd. $2.20 August 1, 2001 (

f) All Transporters, milk to or from Truro: Yarmouth to or from Truro Farmers Cheese Division $5.29/hl. July 30, 1995 Yarmouth from Truro or Shubenacadie Pick Up $4.42/hl. July 30, 1995 Yarmouth from Hammonds Plains or Dartmouth $4.04/hl. July 30, 1995 Yarmouth from Valley or Bridgewater Pick Up $3.14/hl. July 30, 1995

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Part II Regulations (

g) Special Rates Every Day Pick Up 150% Of Normal Rate Return Trip- Additional Charge $50.00/Extra Trip* Minimum 40.00/Week * At the discretion of the transporter This regulation is made in substitution for the Bulk Milk Transporter Rates regulation which was made and effective on May 1, 2001.

Part II Regulations N.S. Reg. 85/2001 Made: July 5, 2001 Filed: July 9, 2001 Nova Scotia Egg Producers: Marketing Plan, Egg Regulations, Pullet Regulations and Composition of Marketing Board Regulations Order in Council 2001-321 made July 5, 2001 Amendment to regulations approved by the Governor in Council pursuant to Sections 9 and 11 of the Natural Products Act The Governor in Council on the report and recommendation of the Minister of Agriculture and Fisheries dated April 25, 2001, and pursuant to Sections 9 and 11 of

Chapter 308 of the Revised Statutes of Nova Scotia, 1989, the Natural Products Act, is pleased to (

a) approve the making by the Natural Products Marketing Council of amendments to the Nova Scotia Egg and Pullet Producers Marketing Plan approved by the Governor in Council by Order in Council 82-1416 dated November 23, 1982, in the manner set forth in

Schedule “A” attached to and forming part of the report and recommendation, effective on and from July 5, 2001; (

b) approve the making by the Nova Scotia E gg Producers of amendments to the regulations respecting eggs approved by the Governor in Council by Order in Council 85-1259 dated November 19, 1985, in the manner set forth in

Schedule “B” attached to and forming part of the report and recommendation, effective on and from July 5, 2001, except Sections 5.01 to 5.06 of the regulations which are effective on and from December 26, 1999; (

c) approve the making by the Nova Scotia E gg Producers of amendments to the regulations respecting pullets approved by the Governor in Council by Order in Council 86-733 dated July 2, 1986, in the manner set forth in

Schedule “C” attached to and forming part of the report and recommendation, effective on and from July 5, 2001; and (

d) approve the making by the Natural Products Marketing Council of amendments to the regulations respecting the composition of the marketing board approved by the Governor in Council by Order in Council 85-1259 dated November 19, 1985, in the manner set forth in

Schedule “D” attached to and forming part of the report and recommendation, effective on and from July 5, 2001.

Schedule “A” Amendments to the Nova Scotia Egg and Pullet Producers Marketing Plan made pursuant to

Section 11 of

Chapter 308 of the Revised Statutes of Nova Scotia, 1989, the Natural Products Act 1

Part I of the Nova Scotia Egg and Pullet Producers Marketing Plan approved by the Governor in Council by Order in Council 82-1416 dated November 23, 1982, is amended by

558 © NS Registry of Regulations. Web version. N.S. Reg. 85/2001 ROYAL GAZETTE

Part II Regulations (

a) striking out “Nova Scotia Egg and Pullet Pr oducers” in

Section 1 and substituting “Nova Scotia Egg Producers’”; (

b) striking out “Nova Scotia Egg and Pullet Producers Marketing Board” in clause 2(

d) and substituting “Nova Scotia Egg Producers”; (

c) striking out “Nova Scotia E gg and Pullet Producers” in clause 2(

i) and substituting “Nova Scotia Egg Producers’”; (

d) striking out “quota-holder” in clause 2(

o) and substituting “quota holder”; and (

e) striking out “22¢” in clau se 20(

b) and substituting “$0.30”. 2

Part II of the Plan is amended by striking out “Nova Scotia Egg and Pullet Producers’ Marketing Board” in the paragraph beginning with “Commodity Board” in

Section 1, and substituting “Nova Scotia Egg Producers’”.

Schedule “B” Amendments to the Regulations Respecting Eggs made by the Nova Scotia Egg Producers pursuant to

Section 9 of

Chapter 308 of the Revised Statutes of Nova Scotia, 1989, the Natural Products Act 1

Section 1.01 of the regulations respecting eggs ma de by the Nova Scotia Egg and Pullet Producers Marketing Board and approved by the Governor in Council by Order in Council 85-1259 dated November 19, 1985, is amended by (

a) striking out “Nova Scotia Egg & Pullet Producers Marketing Board” in the first paragraph and in clauses (

d) and (l), and substituting “Nova Scotia Egg Producers”; (

b) striking out “Nova Scotia Egg and Pullet Pr oducers” in clause (

v) and substituting “Nova Scotia Egg Producers’”; (

c) adding the following clause immediately after clause (s): (sa) “levy” means the levy that (

i) is imposed by the Board on behalf of itself and on behalf of the Agency relative to egg production in the Province, whether the eggs are marketed within the Province or in interprovincial and export trade, and (ii) comprises the various components required to maintain the National and Provincial marketing and industrial product removal systems; (

d) adding the following clause immediately after clause (u): (ua) “national rate of lay” means the rate of lay as established for a quota holder by the Agency in consultation with the Board from time to time;

Part II Regulations (

e) adding the following clause immediately after clause (ee): (eea) “non-quota holder rate of lay” means the rate of lay established for a non-quota holder by the Agency in consultation with the Board from time to time or, in the absence of such a rate of lay, the rate of lay as established for a non-quota holder by the Board from time to time; 2

Section 4.01 of the regulations is amended by (

a) striking out “Nova Scotia Egg and Pullet Producers Marketing Board” and substituting “Nova Scotia Egg Producers”; and (

b) striking out “his” wherever it occurs, and substituting “the quota holder’s”. 3

Section 4.03 of the regulations is amended by st riking out “Schedule “A”” and substituting “Schedule “B””. 4 Sections 5.01 to 5.04 of the regulations are repealed and the following Sections substituted: 5.01 A levy is hereby imposed upon every quota holder in the amount calculated by multiplying the quota holder’s marketing quota by the national rate of lay and the current levy. 5.02 A levy is hereby imposed upon every non-quota holder in the amount calculated by multiplying the number of layers housed by a non-quota holder by the non-quota holder rate of lay and the current levy. 5.03 Where the number of layers housed by a non-quota holder is unavailable, the Board shall have the option of using egg marketing records and the non-quota holder rate of lay in order to estimate the number of layers, and the estimated number shall be deemed appropriate for the purpose of calculating the non-quota holder’s levy pursuant to [sub ]Section 5.02. 5.04 A levy collected by the Board pursuant to Sections 5.01 and 5.02 shall be collected (

a) on behalf of the Board, with respect to e ggs marketed by a producer within the Province; and (

b) on behalf of the Agency, with respect to eggs marketed by a producer in interprovincial and export trade. 5.05 A levy payable by a quota holder shall be prepaid pursuant to Regulation #6. 5.06 A levy payable by a non-quota holder shall be payable within 15 days of the date that the invoice for the levy is sent out to the non-quota holder by the Board. 5

Section 6.01 of the regulations is amended by (

a) renumbering subsection (

b) as

Section 6.01A;

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Part II Regulations (

b) repealing subsection (

a) and s ubstituting the following subsections: (

a) On or before January 15 of each year her eafter, every quota holder shall deliver to the Board a series of 13 equal post-dated cheques for the payment of this levy to the Board for that year. (

b) Each post-dated cheque shall be in the am ount calculated by multiplying the quota holder’s marketing quota by the national rate of lay and the then current levy and dividing the result by 13. (

c) The post-dated cheques sha ll be dated and honoured on the 14th day of each 4-week bird inventory period established by the Board. 6

Section 6.01A of the regulations is amended by striking out “fifteen (15)” and substituting “15”. 7

Section 6.02 of the regulations is amended by (

a) striking out “four-week” and substituting “4-week”; (

b) striking out the quotation marks around “4 Week Bird Inventory”; and (

c) striking out “his” and substituting “the quota holder’s”. 8

Section 6.03 of the regulations is amended by (

a) striking out the quotation marks around “Produ cer’s Weekly Grading and Marketing Report”; and (

b) striking out “him” wherever it occurs, and substituting “the quota holder”. 9 Sections 6.04 and 6.05 of the regulations are repealed. 10

Schedule “A” to the regulations, entitled “Consent to Withhold Transfer of Quota and Consent to Transfer of Quota”, is amended by (

a) striking out “Nova Scotia Egg & Pullet Producers Marketing Board” in the paragraph that begins with “THE UNDERSIGNED” and substituting “Nova Scotia Egg Producers”; and (

b) striking out “198” in the paragraph th at begins with “IN WITNESS WHEREOF” and substituting “20”. 11

Schedule “A” referred to in

Section 4.03 of th e regulations, entitled “Quota Available for Lease”, is redesignated as “Schedule “B”. 12

Schedule “B”to the regulati ons is further amended by (

a) striking out “19” wherever it occurs, and substituting “20”; (

b) striking out “Nova Scotia Egg and Pullet Producers Marketing Board” and substituting “Nova Scotia Egg Producers”; and (

c) adding “B2N 5G9,” immediately after “Truro, Nova Scotia,”.

Part II Regulations 13 The regulations are further amended by (

a) striking out “quota-holder” wherever it occurs, and substituting “quota holder”; and (

b) striking out “non-quota-holder” wherever it occurs, and substituting “non-quota holder”.

Schedule “C” Amendments to the Regulations Respecting Pullets made by the Nova Scotia Egg Producers pursuant to

Section 9 of

Chapter 308 of the Revised Statutes of Nova Scotia, 1989, the Natural Products Act 1 Subsection 1.01(

a) of the regulations respecting pu llets made by the Nova Scotia Egg and Pullet Producers Marketing Board and approved by the Governor in Council by Order in Council 86-733 dated July 2, 1986, is amended by striking out “Nova Scotia Egg and Pullet Producers” and substituting “Nova Scotia Egg Producers’”. 2 The regulations are further amended by stri king out “quota-holder” wherever it occurs and substituting “quota holder”.

Schedule “D” Amendment to the Regulations Respecting the Composition of the Marketing Board made by the Nova Scotia Egg Producers pursuant to

Section 11 of

Chapter 308 of the Revised Statutes of Nova Scotia, 1989, the Natural Products Act Subsection 1.01(

a) of the regulations respecting the composition of the marketing board made by the Nova Scotia Egg and Pullet Producers Marketing Board and approved by the Governor in Council by Order in Council 85-1259 dated November 19, 1985, is amended by striking out “Nova Scotia Egg & Pullet Producers Marketing Board” and substituting “Nova Scotia Egg Producers’”.

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Part II Regulations N.S. Reg. 86/2001 Made: July 5, 2001 Filed: July 9, 2001 Trade Names Equivalency Regulations Order in Council 2001-322 made July 5, 2001 Amendment to regulations made by the Governor in Council pursuant to

Section 41 of the Apprenticeship and Trades Qualifications Act The Governor in Council on the report and recommendation of the Minister of Education dated May 23, 2001, and pursuant to

Section 41 of

Chapter 17 of the Revised Statutes of Nova Scotia, 1989, the Apprenticeship and Trades Qualifications Act, is pleased to amend the Trades Names Equivalency Regulations made by the Governor in Council by Order in Council 97-564 dated August 19, 1997, in the manner set forth in

Schedule "A" attached to and forming part of the report and recommendation effective on and after July 5, 2001.

Schedule "A" Amendments to the Trade Names Equivalency Regulations made by the Governor in Council pursuant to

Section 41 of

Chapter 17 of the Revised Statutes of Nova Scotia, 1989, the Apprenticeship and Trades Qualifications Act

Section 2 of the Trade Names Equivalency Regulations made by the Governor in Council by Order in Council 97-564 dated August 19, 1997, is amended by (

a) striking out "Steel" in clause (

h) and substituting "Metal"; (

b) striking out "Mechanic" in clause (

l) and substituting "Technician".

Part II Regulations N.S. Reg. 87/2001 Made: July 5, 2001 Filed: July 9, 2001 Insured Dental Services Tariff Regulations and MSI Regulations Order in Council 2001-327 made July 5, 2001 Regulations approved by the Governor in Council pursuant to

Section 13 and Amendment to regulations made by the Governor in Council pursuant to

Section 17 of the Health Services and Insurance Act The Governor in Council on the report and recommendation of the Minister of Health dated April 11, 2001, is pleased to: (

a) pursuant to

Section 13 of

Chapter 197 of th e Revised Statutes of Nova Scotia, 1989, the Health Services and Insurance Act, (

i) approve the repeal of the Insured Dental Tariff Regulations approved by the Governor in Council by Order in Council 1999-140 dated March 31, 1999, (ii) approve of the new tariff for insured dental services established by the Minister of Health pursuant to clause 13(1)(

c) of the Act in the form set forth in

Schedule “A” attached to and forming part of the report and recommendation, and (iii) approve the authorization by the Minister of Health of payments in respect of the tariff referred to in subclause (ii), effective on and after April 1, 2000; and (

b) pursuant to

Section 17 of

Chapter 197 of the Revised Statutes of Nova Scotia, 1989, the Health Services and Insurance Act, amend the regulations respecting the M.S.I. Plan made by the Governor in Council by Order in Council 69-276 dated March 28, 1969, in the manner set forth in

Schedule “B” attached to and forming part of the report and recommendation, effect on and after July 5, 2001.

Schedule “A” Regulations Respecting a Tariff for Insured Dental Services made by the Minister of Health pursuant to

Section 13 of

Chapter 197 of the Revised Statutes of Nova Scotia, 1989, the Health Services and Insurance Act Citation 1 These regulations may be cited as the Insured Dental Services Tariff Regulations. Insured dental services tariff 2 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 Prosthdontics Program; (

e) Schedule “E” - Mentally Challenged Program; and

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Part II Regulations (

f) Schedule “F” - Atlantic Provinces Special Education Authority Dental Program. Authorization of payments 3 Payments in respect of the tariff prescribed by these regulations are hereby authorized. Made and dated at Halifax, Nova Scotia April 11, 2001. (Signed) Jamie Muir The Honourable Jamie Muir Minister of Health Tariff of Fees for Insured Dental Services

Schedule “A” 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. ** “E” means Expenses ** “L” means Laboratory Fees ** “PA” means Prior Approval from the Corporation that administers the M.S.I. Plan for the Province [Note: The above 3

definitions were included in a footnote in the original.] Fee Code G.P. Specialist Fee ($) Fee ($)

Part 1 - Diagnostic - 01000-09999 Examinations 1 Examinations and diagnosis, complete oral, to include: - History, medical and dental

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) - 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 27.62 34.47 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 45.70 50.00 01103 Examination and diagnosis, co mplete, permanent dentition to include: extended examination and diagnosis on permanent dentition, recording history, charting, treatment planning and case presentation, including above description 45.70 50.00 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 20.18 24.30 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 15.42 19.16 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.

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Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($) 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) 24.09 32.12 01205 Examination and diagnosis, emergency: examination for the investigation of discomfort and/or infection in a localized area (MSI - includes x-rays) 24.09 32.12 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 Radiographs (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) 69.80 69.80 02102 Radiographs, intra oral, adult, complete series (minimum of 16 films incl. bitewings) 69.80 69.80 2 Radiographs, intra oral, periapical 02111 Single film 8.56 8.56 02112 Two films 11.24 11.24 02113 Three films 16.54 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 films 32.71 32.71 02119 Nine films 35.92 35.92 02120 Ten films 39.18 39.18 02121 Eleven films 42.70 42.70

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 film 20.93 20.93 02132 Two films 32.71 32.71 02133 Three films 44.48 44.48 02134 Four films 56.21 56.21 4 Radiographs, intra oral, bitewing 02141 Single film 8.56 8.56 02142 Two films 11.24 11.24 02143 Three films 16.54 16.54 02144 Four films 19.75 19.75 5 Radiographs, extra oral 02201 Single film 20.93 20.93 02202 Two films 32.71 32.71 02203 Three films 44.48 44.48 02204 Four films 56.21 56.21 6 Radiographs, postero-anterior and lateral skull and facial bone 02301 Single film PA 20.93 02302 Two films PA 32.71 02303 Three films PA 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 film PA 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 film PA 20.93 02502 Two films PA 32.71 02503 Three films PA 44.48

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Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($) 02504 Four films (minimum examination closed and open each side) PA 56.21 02509 Each additional film over four PA PA 10 Radiographs, panoramic 02601 Single film 35.97 35.97 11 Radiographs, cephalometric 02701 Single film 35.97 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 PA PA 15 Radiographs, tomography 02931 Single view PA PA 02932 Two view PA PA 02933 Three view PA 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.

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 21.14 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) 21.14 21.14 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 units PA PA 04714 Four units PA PA 04719 Each additional unit over four PA PA

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Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($) 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 units PA 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 units PA 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 Photographs, Diagnostic 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 Casts, Diagnostic 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 60.86 PA 04924 Cast, diagnostic, mounted using fully adjustable articulator + L (used with 04942) PA PA 3 Casts, diagnostic, orthodontic 04931 Cast, diagnostic, orthodontic (unmounted, angle trimmed and soaped) + L PA 29.76

Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($)

Part 2 - Endodontics - 30000-39999 Pulp Chamber, Treatment of (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 teeth 50.10 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) 40.25 50.05 2 Pulpectomy (as a separate emergency procedure) Pulpectomy, permanent teeth/retained primary teeth 32311 One canal 57.70 57.70 32312 Two canals 89.40 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 Root Canal Therapy 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 canals 333.86 393.86 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 canals 118.14 143.19 33403 Three canals or more 117.98 141.69

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Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 canals 114.95 150.31 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 canals 38.70 44.72 33613 Three canals 38.70 44.72 33614 Four canals or more 38.70 44.72 Periapacal Services 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 roots 267.17 281.53 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 roots 267.17 281.53 34164 Four or more roots 300.83 314.75

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 canals 57.35 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 canals 57.35 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 canals 57.35 70.81 34253 Three canals 69.39 88.51 34254 Four canals 77.79 99.57 Mandibular molar 34261 One canal 47.32 56.79 34262 Two canals 57.35 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 PA PA 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) 57.49 68.94 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 27.09 27.09

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Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($)

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 18.79 22.59 2 Removals, erupted teeth, complicated 71201 Odontectomy, (extraction), erupted tooth, surgical approach, requiring surgical flap and/or sectioning of tooth 97.53 116.37 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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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

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Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 Incisions 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 PA PA Surgical incision and drainage and/or exploration, intra-oral hard tissue 75121 Intra-oral, abscess, hard tissue, trephination and drainage PA PA 75122 Intra-oral, surgical exploration, hard tissue PA PA 75123 Intra-oral, abscess, hard tissue, trephination and drainage in major anatomical area PA PA Treatment of Fractures 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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 Frenectomy/Frenoplasty 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 Hemorrhage, Control of 79401 Primary hemorrhage, control PA PA 79402 Secondary hemorrhage, control PA PA 79403 Hemorrhage control, using compression and hemostatic agent 34.90 41.91 79404 Hemorrhage control, usi ng hemostatic substance and sutures (including removal of bony tissue, if necessary) 34.90 41.91 Post Surgical Care (Required by complications and unusual circumstances, refer to comment at beginning of

Part 3.) 79605 Post surgical care, alveolitis, treatment of (without anaesthesia) 29.55 35.54 79606 Post surgical care, alveolitis, treatment of (with anaesthesia) 29.55 35.54 Implantology (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) PA PA

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Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($) 79952 First stage surgical placement, mandible per implant (+ E - not payable by MSI) PA PA 79953 Second stage exposure and temporization, maxilla per implant (+ E - not payable by MSI) PA PA 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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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) PA 214.00 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

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Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 Desensitization (This may involve application and burnishing of medicinal aids on the root or the use of a variety of therapeutic procedures. More than one appointment may be necessary.) (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 sextant 77.83 93.53 2 Periodontal surgery, gingivoplasty 42201 Per sextant PA 133.75

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 sextant PA 95.98 Gingivectomy, with curettage 42321 Per sextant PA 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 sextant PA 196.08 Flap approach, with curettage of osseous defect 42421 Per sextant PA 196.08 Flap approach, with curettage of osseous defect and osteoplasty 42431 Per sextant PA 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

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Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 units PA 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.)

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 Occlusion 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 conjuncti on 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 units 103.59 124.14 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 Root Planing, Periodontal 43421 One unit of time 34.53 41.38 43422 Two units 69.06 82.76

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Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 43423 Three units 103.59 124.14 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 Appliances 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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 PA PA Forced eruption - one tooth PA PA Forced eruption - more than one tooth PA PA Rapid extrusion - one tooth PA PA Rapid extrusion - more than one tooth PA PA

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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 3 Fluoride treatments 12101 Fluoride treatment, topical application 11.03 11.03 Preventive Services, Other 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 - MS I (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 tooth 1 9.27 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 units 112.74 112.74 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 Space Maintainers (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 109.47 176.64 15105 Space maintainer, band type, fixed, bilateral tubes and locking wires + L 148.65 193.19

Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($) 2 Space maintainers, stainless steel crown type 15201 Space maintainer, stainless steel crown type, fixed + L 112.04 134.46 3 Space maintainers, maintenance of 15601 Maintenance, space maintainer a ppliance, to include adjustment and/or recementation after 30 days from insertion 40.57 40.57

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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) Dentures, Partial, Acrylic 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 PA PA 2 Dentures, partial, tooth borne, cast frame/connector, clasps and rests 53201 Maxillary + L 341.78 PA 53202 Mandibular + L 341.78 PA

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 PA PA Dentures, Adjustments (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 Dentures, Repairs/Additions 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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 Mandibular 100.85 100.85 Denture, reline, direct, partial denture 56221 Maxillary 96.73 96.73 56222 Mandibular 96.73 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 Dentures, Tissue Conditioning 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

Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($) Dentures, Miscellaneous Services 56601 Resilient liner, in relined or rebased denture (in addition to reline or rebase of denture) + L 61.40 61.40 56602 Resetting of teeth (not including reline or rebase of denture) + L PA PA

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 PA 166.80 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 PA PA 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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) Repairs, solder indexing to repair broken solder joint 66721 One unit of time + L PA PA 66729 Each additional unit of time PA PA Fixed Bridge Retainers 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 PA 116.26 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 PA 116.26 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 PA 116.26 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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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) PA PA Fixed Prosthodontics, Abutments/Retainers, Miscellaneous Services 67501 Abutment preparation unde r existing partial denture clasp, in addition to retainer codes + L PA PA 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) PA PA 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 PA PA 2 Fixed prosthetics, splinting 69201 Splinting for extensive or complicated restorative dentistry(per tooth) + L PA PA 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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 Restorations, Amalgam 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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 crown PA PA 21302 Restorations, amalgam core, bonded, in conjunction with crown PA 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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 Restorations, Tooth Coloured 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) 108.29 131.47 2 Restorations, tooth coloured, veneer applications 23121 Tooth coloured veneer application - direct chairside prefabricated - acid etch/bond 108.29 131.47 23122 Tooth coloured veneer application - non prefabricated direct buildup-acid etch/bond 108.29 131.47 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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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) 90.30 98.00 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 crown 90.30 98.00 23602 Restoration, tooth coloured, acid etch/bonded, core, in conjunction with crown 90.30 98.00 Note: Please see prosthodontics

section for inlays, onlays and pins. 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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 Crowns 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 PA PA 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, tran sitional (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

Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($) 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 PA PA 3 Crowns, metal, cast 27301 Crown, metal, full cast, uncomplicated + L 308.38 370.04 27302 Crown, metal, full cast, complicated (restorative, positional) + L 308.38 370.04 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 di rect tooth coloured corner + L 339.69 407.62 4 Crowns made to an existing partial denture clasp (additional to crown) 27401 One crown 38.87 38.87 Copings, Metal/Plastic, Transfer (thimble type) 27501 coping, metal/plastic, transfer (thimble) as a separate procedure + L PA PA 27502 Coping, metal/plastic, transfer (thimble) each additional coping as a separate procedure + L PA PA 27503 Copings, metal/plastic, transf er (thimble) concurrent with impression for crown + L PA PA 27504 Coping, metal/plastic, transfer (thimble), each additional coping concurrent with impression for additional crown + L PA PA Veneers, Laboratory Processed 27602 Veneers, porcelain/ceramic, acid etch/bonded + L PA PA Repairs (single units only, does not include removal and recementation) Repairs, inlays, onlays or crowns, plastic (single units) 27711 Repairs, plastic direct PA PA

Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($) 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 application PA PA 28102 Prefabricated attachment, as an internal or external overdenture retentive device, direct chairside + E PA PA 28103 Natural tooth preparation and fluor ide application, vital tooth PA PA 2 Restorative procedures, overdentures, indirect Coping crowns, metal cast 28211 Coping crown, metal cast - no attachment indirect + L PA PA 28212 Coping crown, metal cast - with attachment indirect + L PA PA Restorative Services, Other 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 units PA PA 29404 Four units PA PA 29409 Each additional unit over four PA PA Tariff of Fees for Insured Dental Services

Schedule “B” 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 II Regulations Fee Code G.P. Specialist Fee ($) Fee ($)

Part 1 - Diagnostic - 01000-09999 Examinations 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. 27.62 34.47 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 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) 24.09 32.12

Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($) 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 NA 54.39 Radiographs (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 film 8.56 8.56 02112 Two films 11.24 11.24 2 Radiographs, intra oral, bitewing 02141 Single film 8.56 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) 35.97 35.97 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) 35.97 35.97

Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($) 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 21.63 21.63 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) 21.14 21.14 5 Tests, pulp vitality 04501 One unit 17.88 17.88

Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($) Casts, Diagnostic (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 60.86 PA

Part 2 - Preventive - 10000-19999 Fluoride Treatments 12101 Fluoride treatment, topical application 11.03 11.03 Preventive Services, Other 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 tooth 19.27 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 units 112.74 112.74

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) Space Maintainers (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 109.47 176.64 15105 Space maintainer, band type, fixed, bilateral tubes and locking wires + L 148.65 193.19 2 Space maintainers, stainless steel crown type 15201 Space maintainer, stainless steel crown type, fixed + L 112.04 134.46 3 Space maintainers, maintenance of 15601 Maintenance, space maintainer a ppliance, to include adjustment and/or recementation after 30 day from insertion 40.57 40.57

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 Restorations, Amalgam 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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 Restorations, Tooth Coloured 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) 108.29 131.47 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) 90.30 98.00

Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($) 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. 5P o s t s 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 Crowns 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.

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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, trans itional (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 PA PA 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 Desensitization This may involve application and burnishing of medicinal aids on the root or the use of a variety of therapeutic procedures. More than one appointment may be necessary. 41301 One unit of time 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.)

Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($) 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%.

Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($) 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 18.79 22.59 2 Removals, erupted teeth, complicated 71201 Odontectomy, (extraction), erupted tooth, surgical approach, requiring surgical flap and/or sectioning of tooth 97.53 116.37 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

Part II Regulations Fee Code G.P.

Specialist Fee ($) Fee ($) 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 Incisions 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 Treatment of Fractures 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 Frenectomy/Frenoplasty 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

Part II Regulations Fee Code G.P. Specialist Fee ($) Fee ($) Hemorrhage, Control of (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 34.90 41.91 79404 Hemorrhage control, using hemo static substance and sutures (including removal of bony tissue, if necessary) 34.90 41.91 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) 29.55 35.54 79606 Post surgical care, alveolitis, treatment of (with anaesthesia) 29.55 35.54 Insured Dental Services Tariff

Schedule “C” 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. Fee Code Specialist Fee ($)

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 II Regulations Fee Code Specialist Fee ($)

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.

Removals 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

Part II Regulations Fee Code Specialist Fee ($) 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 sextant 69.62 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 t uberosity, augmentation + E 641.81 73182 Bilateral, pterygomaxillary t uberosity, 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 sextant 63.91 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

Part II Regulations Fee Code Specialist Fee ($) Removals, tissue, hyperplastic (includes the incision of the mucous membrane, the dissection and removal of hyperplastic tissue, the replacing and adapting of the mucous membrane) 73231 Per sextant 63.91 Removal, mucosa, excess (complete removal without dissection) 73241 Per sextant 63.91 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 sextant 103.74 Sulcus deepening and ridge reconstruction 73421 Per sextant 103.74 Vestibuloplasty, with secondary epithelization 73431 Per sextant 103.74 Vestibuloplasty, with labial inverted flap 73441 Per sextant 130.74 Vestibuloplasty, with skin graft 73451 Per sextant 130.74 Vestibuloplasty, with mucosal graft 73461 Per sextant 130.74 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 sextant 130.74 Extensions, mucous folds, with skin grafts 73621 Per sextant 130.74 Extensions, mucous folds, with mucous graft 73631 Per sextant 130.74

Part II Regulations Fee Code Specialist Fee ($) Surgical Excision (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

Part II Regulations Fee Code Specialist Fee ($) 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 Surgical Incisions 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

Part II Regulations Fee Code Specialist Fee ($) 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 Mandibulectomy 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 Maxillectomy 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 Fractures, Treatment of 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

Part II Regulations Fee Code Specialist Fee ($) 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 (requirin

Document details

Collection	Nova Scotia — Gazette
Citation	N.S. Reg. 82/2001
Date	2001-07-27
Type	gazette
Volume / chapter	just regulations rg2 2001 RG2 2001 07 27
Language	en
Format	pdf
Source	PROVINCIAL
Identifier	762dfe40c33ceb3ab3cf91c7141eef2bd66545da

Source file is stored in the law ingest library (pdf).