Dental Supplement

FEE NO. FEE DESCRIPTION FEE AMOUNT ($)
21235 Five surfaces (maximum) 127.92
Bonded - Molars
21241 One surface 74.03
21242 Two surfaces 95.80
21243 Three surfaces 108.82
21244 Four surfaces 134.63
21245 Five surfaces (maximum) 152.92
Retentive Pins
Note:
Pins are only paid in conjunction with an amalgam or tooth coloured
restoration to a maximum of four pins per tooth in a two-year period.
21401 One pin 18.04
21402 Two pins 25.00
21403 Three pins 31.72
21404 Four pins (maximum) 38.35
FULL COVERAGE PRE-FABRICATED RESTORATIONS
Note:
Limited to one per tooth in a two-year period. No further restorations on the
same tooth will be paid within 2 years of placement of a stainless steel or
plastic pre-fabricated crown. If a pre-fabricated crown is placed within 2 years
of a restoration, the fee for the restoration will be deducted from the
pre-fabricated crown charge.
22201 Stainless steel crown (primary anterior) 119.10
22211 Stainless steel crown (primary posterior) 119.10
22301 Stainless steel crown (permanent anterior) 119.10
22311 Stainless steel crown (permanent posterior) 119.10
22401 Plastic pre-fabricated crown (primary anterior) 119.10
22501 Plastic pre-fabricated crown (permanent anterior) 135.52
TOOTH COLOURED RESTORATIONS
Note:
Maximum fee allowance is five surfaces or the dollar equivalent per tooth in a
two-year period. Tooth numbers are required. When billing for restorations,
the total number of surfaces restored in that sitting on that tooth should be
billed cumulatively. Where two different filling materials are used, these
restorations may be billed separately.
Tooth Coloured – Permanent Teeth
Non-bonded - Anterior
23101 One surface 65.16
23102 Two surfaces 74.64
23103 Three surfaces 92.54
23104 Four surfaces 113.55
23105 Five surfaces (maximum) 137.21
Bonded - Anterior
23111 One surface 75.47
23112 Two surfaces 90.56
April 1, 2010 8