Department of Health & Wellness
Dental Programs
Dentists Guide
January 2017
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 1
GENERAL PREAMBLE ............................................................................................................ 4
INTRODUCTION .................................................................................................................... 4
GENERAL CONSIDERATIONS ............................................................................................. 4
TERMS AND DEFINITIONS USED IN ALL SECTIONS ......................................................... 5
PRINCIPLES OF ETHICAL BILLING ...................................................................................... 9
TARIFF................................................................................................................................... 9
PROCEDURE FOR AMENDMENTS TO THE PREAMBLE AND FEE SCHEDULE ..............10
COMMUNICATION ...............................................................................................................10
CONDITIONS OF PARTICIPATION FOR DENTISTS ..............................................................11
INTRODUCTION ...................................................................................................................11
REGISTRATION FOR PARTICIPATION ...............................................................................11
REGISTRATION FOR NON-PARTICIPATING DENTIST ......................................................12
PAYMENT TO NON-PARTICIPATING DENTISTS................................................................14
BILLING ABOVE TARIFF ......................................................................................................14
BILLING AND PAYMENT.........................................................................................................15
REGULATED FEES ..............................................................................................................15
CLAIM PAYMENT .................................................................................................................15
PAYMENT STATEMENT.......................................................................................................15
COMPUTER BILLING ...........................................................................................................16
ADMINISTRATION ...................................................................................................................17
CLAIMS ASSESSMENT ........................................................................................................17
POST PAYMENT REVIEW ...................................................................................................17
CLAIM PREPARATION AND SUBMISSION ............................................................................21
INTRODUCTION ...................................................................................................................21
GENERAL .............................................................................................................................21
INSTRUCTION FOR COMPLETING GSC/DHW CLAIM FORM ............................................23
PAY-PATIENT CLAIMS (NON-PARTICIPATING DENTISTS) ...............................................26
DENTAL TREATMENT PLAN Predetermination or Pre-authorization ...................................26
PREPARATION OF DENTAL TREATMENT PLAN ...............................................................27
CHILDREN’S ORAL HEALTH PROGRAM PREAMBLE .........................................................29
INTRODUCTION ...................................................................................................................29
ELIGIBILITY ..........................................................................................................................29
INSURED SERVICES ...........................................................................................................29
CHILDREN’S ORAL HEALTH PROGRAM (COHP) DIAGNOSTIC PREAMBLE ..................32
REQUEST FOR BENEFIT FREQUENCIES APPLICATION FORM ......................................34
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DENTAL SURGICAL (IN-HOSPITAL) PROGRAM PREAMBLE ..............................................35
INTRODUCTION ...................................................................................................................35
CONDITIONS FOR INSURABILITY ......................................................................................35
PREMIUM FEES FOR NON-ELECTIVE ORAL AND MAXILLOFACIAL PROCEDURES .....37
PREMIUM FEE TABLE .........................................................................................................38
SURGICAL ASSISTANT .......................................................................................................38
MENTALLY CHALLENGED PROGRAM PREAMBLE .............................................................40
INTRODUCTION ...................................................................................................................40
REGISTRATION PROCEDURES ..........................................................................................40
INSURED SERVICES ...........................................................................................................40
PREMIUM FEES ...................................................................................................................41
REGISTRATION FORM ........................................................................................................42
REQUEST FOR BENEFIT FREQUENCIES APPLICATION FORM ......................................43
CLEFT PALATE/CRANIOFACIAL PROGRAM PREAMBLE ...................................................44
INTRODUCTION ...................................................................................................................44
REGISTRATION PROCEDURES ..........................................................................................44
MAXILLOFACIAL PROSTHODONTICS PROGRAM PREAMBLE ..........................................49
INTRODUCTION ...................................................................................................................49
REGISTRATION PROCEDURES ..........................................................................................49
EXCEPTIONAL CIRCUMSTANCES ........................................................................................50
INTRODUCTION ...................................................................................................................50
REGISTRATION PROCEDURES ..........................................................................................50
ELIGIBILITY FOR SERVICES ...............................................................................................50
INSURED SERVICES ...........................................................................................................50
APPLICATION COVER PAGE Complete this cover page and include with your application .51
OUT OF PROVINCE BENEFITS ..............................................................................................53
INTRODUCTION ...................................................................................................................53
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NOVA SCOTIA DEPARTMENT OF HEALTH & WELLNESS
DENTISTS GUIDE
GENERAL PREAMBLE
INTRODUCTION
The Preamble is the authority for the proper interpretation of the Fee Schedule as listed
in the Insured Dental Services Tariff Regulations. Fees will not be correctly interpreted
without reference to the Preamble. This Fee Schedule is negotiated and maintained
through agreement by the Department of Health and Wellness (DHW) and the Nova
Scotia Dental Association (NSDA).
GENERAL CONSIDERATIONS
1.1
Each dentist who participates in the care of a patient is entitled to compensation
for the services rendered to the patient.
1.2
The Fee Schedule identifies the amounts prescribed as claimable for insured
services rendered by dentists. Insured services means, dental services that are
medically and/or dentally necessary as specified by the associated DHW
program criteria and are listed in the Fee Schedule of the Insured Dental
Services Tariff Regulations. The listing of any service or procedure in the Fee
Schedule does not ensure payment by Department of Health and Wellness
(DHW) if the dental service is provided when it is not medically/dentally
necessary.
1.3
Unless otherwise indicated, fees listed are for professional services only.
1.4
Professional services provided to a patient may be claimed by a dentist only
when he or she personally renders or supervises the service.
January 2017
1.4.1
All insured services include, where appropriate, any necessary discussion
or advice to the patient or their agent, completion of a dental record,
prescribing of medication or therapy, requisitioning of diagnostic services,
arranging referrals, including a letter of referral where required, and
similar activities normally associated with providing insured services to
patients.
1.4.2
Where provision of a service generates charges for long distance
telephone calls, unusual postal or other expenses, the dentist may deem
them to exceed the normal allowance made in the tariff and bill the patient
directly, subject to the conditions for billing non-insured services.
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1.5
Dentists are required to submit claims for insured services provided to eligible
patients in the format prescribed by GSC. Non-participating dentists are required
by Regulation under the Health Services and Insurance Act (See Section 28 (1)
of the Health Services and Insurance Act) to give reasonable notice of this fact to
a patient or someone acting on his or her behalf, before providing a service.
http://www.nslegislature.ca/legc/statutes/healthsi.htm
1.6
Claims and/or resubmitted claims received beyond six (6) months from date of
service shall not be payable unless GSC is of the opinion the delay is justified.
Claims received after fifteen (15) months of the date of service are not
considered for payment under any circumstance.
1.7
Dentists are entitled to payment for insured services where:



1.8
The service has been performed;
Supporting documentation exists to verify the type and extent of the service
relative to the fee claimed;
There is an indication in the chart, where applicable, that guidelines for
payment eligibility have been met. If a claim for a service is submitted,
GSC/DHW will assume, on a prepayment basis, that guidelines have been
met.
All DHW services are subject to post-payment audit. A dentist shall, upon request
by the appointed DHW dental auditor and at the auditor’s discretion provide or
make available for on-site examination, patient records maintained by the dentist
with respect to the insured dental services under review, as may be required by
the auditor, to clarify or verify services for which fees have been claimed. If the
patient’s chart and/or other pertinent patient records cannot support the claim
either in part or full, then the appointed DHW auditor has the authority to request
reimbursement for the partial or full payment amount of the service or of the
lesser service provided. The appointed DHW auditor may make notes or
photocopies of the documentation or records relevant to the insured services
under review, as necessary to document and support their findings.
TERMS AND DEFINITIONS USED IN ALL SECTIONS
2.1
Medical Necessity
The provision of a service listed in the Schedule of Benefits does not ensure payment
by GSC/DHW. Dental services provided in circumstances where they were not medically
and/or dentally necessary as specified by the associated DHW program criteria are not
insured. For the purpose of this Preamble, dental services which are explicitly deemed to
be non-insured under the Health Services and Insurance Act or its Regulations remain
uninsured regardless of individual judgments regarding their medical/dental necessity.
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2.2
Schedule of Benefits
The Schedule of Benefits lists all insured procedures, their descriptions and codes,
any special conditions, and the fees payable. When the term “schedule” is used in this
Preamble, it means the Schedule of Benefits.
2.3
Dentist
Dentist means a person lawfully entitled to practice dentistry in the place in which
such practice is carried on by him/her. Services rendered under these programs shall
only be insured when rendered by a person licensed with the Provincial Dental Board
of Nova Scotia.
2.4
General Practitioner
General Practitioner GP means a dentist who engages in the practice of general dentistry.
2.5
Specialist/Specialty
A specialist is defined as one whose name appears in the Specialist Register of the
Provincial Dental Board of Nova Scotia and who is registered as a Specialist. However,
when the term “specialty” is used, it means any or all specialists.
2.6
Statutory Holidays (Applies to Dental Surgical Program)
Holidays are defined, for the purpose of claiming special premium rates, as New Year’s
Day, Good Friday, Easter Monday, Victoria Day, Canada Day, Civic Holiday, Labour Day,
Thanksgiving, Remembrance Day, Christmas Day and Boxing Day.
Note: If a Dentist chooses to provide routine, scheduled services during a statutory
holiday, he/she is not entitled to premium fees.
2.7
Terms used for reporting or describing services to GSC/DHW:
2.7.1
Services
When the term “services” is used in this guide, it is in the context of an insured
visit or procedure that is identified by a specific fee code in the DHW Schedule of
Benefits.
2.7.2
Tariff
The DHW tariff is the actual monetary value of a service. The DHW tariff is
determined through negotiations between the Nova Scotia Dental Association
(NSDA) and the Nova Scotia Department of Health and Wellness (DHW), in
accordance with the provisions of section 13A of the Health Services and
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Insurance Act and is embedded in the Insured Dental Services Tariff
Regulations.
2.8
Dental Consultation
Dental Consultation refers to a request by one dentist or physician for an opinion from a
dentist competent to furnish advice when circumstances of the patient’s condition demand
a further opinion.
A Dental Consultation shall consist of an oral examination, review of pertinent x-ray films,
laboratory or other data and a written report of opinions and recommendations to the
referring dentist or physician.
2.9
Repeat Consultation
A repeat consultation only applies where there has been a subsequent referral by the
attending dentist or physician to the same dental consultant for the same illness, or
complication thereof, within 30 days of the initial consultation.
2.10 Intra-Group Consultations
Dentists formally organized as a group practice, clinic, etc., are entitled to the usual rate
listed in the fee schedule.
The Health Services and Insurance Act provides that the Nova Scotia Department of
Health and Wellness (DHW) has the right to request a copy of the consultation report.
2.11 Referral
A dentist referral takes place when one dentist or physician requests the services of a
specialist or a dentist who by training and experience is able to provide a specialized
service for consultation, diagnosis or treatment.
A patient ceases to be a referral for tariff purposes at the completion of the referred
treatment plan and follow-ups specific to that treatment plan.
2.12 Transferal
A transferal, as distinguished from a referral, takes place where the responsibility for the
care of the patient is completely transferred, permanently or temporarily, from one dentist
to another. In such cases, the dentist to whom the patient is transferred is not entitled to
a specialist’s fee.
2.13 Hospital
For the purpose of this Preamble, hospital means a facility for the observation, care, and
treatment of persons suffering from a psychiatric disorder; a hospital for treatment of
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persons with sickness, disease or injury, including maternity care, as approved under the
Health Services and Insurance Act.
2.14 Office
An “office” is defined as the location where a dentist is practicing his or her profession.
2.15 Participating Dentist
A dentist who is registered with GSC/DHW to receive direct compensation for insured
dental services from GSC/DHW.
2.16 Non-Participating Dentist
A dentist who has elected not to receive direct compensation for insured dental services
from GSC/DHW.
2.17 Interpretive Component (DHW – Applies only to in-hospital radiographs)
This is the interpretation of the results of a diagnostic procedure for which a fee may be
claimed separately from performing the procedure itself.
2.18 Premium Fees (Applies to Dental Surgical Program)
Premium fees are additional amounts paid above normal or customary rates on specific
eligible services provided on an emergency basis during designated times. An emergency
basis is defined as services which must be performed without delay because of the
medical condition of the patient. Refer to Preamble for Dental Surgical Program.
2.19 Pre-Authorized (Listed as PA in the Fee Schedules)
Pre-Authorization is a process for assessing eligibility for coverage of a service before
the treatment begins.
2.20 Cavitated Lesion
A lesion where there is clinical or radiographic evidence of dentinal involvement of
tooth decay.
2.21 Locum Tenens
A dentist who temporarily replaces another dentist who is absent from the practice.
Note: The locum dentist may not claim under the billing number of the dentist being
replaced. See details under “Conditions of Participation”.
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PRINCIPLES OF ETHICAL BILLING
3.1
A dentist who provides professional services to a patient is entitled to
compensation commensurate with the services provided to the patient. These
services are designated as either insured or non-insured. Insured services are
those listed in the GSC/DHW Dentists Guide.
3.2
The following principles apply to claims for insured services:
3.3
3.2.1
All insured services claimed must reflect services rendered personally by
the dentist in an appropriate clinical setting. In accordance with the Dental
Act, certain delegated dental acts done under supervision of the
dentist present on the premises may also be claimed.
3.2.2
As part of the provision of an insured service, patients may be charged
directly for the provision of consumable items not covered by DHW, such
as non-insured dental services, completing forms, photocopying, long
distance telephone, and similar charges. These charges must be
explained and agreed to by the patient before the insured service is
provided.
Billing for insured and non-insured dental services at the same visit:
3.3.1
A dentist must exercise caution whenever billing GSC/DHW and the
patient or a third party during the same visit. In principle, under no
circumstances should any service, or any component of a service, be
claimed for twice.
3.3.2
Whenever possible, the attending dentist must acquaint the patient, or
person responsible for the patient, with the financial obligation involved in
the patient’s care.
3.3.3
The provision of insured services should not be contingent upon the
patient agreeing to accept additional non-insured services.
TARIFF
The fee schedule as listed in the Insured Dental Services Tariff Regulations has been
negotiated and maintained between the Department of Health and Wellness (DHW) and
the Nova Scotia Dental Association (NSDA).
4.1
January 2017
The Canadian Dental Association (CDA) Uniform System of Coding and List of
Services (USC&LS) as licensed to the Nova Scotia Dental Association (NSDA)
employed with the permission of the licensee forms the basis for description of
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services in the Fee Schedule. The USC&LS replaces the previous system of
codes used by DHW.
4.2
The GSC/DHW adaptation of USC&LS does not include all possible USC&LS
codes and GSC/DHW may use qualifiers as described in the program Fee
Schedule.
4.2.1
Qualifiers are appended to USC&LS codes to distinguish between related
procedures applied to the same anatomic area or condition, or to
accommodate procedures that are a composite of two or more services.
4.2.2
Fees for services are determined through a process of internal (within
NSDA) and external (with the DHW) negotiation and maintenance.
4.2.3
If a dentist feels a particular fee is under or overvalued in relation to a
similar service, he or she should request that the NSDA consider
renegotiating the fee with the DHW.
PROCEDURE FOR AMENDMENTS TO THE PREAMBLE AND FEE
SCHEDULE
5.1
When a service is not listed in the Fee Schedule, a dentist may request that the
NSDA consider negotiating its inclusion in the insured program(s).
5.2
The Officers of the NSDA may initiate discussion with the DHW in order to have
the change considered and approved as an insured service under a DHW
program. When approved, the amendments will be published in the DHW
Dentists Guide.
COMMUNICATION
6.1
January 2017
Changes to programs, fees and other information pertaining to program
administration will be communicated to dentists in a timely manner through
release of Dentists’ Bulletins and Dentists Guide updates by GSC/DHW. The
DHW is hereby notified by GSC that, from time to time, GSC adopts
Administrative Policies and currently has Administrative Policies in force and
effect. GSC hereby reserves and shall have the right, at all times and from time
to time, to create, adopt, amend, alter or revise Administrative Policies. Notice
will be made to Department of Health and Wellness prior to any of the
Administrative Policy additions/changes are implemented.
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CONDITIONS OF PARTICIPATION FOR DENTISTS
INTRODUCTION
The Health Services and Insurance Act is so written that a dentist may or may not
participate in the Department of Health and Wellness (DHW) Plan. However, since the
plan is for all Nova Scotia residents, there is, inevitably, a degree of involvement for all
practicing dentists.
The fundamental difference between the “opted-in” and “opted-out” dentist is that the
“opted-in” dentist will submit claims for, and receive payment directly from GSC/DHW for,
insured services rendered. The “opted-out” dentist will deal directly with his/her patient
on financial payment matters. Regardless of whether a dental provider has elected to
participate in the DHW plan or not, there is no difference in the allowed fees that can be
billed to a resident for DHW eligible benefits and balance billing above DHW tariff for
those DHW eligible benefits is not allowed. See the Claims Preparation and Submission
section of this guide. See also Billing Above Tariff below.
DEFINITION OF A DENTIST
Regulations under the Health Services and Insurance Act define a dentist as a person
lawfully entitled to practice dentistry in the place in which such practice is carried out
by him/her.
REGISTRATION FOR PARTICIPATION
NEW DENTIST
A dentist commencing practice in Nova Scotia, who is duly registered with the Canadian
Dental Association (CDA), will automatically be registered with GSC as a participating
dentist. The dentist will be considered to be a participating dentist from the date of
commencing practice in Nova Scotia if the above requirements are met.
PARTICIPATION BY “OPTED-OUT” DENTIST
Dentists who have opted out of the DHW programs may at any time, change the election
and participate in the plan, providing the dentist’s privilege of assignment of payment with
GSC/DHW is in good standing.
Dentists can revoke their election to opt out of the DHW plan by submitting a written
notification of their intent to revoke their election. Notification should be directed to GSC
with a copy to the DHW. The decision to opt back in does not take effect until the first day
of the month beginning after the expiration of 30 days from the date GSC/DHW receives
the notice. (For example, if GSC/DHW receives the written notice on July 15, the election
to opt in would take effect on September 1.)
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AUTHORIZATIONS
TO ASSIGN PAYMENT
A Participating Dentist may assign his entitlement to payment for insured services to one
or more – e.g. his employer, group, partnership, clinic, teaching unit, etc. – by special
arrangement with GSC/DHW.
TO USE FACSIMILE SIGNATURE
A Participating Dentist, can choose to use a rubber signature stamp or other facsimile
signature instead of personally signing each claim. This form of valid office verification
follows CDA verification standards.
LOCUM TENENS
A dentist who is going to take a locum in Nova Scotia must communicate their intentions
to the CDA as billing arrangements specific to that location must be set up with GSC/DHW
through data received from the CDA. Providers are not to bill DHW under another
provider’s CDA number.
REGISTRATION FOR NON-PARTICIPATING DENTIST
REVERSAL OF ELECTION TO PARTICIPATE
A Participating Dentist who wishes to reverse an election to participate may do so at any
time by submitting written notification of their intent. Notification should be directed to
Green Shield Canada with a copy to the DHW. The decision to opt out does not take
effect until the first day of the month beginning after the expiration of 60 days from the
date GSC/DHW receives the notice. (For example, if GSC/DHW receives the written
notice on July 15, the election to opt in would take effect on October 1.)
The Nova Scotia Health Services and Insurance Act (the “Act”) sets out dentists’
obligations in respect of insured services under the DHW Plan.
The Act permits a dentist to opt out of the DHW Plan and collect fees for insured services
directly from a patient. If a dentist opts out, he or she will not be entitled to any payment
under the DHW Plan. It is also important to be aware that opting out of the DHW Plan will
not permit a dentist to charge higher fees. Even if a dentist opts out of the DHW Plan, the
dentist cannot charge a patient more than fees which otherwise could be charged to DHW
(set by the Insured Dental Services Tariff Regulations) for an insured service.
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To opt out of the DHW Plan, dentists must meet the following requirements:
The dentist must notify the DHW and GSC of his or its intention to opt out of the DHW
Plan and to collect fees other than under the DHW Plan. The notice must be provided in
writing.
The election to opt out does not take effect until the first day of the month beginning after
the expiration of 60 days from the date the Department receives the notice. (For example,
if the Department receives the written notice on July 15, the election to opt out would take
effect on October 1.)
Dentists cannot seek payment from a patient for insured services immediately after
providing notice to the DHW. They must wait until the date that the election to opt out
takes effect and cannot bill the patient a higher fee than that of the DHW tariff regardless
of participating status.
After a dentist has opted out of the DHW Plan, the dentist must continue to meet the
following requirements:
The dentist must provide reasonable notice to a patient (or a person acting on the
patient’s behalf) that he or she has opted out of the DHW Plan before providing services.
At the request of a patient (or a person acting on the patient’s behalf), the dentist must
complete a DHW claim form or provide that person with enough information to complete
the claim form.
MAILING ADDRESS TO SEND THE LETTER OF NOTICE:
Dental Claims Services
Green Shield Canada
8677 Anchor Drive
PO Box 1671
Windsor, Ontario N9A 0A8
Copy to:
Manager, Insured Dental Programs
Pharmaceutical Services & Extended Health Benefits
1894 Barrington Street
PO Box 488
Halifax, NS B3J 2R8
Note at the top of the letter — “Notice of Opting out of DHW”
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NEW DENTIST
A dentist, who becomes entitled to practice in Nova Scotia and subsequently establishes
practice in the Province, may elect not to participate in DHW by advising GSC/DHW in
writing of this intention. If GSC/DHW receives the written notice within thirty days of the
first day on which the dentist becomes entitled to practice in Nova Scotia, the election
shall take effect on the day of being entitled to practice in Nova Scotia.
If such notice of election is not received by GSC/DHW within thirty days of the first day on
which the dentist becomes entitled to practice in Nova Scotia, the waiting period indicated
above in the reversal of election to participate section, will apply.
PAYMENT TO NON-PARTICIPATING DENTISTS
A dentist who is not participating in the DHW plan will not be reimbursed directly by
GSC/DHW. Any valid claim received in respect of insured services rendered by a nonparticipating dentist to an eligible resident will be paid directly to the resident/parent or
guardian. The dentist may not be so designated.
Where a dentist who has elected not to participate in the DHW plan renders an insured
service to a resident, the dentist shall not be entitled to charge the patient for the service
unless, prior to rendering it, reasonable notice of non-participation was given to the
resident or some other person acting on behalf of the resident (See Section 28 (1) of
the Health Services and Insurance Act).
BILLING ABOVE TARIFF
The tariff for the DHW Dental Plans is negotiated between the Nova Scotia Dental
Association (NSDA) and the Nova Scotia Department of Health and Wellness (DHW) and
regardless of whether a dentist has elected to “opt-in” or “opt-out” of the plan, he/she is
required to bill to tariff and no balance billing is permitted for any procedure listed as an
eligible DHW benefit in the tariff. (Refer to Section 29 of the Health Services and
Insurance Act). For the purposes of the Act, a dentist is deemed to be a physician.
For procedures not listed in the DHW dental plan tariff, the dentist may charge the patient
the full fee for the service or may balance bill the difference not covered through a private
plan. This is only allowed when the procedure is not an eligible DHW procedure. Eligibility
may be based on frequency of a service, and for those services if the patient has already
received his/her service in accordance with the program schedule, subsequent services of
the same nature are not insured by DHW.
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BILLING AND PAYMENT
INTRODUCTION
This section provides the necessary details for recording fees charged to DHW
for insured services rendered. It also explains the method of payment of approved claims.
REGULATED FEES
Regulated fees as listed under the Insured Dental Services Tariff Regulations under
the authority of the Health Services and Insurance Act are available online at:
http://novascotia.ca/just/regulations/regs/hsidental.htm
CLAIM PAYMENT
SUBMISSION DATE
Claim should be submitted in a timely fashion. Please be reminded that claims must
be received within six months of the date of service (see General Preamble 1.6).
NORMAL PAYMENT
Direct deposit for approved claims will be issued every two weeks. Cheques will
be issued every four weeks for dentists who have not authorized direct deposit.
The schedule of payments and claim processing periods is available through GSC’s
providerConnect™ portal. An explanation of benefits statement will be issued, which
will include a record of all claims processed with a specific claiming period.
PAYMENT STATEMENT
An explanation of benefits statement is issued with every payment cycle period.
The information provided in this explanation of benefits statement includes full
identification of all claims submitted with the amounts that are being reimbursed,
the amount claimed by the dentist and an explanation of any non-reimbursement by
GSC/DHW. Whenever there is an apparent discrepancy between the claim submitted
and the information given on the statement, there will be an explanation provided.
Adjustments to amounts previously paid will also be recorded on this statement. All
adjustments refer to specific claims and the patient and claim identification information
will be shown. Adjustments should be submitted in a timely fashion.
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COMPUTER BILLING
GSC/DHW accepts dentist’s claims electronically through office systems approved
by the Canadian Dental Association (CDA) and connected to the CDAnet.
This method of claim submission has benefits:

It reduces clerical errors, which in turn reduces the number of claims being returned
for corrections

Claims are more accurate, therefore payment is faster
GSC also accepts computer printed claim forms and handwritten paper claims via postal
mail or providerConnect by using the sending an attachment feature.
Your DHW payment statement will remain the same for claims submitted through all
channels. There will be no distinction for reconciliation.
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ADMINISTRATION
CLAIMS ASSESSMENT
It is necessary to ensure that public funds used to cover the cost of dental services have
been spent appropriately. As the administrator of the Department of Health and Wellness’
(DHW) Dental Programs, it is Green Shield Canada’s (GSC) responsibility
to ensure that claims are assessed and paid appropriately.
APPEAL PROCEDURE
A dentist wishing to appeal the assessment of specific claims where it is felt that claims
have not been dealt with satisfactorily, has the right to appeal in writing to GSC stating
all the necessary details of the complaint.
On receipt of the complaint, it will be dealt with by the following appeal procedure, in which
each step represents a higher authority until the complaint is resolved.




Contact a GSC Customer Service Representative at 1-888-711-1119
If you are not satisfied, please ask the Customer Service Centre Representative
to immediately put you in touch with the most appropriate Supervisor or Manager.
If you are still not satisfied, contact the GSC Complaints Officer using the instructions
available online at greenshield.ca.
Where GSC does not settle the complaint to the satisfaction of the complainant,
he/she may appeal in writing to the Manager, Insured Dental Programs,
Pharmaceutical Services and Extended Health Benefits, Nova Scotia Department of
Health and Wellness or Designate.
POST PAYMENT REVIEW
The mandate of the dental monitoring function is to determine, on a post payment basis,
whether claims are valid and appropriately billed according to the terms of the Insured
Dental Services Tariff Regulations and the Dentists Guide. The post payment review of
claims is conducted to determine if the service was performed, whether the dental service
was medically/dentally necessary as specified by the associated DHW program criteria
and to ensure that the service was not misrepresented when the claim was paid.
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PROFILE AND CLAIMS REVIEW PROCESS
A billing audit may be initiated from the review of a dental profile; the review of claims
submitted for payment; the review of a service verification letter; or a complaint, in writing,
from the public.
DENTAL PROFILES
Computerized dental profiles (sample and legend follow) are prepared regularly for all
dentists who claim under the Children’s Oral Health Program or the in-hospital Dental
Surgical Program.
The dental profile consists of a summary of DHW fee for service claims data by dental fee
group. Peer group information is also included in the profile. Indices show the relationship
of each dentist to the peer group average. The comparison is expressed as a percent
with 100 representing the average. For example, if a dentist has an index of 150 for
payment, this would indicate that the dentist is 50% higher than the peer group average
for payment.
AUDIT PROCESS
The audit process seeks to determine whether an insured service was performed, that
it was medically necessary, and that it was not misrepresented in the claim for payment.
Dentists should be prepared to substantiate claims submitted to GSC/DHW for payment
through properly documented patient records. During the course of an on-site audit,
photocopies of the documentation relevant to the claim(s) under review are made as
necessary so that documentation is available for future review. The appointed DHW
auditor will undertake a review of the audit findings to determine if the documentation
supports the claim.
For a post-treatment review, an examination of the patient by another dentist may be
necessary. Such a review would be for the purpose of verifying the validity of the service
claimed to GSC/DHW and would not be related to the quality of the dental service
provided.
DENTAL REVIEW COMMITTEE
If there are unresolved issues associated with a billing audit, GSC/DHW may seek the
advice of the Dental Review Committee. The Committee’s principle function is to review
audit findings regarding specific dentists’ billing practices and recommend to GSC/DHW
whether billings are in accordance with the Dentists Guide and its Preamble. The
Committee also assesses, in the cases presented for its review, whether there are
grounds to believe that a provider has fraudulently submitted claims or claimed for
services that were not dentally required.
The Dental Review Committee shall consist of five (5) practicing dentists (voting)
appointed by the DHW from nominations made by the Nova Scotia Dental Association;
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one (1) layperson (voting); one (1) DHW Representative (nonvoting); the DHW Dental
Consultant (nonvoting) who shall also act as Secretary; other resources as required to be
appointed by the DHW (nonvoting), and additional resource staff (nonvoting) as required.
In performing its duty, the Committee will review all relevant material presented to
it and, if necessary to complete its review, may take further action, including
the following:

form committees or working groups;

obtain information from consultants, or any other person, with respect to any matter
or procedure that may come before it;

request GSC/DHW to conduct further review and investigation as the Committee
deems appropriate, including affidavits from beneficiaries;

request any dentist or other person to appear before the Committee to provide
information to assist the Committee in its review of a case; and

obtain necessary statistical data.
AUDIT OUTCOME
Where the DHW appointed auditor determines, after an audit, that a provider has
inappropriately billed services to GSC/DHW or has been inappropriately paid, GSC/DHW
may do one or more of the following:

enter into an agreement with the provider in settlement of the matter, upon any
terms as may be agreed to;

subsequent audit of the provider within a specified time period to ensure that billings
are appropriate.

refuse or reduce payment of a claim or claims for insured services, or an account;

recover any overpayment made by GSC/DHW to the provider by deducting the
amount of the overpayment from any other amounts payable by GSC/DHW to the
provider;

commence and maintain civil proceedings in the Supreme Court of Nova Scotia,
for recovery of any overpayment made to a provider, as a debt owing to GSC/DHW;

refer the matter to the appropriate law enforcement authority or to the appropriate
licensing authority, or to both; and /or
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
refer the matter to the Executive Director, Pharmaceutical Services and Extended
Health Benefits, Nova Scotia Department of Health and Wellness, pursuant to
Section 30 of the Act.
The sample audit results may be extrapolated over all of the claims paid during the
period from which the sample was drawn for the purpose of calculating a recovery.
APPEAL OF AUDIT POSITION
Where a dentist wishes to dispute the position being adopted by GSC/DHW, the provider
may appeal in writing to the Manager, Insured Dental Programs, Pharmaceutical Services
and Extended Health Benefits, Nova Scotia Department of Health and Wellness.
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CLAIM PREPARATION AND SUBMISSION
TREATMENT PLAN PREPARATION
INTRODUCTION
The following section is provided to help you submit a GSC/DHW claim. The key identifier
for all communications with and claim submission to GSC/DHW is the 3 alpha character
prefix identifying the program and the resident’s Medical Services Insurance (MSI) health
card number.
Alpha Prefix
Program Name
COH
Children’s Oral Health Program
MFS
Dental Surgical Program
SNP
Mentally Challenged Program
MAX
Maxillofacial Prosthodontic Program
CPC
Cleft Palate/Craniofacial Program
ECR
Exceptional Circumstance Request
GENERAL
PRESCRIBED FORMATS
The Regulations under the Health Services and Insurance Act require that all claims must
be submitted in a format prescribed by the Department of Health and Wellness (DHW).
The preferred method is electronic submission through the dental office system connected
to the CDAnet.
How to submit claims to GSC electronically
 Using your CDAnet software, select Green Shield Canada (GSC) as the carrier and
000102 as the carrier ID.
 Primary Policy/Plan Number – while mandatory with the CDAnet system, we do not
use this field. Please populate with any value (e.g. 99999)
 Enter your patient’s MSI number (no spaces) in the certificate field and refer to the
chart above for the alpha prefix specific to the program you are claiming. The alpha
prefix will be entered in the division field. If your software does not have a division
field, simply enter the alpha prefix and the MSI number in the certificate field.
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When electronic submission is not possible, a form is available for paper claim
submission, claim forms for insured services are provided to all participating dentists.
Supplies can be obtained online through providerConnect™ portal or by calling or writing
to Green Shield Canada (GSC).
The form is based on the standard CDA claim form modified slightly to include some
program specifics. Either the standard CDA dental claim form or the program specific
claim form can be used for manual claims and must be completed fully and accurately
to ensure prompt processing.
ENTITLEMENT TO INSURED SERVICES
Before making a claim for an insured service, it is the responsibility of the dentist to
determine that the patient is entitled to receive the service. The patient should have
a valid Nova Scotia Medical Services Insurance (MSI) Health Card. If other identification is
accepted and the claim cannot be processed due to identification errors, it will be the
responsibility of the dentist to locate the patient/parent/guardian for correct information. In
the absence of proper patient identification, a dentist is advised to deal directly with the
patient who will then be responsible for making a claim to GSC/DHW.
CLAIM INFORMATION REQUIREMENTS
Dentists are required to provide the information listed below when submitting claims
to GSC/DHW.
















Patient’s MSI Health Card Number
Program identifier (3 character alpha program prefix) to identify the program to which
the claims are being submitted.
Dentist’s nine (9) digit CDA Provider Number
Patient’s Name (in full)
Patient’s Gender/Date of Birth
Diagnosis
Fee Code
Location Where Services Provider (office or Hospital)
Name of Hospital (if applicable)
Quadrant/Tooth Number
Surfaces Filled
Date of each Service
Dental Fee
Lab Fee
Office Verification (Dentist signature or stamped signature)
Name of Referring Dentist (if applicable)
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Dentists who have opted out of the DHW programs are required to provide any information
necessary for the patient to complete a Pay-Patient claim. This would be done through
submitting an online claim on the behalf of the patient or providing the patient with a
completed CDA standard form or program claim form. It should be indicated on the form
submitted that payment is directed to the patient.
ACCURACY OF INFORMATION
Incomplete or incorrect information will result in the return of claims to dentists with
probable delay in processing and payment.
SEPARATE CLAIMS
A separate electronic claim or form is required for each patient and all dentists involved
in a particular case must file separate claims.
CLAIM SUBMISSION DATES
Claims received beyond six months from date of service will be invalid unless a
reasonable explanation for the late submission is provided and considered to be
acceptable. To request a review for an exception of a claim denied due to invalid
submission date, a written request including supporting documentation must be sent
to the NS Government Dental Program attachment option through providerConnect™
portal or mailed to: GSC NS Government Dental Programs P.O. Box 1607, Windsor, ON.
N9A 0A8.
INSTRUCTION FOR COMPLETING GSC/DHW CLAIM FORM
DENTIST INFORMATION
This section should be completed in full manually, by stamp or by computer.
CDA PROVIDER NUMBER
Please use all nine (9) digits of the CDA provider number.
PATIENT INDENTIFICATION
Please provide patient’s first and last name, the MSI Health Card Number, gender and
date of birth. As status codes are no longer in use, do not add to the beginning of
the MSI Health Card Number.
PROGRAM INFORMATION
Please indicate the program under which the patient is eligible for coverage by including
the program 3 character alpha prefix or program name.
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DATE OF SERVICE
Enter the day, month and year in which the services claimed were rendered, for each line
of service provided.
LOCATION OF SERVICE
The location of the service is entered in the “FAC” (facility) column of the claim form or in
the comment section of the standard form. A service performed in the office is indicated
with an “O” and a service in the hospital by an “H” and must include the hospital name.
FEE CODE
The current Schedule of Fees as listed in the Insured Dental Tariff Regulations and
published in this guide, is the basis for claiming and payment by GSC/DHW.
When completing the fee code column of the claim form, the dentist must enter
the five (5) digit CDA fee code number shown in the Schedule which corresponds to the
service rendered. A separate line must be used for each different fee code number.
INTERNATIONAL TOOTH CODE
The International Standards Organization Designation System (ISO) is used to identify
a tooth by quadrant, sextant or tooth number.
TOOTH SURFACES
For each filling, a separate line of service is required. The tooth surface filled is
entered in this column. The following surface codes should be used:
M
I
O
D
V
L
– Mesial
– Incisal
– Occlusal
– Distal
– Vestibular Buccal or Labial
– Lingual
PREMIUM TIME
The premium time must be included in the instructions when applicable for the Dental
Surgical Program only. Please see the preamble for the Dental Surgical Program
for details.
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MAXILLOFACIAL PROSTHODONTICS PROGRAM UNITS
The program units may be included in the instructions when applicable for the Maxillofacial
Prosthodontics Program only. Please see the preamble for the Maxillofacial
Prosthodontics program for details.
LAB FEE
The full lab fee is entered in this column, on the same line as the related dental fee.
A copy of the commercial and/or in-house invoice may be requested by GSC/DHW
to support a claim.
DENTAL FEE
The full fee schedule amount is to be entered in this column.
When there is doubt concerning eligibility of the patient or the treatment intended, the
dentist may elect to submit a GSC/DHW Dental Treatment Plan, electronically or manually
prior to rendering the services. (See Dental Treatment Plan for further detail.)
NAME OF THE HOSPITAL
Where applicable, provide the name of the provincially funded hospital where services
were provided and indicate whether or not general anesthetic was used.
REFERRING DENTIST
This space is used by specialists only, to indicate name of the referring dentist.
DENTIST’S SIGNATURE
The dentist is required to sign the declaration in the appropriate space on each claim
submitted. Rubber stamp or other facsimile type of signature may be used in this area
of the form as office verification consistent with standard CDA guidelines.
DENTIST COMMENTS
Use this space as necessary to provide additional information to support your claim.
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PAY-PATIENT CLAIMS (NON-PARTICIPATING DENTISTS)
It is a requirement of the Insured Dental Services Tariff Regulations that a dentist who
has elected to opt out of the DHW programs, shall provide patients with all information
necessary to complete and submit a claim form. In practice, it is easier and faster for
the dentist to complete and submit the form either electronically or manually on behalf
of his/her patient. It should be indicated on the form submitted that payment is directed
to the patient.
It is also a requirement of the Regulations that a dentist who has elected to opt out of the
DHW programs must give reasonable notice of this fact to a patient or someone acting on
his/her behalf, before providing a service. Provider cannot bill the patient above the DHW
tariff for any DHW eligible procedure regardless of participating status.
FORMS INVOLVING THIRD PARTY
When providing dental services where a third party liability is involved — e.g. a car
accident, complete the DHW claim form.
DENTAL TREATMENT PLAN Predetermination or Pre-authorization
GENERAL
Provision has been made for the filing of a Dental Predetermination or Treatment Plan,
which is intended to:





Confirm patient eligibility for benefits
Determine whether services planned are insured
Determine DHW payment level
Determine patient liability (if applicable)
Determine need for specialist treatment
FILING OF PLAN
If you are uncertain as to eligibility of patients or benefits or wish to have predetermined
the DHW payment level or patient liability (if applicable), you may elect to submit either an
electronic predetermination through the CDAnet in the prescribed format, manually submit
or upload a predetermined treatment plan via providerConnect™ send an attachment.
When the electronic claim information is insufficient for GSC to provide a benefit
determination, additional information can be submitted through providerConnect™
as send an attachment.
The dental authorization may be submitted prior to rendering necessary services or
coincident with the commencement of treatment.
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PRESCRIBED FORM
The DHW Dental Treatment Plan can be submitted to GSC/DHW on standard CDA
treatment form or standard CDA claim form indicating for predetermination of treatment.
PREPARATION OF DENTAL TREATMENT PLAN
PATIENT IDENTIFICATION
Information required relating to the dental treatment plan is similar to all information
supplied for a rendered claim including the name of the program in which treatment
is to be rendered and the patient’s MSI Health Card Number.
DENTIST IDENTIFICATION
Information relating to dentist identification includes all nine (9) digits of the CDA provider
number.
DIAGNOSIS/COMMENTS
This section is provided so that the dentist may write a narrative diagnosis or comments,
which may assist in the assessment of the treatment plan.
If any procedure on the treatment plan involves a general anesthetic, this should be
included as a separate line in the details for the services section using the appropriate
CDA procedure code.
DETAILS OF SERVICES
Below the “Diagnostic/Comments” section, the actual details of the individual services
are recorded. These details include the fee code, the quadrant, tooth numbers, the
surface codes, a brief description of the services when required, the rendered dental fee
and the estimated lab fee, if applicable, to the treatment. The guidelines for completing
these columns are the same as those outlined for completing the claim form and follows
CDA standards.
DENTIST’S SIGNATURE
Below the section for recording the details of the individual services, a space is provided
for the dentist’s signature or stamped signature provided as office verification and the date
of the estimate.
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SUBMISSION OF DENTAL TREATMENT PLAN
Upon completion, the Dental Treatment Plan should be submitted to GSC/DHW for
approval either electronically, manually or via providerConnect™.
APPROVAL OF DENTAL TREATMENT PLAN
Upon receipt of a treatment plan, GSC/DHW will assess the information in relation to the
five (5) points of general provisions and according to the benefits eligibility of the program
associated with the claiming.
Each line of service on the treatment plan will be individually assessed and an explanation
of benefits statement will be issued to the requesting provider in the same way that you
would normally receive your claim’s payment statements.
APPROVED – TREATMENT PLAN
Approved treatment plans will be valid for 1 year from the date of approval issue. Any
changes in the programs could alter the results in the approval. Once treatment
is rendered, these claims will be paid in the usual manner.
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CHILDREN’S ORAL HEALTH PROGRAM (COHP)
PREAMBLE
INTRODUCTION
The Children’s Oral Health Program (COHP) provides diagnostic, preventive and
treatment services and is administered by Green Shield Canada (GSC)/Department of
Health and Wellness (DHW).
REGISTRATION PROCEDURES
Resident children are registered for the COHP through the provision of a valid Nova
Scotia Medical Services Insurance (MSI) Health Card.
ELIGIBILITY
The COHP is offered to Nova Scotian residents age 14 or younger who have a valid Nova
Scotia MSI Health Card.
Children with private dental plans are required to access their private coverage first.
The COHP will pay any eligible balance left over after the child’s private coverage has
been accessed up to the DHW tariff rate. Balance billing above tariff rate for any eligible
DHW benefit is not allowed. All claims for coordination of benefits with the COHP,
including such claims to be made payable to the child’s parent or guardian, must meet the
terms of the COHP.
Claim submission tip: When submitting to a private carrier do not indicate there is
other coverage as the private carrier is considered primary.
INSURED SERVICES
The dental necessity of the procedures carried out must be firmly established; otherwise,
the services will not be insured.
Benefit frequency limits on recall exams, caries prevention services and topical fluoride
treatments may be waived where it can be demonstrated to GSC/DHW that additional
dental services are medically necessary, such as in patients with medical complications.
Please forward a completed Frequency of Benefit Request Form to GSC for review as all
patients in this category must be registered in advance of additional treatment.
Insured services are those described in the fee schedule for the COHP. All children who
meet the age criteria are eligible for one annual examination, two routine radiographs and
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one caries prevention service per year. A limited number of other diagnostic and
preventive services are insured according to the fee schedule. Restorative services,
according to the COHP fee schedule, are insured for all age-eligible children.
Coverage guidelines apply for some services. Eligibility is determined by the performing
dentist according to the coverage guidelines listed below and pre-authorization is not
required when the guidelines are determined by the performing dentist to be met.
Supporting documents as evidence of eligibility, including chart entries and diagnostics,
must be provided in the event of a post audit.
TOPICAL FLUORIDE APPLICATIONS
Children who have been diagnosed with cavitated (clinical or radiographic evidence
of dentinal involvement) smooth surface caries, are insured for two topical fluoride
applications per 12 month period from first paid claim, from the time of the diagnosis until
the end of the month in which they turn 15 years of age. Smooth surface caries are those
found on the approximal tooth surfaces (including fillings with recurrent cavitated caries)
and those found on buccal or lingual cervical smooth surfaces (including fillings with
recurrent cavitated caries).
PIT AND FISSURE SEALANT APPLICATION
Pit and fissure sealant applications are insured for all children on recently erupted
permanent molars (6-year and 12-year molars), on the basis of one application
per tooth, per 12 months period from first paid claim if they meet the
following criteria:

A tooth has deep retentive narrow pits and fissures, or is showing white chalky
areas (white spot lesions) or stained fissures; and

There is no radiographic evidence of caries on the occlusal surfaces (if such
evidence is available; and

There is no evidence of caries on the approximal surfaces; and

The tooth is sufficiently erupted to enable proper isolation.
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EXTRACTIONS
Extractions are insured in the event of:

Un-restorable caries, demonstrable pain (excluding pain associated with crowding),
infection or trauma;

Ankylosis

Supernumerary teeth (including mesiodens).
STAINLESS STEEL CROWNS
Stainless steel crowns are only payable for children where medical necessity can be
established. Evidence of severely decayed or damaged teeth must be demonstrated
radiographically or by photograph for these services to be insured, whether the services
are rendered in-hospital or in-office.
The first 3 stainless steel crowns provided on the same day with general anaesthetic will
be paid at 100% of the DHW tariff. Any additional crowns provided
with general anaesthetic on the same day will be payable at 50% of the DHW tariff.
PA — PRE-AUTHORIZATION
Preauthorization is a process for assessing eligibility for coverage of a service before
the treatment begins. Pre-authorizations are required for procedures listed in the DHW
tariff and indicated as PA.
NA — NOT APPLICABLE
Procedures listed in the DHW tariff are not eligible for reimbursement when performed
by the provider type indicated as NA.
OUT OF PROVINCE
There is no coverage, under the COHP, for services performed outside of Nova Scotia.
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CHILDREN’S ORAL HEALTH PROGRAM (COHP)
DIAGNOSTIC PREAMBLE
COMPLETE (INITIAL) ORAL EXAMINATIONS (01101/01102/01103)
 This service is allowed once in a patient’s lifetime, when continuity of treatment is
maintained. Where there is a gap in complete dental treatment of 2 years or more,
a further Complete Oral Examination is warranted and is covered under the Plan. There
may be other cases where a further Complete Oral Examination is warranted and covered
under the Plan. Written explanation must be submitted for further assessment of eligibility
in these cases.
 A Complete Oral Examination performed by another dentist may be permitted under the
plan subject to assessment, 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 or other group
practice, Complete Oral Examinations by both dentist and dental specialist are allowed.
PREVIOUS PATIENT (RECALL) ORAL EXAMINATION (01202)
 This service is allowed after a 12 month period has elapsed from the previous complete
or recall examination. A recall will be accepted if rendered 12 months following the date
of the complete or previous recall examination but will be rejected if the service is
rendered any time prior to the 12 month from first paid claim rule.
 If procedures or treatment services are provided during the same appointment, the fees
for both the examination and procedure(s) are allowed.
SPECIFIC (01204) ORAL EXAMINATION
 The fee for this service is applicable only when no other treatment is rendered during
the same appointment. If a procedure or treatment service payable by DHW is provided
on the same visit, only the fee for the procedure or the exam is paid, whichever carries
the higher fee.
 The fee for Specific Examinations include all radiographs required to assist in the
diagnosis.
 These services are not payable when performed in connection with habit appliances,
spacing, crowding, common eruption problems, and other orthodontic-related concerns.
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EMERGENCY (01205) ORAL EXAMINATION
 The fee for this service is payable at 50% of the DHW tariff when any other procedure
or treatment service payable by DHW is rendered during the same appointment.
 The fee for Emergency Examinations include all radiographs required to assist in the
diagnosis.
 These services are not payable when performed in connection with habit appliances,
spacing, crowding, common eruption problems, and other orthodontic-related concerns.
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.
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GSC/DHW
REQUEST FOR BENEFIT FREQUENCIES APPLICATION FORM
PATIENT INFORMATION
Patient’s Full Name: ________________________________________________
MSI Health Card Number: ___________________
Date of Birth:________________
Private Dental Coverage:
Yes
No
Program Claiming under:
COHP Children’s Oral Health
SNDP Mentally Challenged Program
PROVIDER INFORMATION
Provider’s Name and Address : _________________________________________________
_________________________________________________
_________________________________________________
Telephone #: ___________________ Fax#: _______________________
Provider Unique/ID #: ____________________________
DENTIST’S REQUEST
Procedure code
Description
Frequency Request
Rendered Fee
Statement for Dental/Medical Need of Request:
Describe any Dental, Medical, Physical Developmental or Special Needs that may apply
and explain how it is affecting the patient’s dental/medical status.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Dentist signature: ___________________________________
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DENTAL SURGICAL (IN-HOSPITAL) PROGRAM
PREAMBLE
INTRODUCTION
The Dental Surgical Program provides coverage for medically necessary oral
and maxillofacial surgical services required to be delivered in-hospital to all
eligible residents.
ELIGIBLE RESIDENTS
“Eligible resident” means a person who is insured within the meaning of the Health
Services and Insurance Act, RSNS, 1989, c. 197 or any successor legislation thereto
and whose condition makes it medically necessary that the required dental surgical
procedures be done in a hospital.
INSURED SERVICES
The following Dental Surgical Program fee schedule outlines the range of insured services
payable in the province of Nova Scotia:

Fees for dental surgical procedures include immediate pre-operative, operative and
post-operative care provided within the 30 days following surgery.

In-hospital consultations are benefits of the plan when they are requested by a
physician, or dental/oral maxillofacial surgeon, in light of his/her professional
knowledge of the patient. A consultation report must be entered on the patient’s chart.
CONDITIONS FOR INSURABILITY
All Services
The Nova Scotia Department of Health and Wellness (DHW) insures dental surgical
services only in the case of medical necessity. For purposes of the program, this
means that in all cases, services are insured only where the patient’s medical condition
is such that in-hospital delivery of the service is imperative to ensure patient safety.
Services for patients for whom this medical necessity criterion is not met do not qualify
for payment through DHW. Services delivered in-hospital at the request of the patient
are not insured.
The services performed are insured through DHW only when the particular medical
condition and its attendant risk factors in each case has a direct bearing on the
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dental/oral/facial condition which the procedure seeks to correct or ameliorate,
and therefore, the safe performance of the dental surgical procedure.
Eligibility is determined by the performing dentist according to the coverage guidelines.
Payment for these services are approved only when the above conditions are met AND
only when pertinent details of the condition and its relationship to the procedure(s) are
outlined clearly on each claim or estimate with supporting documentation in the resident’s
chart. For the purpose of the program, tumors, cysts and fractures can, themselves, be
considered to be medical conditions. Assessment for payment decisions will, when
necessary, involve medical and other professional consultations.
In all cases providers must be prepared to produce radiographs and/or chart entries
including medical condition to support submitted claims upon request and/or in the event
of a post audit.
Removal of Impacted Teeth (Fee Codes 72111, 72119, 72211, 72219, 72221, 72229,
72231 & 72239)
In addition to satisfying the criteria outlined in “All Services”, the removal of impacted teeth
is insured only where there exists radiographical evidence of infection, or, destruction
of adjacent tooth and bone. Procedures performed for local or generalized pain and/or
discomfort which are unsupported by radiographic evidence are not insured services.
Complicated Removals of Erupted Teeth (Fee Codes 71201 & 71209)
In addition to satisfying the criteria outlined in “all Services”, these services are insured
only when there is radiographic evidence that their presence is causing infection or
destruction of adjacent tooth and bone. Removal of teeth due to the presence, by itself, of
unrestorable caries, do not meet the criteria for insurability.
Removals of Residual Roots (Fee Codes 72311, 72319, 72321, 72329, 72331`
& 72339)
For purposes of the program, complicated removals of root tips only are considered
for coverage.
In addition to satisfying the criteria outlined in “All Services”, these services are insured
only when there is radiographic evidence that their presence is causing infection or
destruction of adjacent tooth and bone. Uncomplicated removals of residual roots
do not meet the criteria for insurability.
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Orthognathic Surgery
In addition to satisfying the criteria outlined in “All Services”, these procedures are payable
only when required for functional correction and are not payable for cosmetic purposes.
Other Extraction Services
In addition to satisfying the criteria outlined in “All Services”, tooth removal, when
indicated to safely complete another insured oral surgical procedure, such as fracture
treatment or osteotomy, is insured. This does not include the removal of primary teeth to
access permanent teeth being removed, the removal of teeth that do not meet the criteria
described above, or the removal of teeth that are not associated with the procedure.
GENERAL ANESTHETIC COSTS
If general anesthetic is deemed medically necessary when providing a dental service,
the anesthetic fee is payable whether the dental surgery is an insured or uninsured
service. The anesthetist must indicate the medical necessity in the patient’s chart entry
as supporting documentation.
SPECIALIST ON-CALL FEES – ORAL & MAXILLOFACIAL SURGEONS
Qualified oral and maxillofacial surgeons who are required to serve on a regular on-call
schedule with their medical colleagues will be compensated at the same rate as that
provided to the physician group. The medical manager responsible for the on-call rotation
at the Nova Scotia Health Authority hospital. On-call remuneration is administered by
the DHW, which provides the funds to the Nova Scotia Health Authority to distribute to
the surgeon.
PREMIUM FEES FOR NON-ELECTIVE ORAL AND MAXILLOFACIAL
PROCEDURES
Premium fees are additional amounts paid over and above normal or customary rates
on eligible services provided on an emergency basis during designated times. An
emergency basis is defined as services which must be performed without delay because
of the medical condition of the patient. In such cases the premium fee paid will be the
customary fee, plus an additional percentage depending on the time and day. Date and
time of an emergency procedure must be indicated on claim submission and the rendered
fees must be inclusive of the additional premium percentage.
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PREMIUM FEE TABLE
Day
Time
Additional Percentage Added to Fee
Monday to Friday
1700 – 2400
35%
Tuesday to Saturday
0000 – 0800
50%
Saturday
0800 – 1700
35%
Saturday to Monday
1700 – 0800
50%
Recognized Holidays
0800 – 2400
50%
NOTE: If an oral and maxillofacial surgeon chooses to provide routine, scheduled services
during premium fee hours or a statutory holiday, he/she is not entitled to premium fees.
If the service requires an anesthetic, the anesthetic start time determines whether a
premium fee is applicable.
Premium fees are payable for the following fee codes: 76201-204, 76301-305, 76401403, 76501-507, 76601-605, 76701-704, 76801, 76802, 76911-913, 76921-924, 76931934, 76961-969, 76971-979, 76981-989.
MULTIPLE OPERATIVE PROCEDURES
Unless otherwise specified, bilateral procedures are entitled to an additional fee
equivalent to 50% of that shown for the unilateral procedure. When done under separate
anesthetics, at an interval, the full fee should be charged for each procedure.
The right and left maxilla and mandible are thought of as quadrants. Some surgical
procedures are not only bilateral but involve all four quadrants, with separate incisions in
each. When two quadrants are involved in surgical procedures, the first procedure will be
paid at 100% and the subsequent procedure at 50%. When more than two quadrants are
involved, the first two are paid at 100% and subsequent procedures at 50%. The same
rules apply in the case of sextants.
SURGICAL ASSISTANT
Surgical assistant fees are payable for selected dental surgical fee codes where it has
been deemed that the complexity of the procedure requires an assisting surgeon, dentist
or physician. Assistant’s fees are not payable for procedures where an assistant is not
normally required. Surgical assistant fees for dentists and oral and maxillofacial surgeons
are paid at 25% the rate the primary surgeon receives for the service assisted on (note:
surgical assistant fees are subject to premium fee and multiple operative procedures
rules, as explained above). Primary surgeon and surgical assistant claim should be
submitted together to ensure proper payment.
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Surgical assistant fees are payable for the following fee codes: 73301-303, 73441,
73451, 73461, 73621, 73631, 76201-204, 76301-305, 76505-507, 76603-605, 76703,
76704, 76801, 76802, 76913, 76923, 76924, 76931-934, 77102, 77108, 77201203,77301-304, 77411-414, 77421-425, 77501-504, 77603, 77701-705, 77911-914,
77917, 78101, 78201-209, 78301-303.
IN-HOSPITAL ROUTINE EXTRACTIONS
Routine extractions will be covered by DHW upon prior approval for medically
compromised patients (i.e. cardiac, transplant, immunocompromised and radiation
patients). Undergoing active treatment in a public hospital and the attendant medical
procedure requires the removal of teeth that would otherwise be considered routine
extractions.
The medical specialist providing the care must maintain supporting documents in the
resident’s chart to indicate/support the patient’s medical diagnosis, including the ICDA
Code, for one of the four conditions described above, and it must be stated the routine
dental extractions are medically required. Eligibility is determined by the performing dentist
according to the coverage guidelines and is subject to post audit. Failure to comply with
any of these conditions will result in a reduction in payment or non-payment.
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MENTALLY CHALLENGED PROGRAM
PREAMBLE
INTRODUCTION
The Mentally Challenged Program is designed to meet the basic dental needs of Nova
Scotia residents who have been diagnosed (ICDA Code required), by a Medical
Specialist, to have an intellectual disability to a degree where chair management for dental
services is untenable and whose dental needs may necessitate delivery in a hospital
setting under a general anesthetic or acceptable alternative. Services delivered in an
office setting are subject to the terms and conditions associated with payer of last resort
regulations whereby private insurance benefits must be accessed first.
REGISTRATION PROCEDURES
Residents are registered with DHW in the Mentally Challenged Program through the
submission of a specially designed registration form (form follows). The registration
process requires that a Medical Specialist has certified by diagnosis that the patient is
intellectually disabled to a degree where chair management is untenable. This certification
can take the form of a written opinion in the case of a newly diagnosed individual or can
be based on a previous diagnosis which would be in the resident’s medical file. In the
latter case the name of the specialist must be provided by the family physician. Once
signed by the physician, the dental provider signs and forwards the form to GSC/DHW on
behalf of the resident. Any incomplete forms may result in the delay of processing.
ELIGIBLE RESIDENTS
“Eligible resident” means a person who is insured within the meaning of the Health
Services and Insurance Act, RSNS, 1989, c. 197 or any successor legislation thereto, and,
who is deemed to be intellectually disabled to a degree where chair management is
untenable, and whose dental needs may necessitate delivery in a hospital setting under a
general anesthetic or acceptable alternative. There is no age restriction.
INSURED SERVICES
Insured services are those described in the Fee Schedule for the Children’s Oral Health
Program which are paid at the Nova Scotia Dental Association Schedule of fees. Where
major restorative and/or dental surgical program services are required, preauthorization
must be obtained from GSC/DHW prior to beginning treatment. Scaling service of up to
two units when seen in the office or up to four units for a hospital based service, once
every 12 months from first paid claim, are available under this program. Only scaling fee
codes 11111, 11112, 11113 and 11114, OR, as an alternative, root planing fee codes
42111, 42311, 42321, 42341, 42551, 43421, 43422, 43423, 43424, 43425, 43426, 43427
and 43429 from the Cleft Palate/Craniofacial Program can be claimed for this service.
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PREMIUM FEES
These services are subject to a 30% premium fee on the base when delivered in a
provincially funded hospital setting. Hospital based services are not subject to payer of last
resort regulations. Hospital setting indication and hospital name must be indicated on
claim form for services rendered in hospital setting. Total rendered amount inclusive of the
30% premium fee must be indicated on the claim form for auditing purposes.
OUT OF PROVINCE COVERAGE
There is no coverage, under the Mentally Challenged Program, for services performed
outside of Nova Scotia.
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GSC/DHW
MENTALLY CHALLENGED PROGRAM
REGISTRATION FORM
PATIENT INFORMATION
Patient’s Full Name: __________________________________________________________
MSI Health Card Number: ______________________
Date of Birth: __________________
PHYSICIAN’S STATEMENT (PROVIDE COMPLETE DETAILS OF MEDICAL
DIAGNOSIS INCLUDING THE ICD CODE)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
_______________________ ICD code: _____ Chair management untenable:
Yes
No
This is to confirm that the above patient has an intellectual disability to the degree that chair
management for dental services is untenable.
Physician’s Name: ______________________ Physician’s Signature: _________________
Date: ____________
DENTIST’S STATEMENT
Due to the medical condition of this patient as verified by this form, which has been signed by
Dr.
, M.D., the proposed dental treatment can be performed
in office or in hospital setting.
Dentist’s Name: ________________________ Dentist’s Signature: ____________________
Date: ___________ Fax #: ___________________ Email: _________________________
GSC/DHW USE ONLY
Registration Confirmed:
Yes
No
Comments: _________________________________________________________________
___________________________________________________________________________
Signature: _______________________
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GSC/DHW
REQUEST FOR BENEFIT FREQUENCIES APPLICATION FORM
PATIENT INFORMATION
Patient’s Full Name: ________________________________________________
MSI Health Card Number: ___________________
Date of Birth:________________
Private Dental Coverage:
Yes
No
Program Claiming under:
COHP Children’s Oral Health
SNDP Mentally Challenged Program
PROVIDER INFORMATION
Provider’s Name and Address: _________________________________________________
_________________________________________________
_________________________________________________
Telephone #: ___________________ Fax#: _______________________
Provider Unique/ID #: ____________________________
DENTIST’S REQUEST
Procedure code
Description
Frequency Request
Rendered Fee
Statement for Dental/Medical Need of Request:
Describe any Dental, Medical, Physical Developmental or Special Needs that may apply
and explain how it is affecting the patient’s dental/medical status.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Dentist signature: ___________________________________
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CLEFT PALATE/CRANIOFACIAL PROGRAM
PREAMBLE
INTRODUCTION
The Cleft Palate/Craniofacial Program provides coverage for residents with craniofacial
anomalies, which directly influence the growth and development of the dentoalveolar and
craniofacial structures. From birth to age fifteen, these patients will be insured for basic
dental services available through the Children’s Oral Health Program, as well as other
services deemed necessary as a result of the anomaly. From age 15 to the end of the
month of their 23rd birthday, additional services are insured on a preauthorization basis
depending on the treatment required. Specifically, treatment made necessary as a result
of the anomaly will be considered for coverage.
REGISTRATION PROCEDURES
Residents are registered into the Cleft Palate/Craniofacial Program by the Cleft Palate/
Craniofacial Team (CPT) at the IWK Health Centre. Registration does not guarantee
eligibility for funding for treatment under the Cleft Palate/Craniofacial Program.
Registration letter including CPT signature is required to register resident.
ELIGIBLE PATIENTS
“Eligible resident” means a person who is insured, within the meaning of the Health
Services and Insurance Act, RSNS, 1989, c.197 or any successor legislation thereto,
and, who have a craniofacial anomaly that directly influences the growth and development
of the dentoalveolar and craniofacial structure may be eligible for services under the
program.
Such anomalies may include, but are not limited to, clefts of the hard and soft palates,
lip and/or alveolus. Apert’s Syndrome, Crouzon Syndrome, Treacher Collins Syndrome,
Lateral Facial Dysplasia and Achondroplasia. Other conditions not listed here may confer
eligibility for coverage, pending assessment by the CPT.
Residents deemed eligible for coverage of selected treatment will be entitled to program
benefits from birth to the end of the month in which they turn 23 years of age.
ELIGIBILITY FOR SERVICES
Eligibility for coverage of dental services, beyond the eligibility under the Children’s Oral
Health Program (COHP), will be determined when specific treatment is recommended by
the dentist on behalf of their patient. Eligibility is not based on the financial need of the
patient or family.
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INSURED SERVICES
Insured services past the age of eligibility for the COHP will be limited to those related to,
though not necessarily restricted to, the area of the craniofacial deformity. GSC/DHW will
with the support of the CPT, approve or deny treatment coverage.
CONSENT AND COMPLIANCE
Participation as an insured resident under the program requires the resident and
parent/guardian to agree to comply with treatment recommendations set out in
consultation with the dentist providing the treatment. Failure to comply with the treatment
recommendations may result in the loss of benefits. Areas in which the resident and the
parent/guardian compliance is mandatory include maintenance of proper oral hygiene,
attendance at scheduled appointments and other elements relating to treatment success.
Treatment/retreatment made necessary as a result of lack of compliance will not be
funded by the program.
RETREATMENT
There is no coverage for retreatment under the program. Under extenuating
circumstances, only, where the CPT has determined that a condition requiring retreatment
has resulted directly from the progression of the congenital/developmental craniofacial
anomaly, additional funding may be considered.
SPECIAL CONSIDERATION
For residents whose condition is not described in the conditions of eligibility, an application
for Exceptional Circumstance coverage. In such cases, fees associated with
documentation needed to support the request, such as those for assessments and
diagnostic records and/or assessment fees for insured services provided by the CPT, are
the responsibility of the resident and/or parent/guardian. Coverage applications for
Exceptional Circumstances should be sent to GSC/DHW.
TREATMENT PLAN FORMS
Specialized treatment plan forms (sample located at the beginning of this section) can be
obtained from GSC/DHW for any providers wishing to make application, under the above
terms, on behalf of their patients.
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OUT OF PROVINCE
There is no coverage under the Cleft Palate/Craniofacial Program for services provided
outside of Nova Scotia.
PREAUTHORIZATION
Pre-authorization is a process for assessing eligibility for coverage of a service before the
treatment begins.
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CLEFT PALATE / CRANIOFACIAL PROGRAM
DIAGNOSTIC PREAMBLE
COMPLETE (INITIAL) ORAL EXAMINATIONS (01101/01102/01103)
 This service is allowed once in a patient’s lifetime, when continuity of treatment is
maintained. Where there is a gap in complete dental treatment of two (2) years or more,
a further Complete Oral Examination is warranted and is covered under the plan. There
may be other cases where a further Complete Oral Examination is warranted and covered
under the plan. Written explanation must be submitted for further assessment of eligibility
of these cases.
 A Complete Oral Examination performed by another dentist may be permitted under the
plan subject to assessment, 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 or other group
practice, Complete Oral Examinations by both dentist and dental specialist are allowed.
PREVIOUS PATIENT (RECALL) ORAL EXAMINATION (01202)
 This service is allowed after a 12 month period has elapsed from the previous Complete
or Recall Examination. A recall will be accepted if rendered 12 months following the
complete or previous recall examination, but will be rejected if the service is rendered
any time prior to the 12 month from first paid claim rule.
 If procedures or treatment services are provided during the same appointment, the fees
for both the examination and procedure(s) are allowed.
SPECIFIC ORAL EXAMINATION (01204)
 The fee for this services is applicable only when no other treatment is rendered during
the same appointment. If a procedure or treatment service payable by DHW, is provided
on the same visit, only the fee for the procedure or the exam is paid, whichever carries
the higher fee.
 The fee for Specific Examinations include all radiographs required to assist in the
diagnosis.
 These services are not payable when performed in connection with habit appliances,
spacing, crowding, common eruption problems and other orthodontic related concerns.
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EMERGENCY ORAL EXAMINATION (01205)
 The fee for this service is payable at 50% of the DHW tariff when any other procedure
or treatment service payable by DHW is rendered during the same appointment.
 The fee for Emergency Examinations include all radiographs required to assist in
the diagnosis.
TESTS AND LABORATORY EXAMINATIONS (15 – 23 YEAR OLDS)
 Services should be claimed under COHP until the end of the month of the resident’s
15th birthday.
 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 the 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.
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MAXILLOFACIAL PROSTHODONTICS PROGRAM
PREAMBLE
INTRODUCTION
The Maxillofacial Prosthodontics Program seeks to meet the anatomical, functional and
significant emotional (arising from having a significant physical defect) needs of residents
through the rehabilitation of head and neck deficits so that these individuals may
reintegrate and continue to be functional members of society. Service provision within the
program is currently limited to 2 providers who possess specialized qualifications in this
area.
REGISTRATION PROCEDURES
Residents having been deemed eligible for the program by the qualified specialists, will be
registered with GSC/DHW in the Maxillofacial Prosthodontics Program at the time of
submission of their initial claim on the resident’s behalf. The initial submission will be
accompanied with a supporting letter from the referring physician.
ELIGIBLE PATIENTS
“Eligible resident” means a person who is insured within the meaning of the Health
Services and Insurance Act, RSNS, 1989, c. 197 or any successor legislation thereto, and
whose maxillofacial prosthodontic needs have been the result of congenital facial
disorders, cancer, surgery, trauma, and neurological deficit. There is no age restriction.
ELIGIBILITY FOR SERVICES
The program provides a range of medically required dental services for residents whose
maxillofacial prosthodontic needs have been the result of congenital facial disorders,
cancer, surgery, trauma, and neurological deficiencies.
INSURED SERVICES
Insured services are those described in the fee schedule for the program.
OUT OF PROVINCE
There is no coverage, under the Maxillofacial Prosthodontics Program, for services
performed outside of Nova Scotia.
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EXCEPTIONAL CIRCUMSTANCES
INTRODUCTION
Benefits for treatment services for reasons of medical necessity, may be eligible under
an Exceptional Circumstance available to Nova Scotia residents with a valid Medical
Services Insurance (MSI) Health Card Number.
REGISTRATION PROCEDURES
A dentist shall submit an application request to GSC/DHW, for dental services he/she
recommends should be insured for reasons of medical necessity, and where the service is
not insured by any existing DHW dental program.
“Eligible resident” means a person who is insured within the meaning of the Health
Services and Insurance Act, RSNS, 1989, c. 197 or any successor legislation thereto, and
for reasons of medical necessity.
ELIGIBILITY FOR SERVICES
Coverage for treatment of service of Exceptional Circumstance must have treatment
approval prior to the commencement of treatment.
INSURED SERVICES
Insured services are those approved for reasons of medical necessity under Exceptional
Circumstances to preapproved fees.
OUT OF PROVINCE
There is no coverage, under Exceptional Circumstance, for services performed outside
of Nova Scotia.
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DHW Dental Coverage
Request for Exceptional Circumstances
APPLICATION COVER PAGE
Complete this cover page and include with your application
PATIENT INFORMATION
PATIENT SURNAME
PATIENT GIVEN NAME MSI HEALTH CARD NUMBER
PATIENT ADDRESS
EXPIRY DATE
DATE OF BIRTH
DENTISTS / SPECIALISTS
COORDINATING DENTIST
ALL DENTISTS / SPECIALISTS IN TREATMENT PLAN
SUBMISSION DATE (YYYY/MM/DD)
Is patient currently enrolled in Cleft Palate Program: Yes
No
CHECKLIST
ENSURE EACH SECTION IS INCLUDED:
This cover page
Outline of any other public or private dental benefits available to the patient
Description of relevant patient medical and drug history
Explanation of the medical necessity of the proposed dental treatment that is required to meet the
basic needs of the patient, including relevant source documents such as radiographs, photographs,
etc. used for diagnosis
Description of proposed dental treatment plan, compiled from all providers, with estimated
treatment timeline
List of dental services to be provided by each dentist with applicable codes and associated fees
Description of any follow up requirements
A written recommendation in support of the treatment plan, confirming that this is the coordinating
dentist’s recommendations and that the application is not being provided solely at the request
of the resident
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SUBMISSION INFORMATION
Submit the entire package to Green Shield Canada by either Provider Connect with an attached file to the NS
Government mailbox online or by manual submission via postal mail to:
Green Shield Canada
Attn: Dental Dept - Request for Exceptional Circumstances
P.O. Box 1671
Windsor, Ontario N9A 0A8
A response will be provided within 30 days from the date the application is received. Only complete applications will be considered.
Note: This application process replaces the previous Special Consideration application.
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OUT OF PROVINCE BENEFITS
Applicable only to in-hospital emergency dental services
INTRODUCTION
While most services listed under the Department of Health and Wellness (DHW) Dental
Programs are only covered if delivered in Nova Scotia, certain emergency dental services
are covered in other Canadian provinces/territories if the emergency service is considered
medically necessary and the service is provided by a licensed oral surgeon in a publicly
funded hospital. Funding for this insured service is provided by the DHW Dental Surgical
Program.
ELIGIBLE RESIDENTS
“Eligible resident” means a person who is insured within the meaning of the Health
Services and Insurance Act, RSNS, 1989, c. 197 or any successor legislation thereto
and whose condition makes it medically necessary that the required dental surgical
procedures be done in a hospital.
PAYMENT FOR ELIGIBLE SERVICES
An oral surgeon who provides emergency services for a resident in a publicly funded
hospital in a Canadian province/territory outside of Nova Scotia may submit a claim to the
Administrator for coverage of insured services.
or
A resident who receives emergency services in a Canadian province/territory outside of
Nova Scotia may submit their paid invoice to the Administrator for coverage of insured
services.
Oral surgeons and resident’s fees shall be reimbursed, for insured out of province
emergency services, at the provincial/territorial regulated rate where the emergency
service was delivered, except for insured services delivered in Quebec.
For insured services delivered in Quebec, the oral surgeon or resident’s fees shall be
reimbursed at the Nova Scotia regulated tariff rate or at the rate submitted with the claim
or invoice, whichever is the lesser.
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PROVIDER SUBMISSIONS
The DHW claim form (see Appendix A) must be used and submitted by mail to GSC, the
Administrator. Copies shall be made available by the Administrator.
Resident invoices: A resident who pays for an insured service from an out-of-province
dentist should ask for an itemized statement and or receipt showing details of each
service rendered and the dentist’s charge for each service provided. It is the responsibility
of the resident to submit the invoice to GSC/DHW for reimbursement.
Claims or invoices received beyond 6 months from the date of service will be invalid
unless a reasonable explanation for the late submission is provided and considered to be
acceptable.
This policy does not apply to:

Individuals who are entitled to Health Care Benefits under any other public or
private plan.

Residents who receive emergency services outside of Canada.
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CHILDREN'S ORAL
HEALTH PROGRAM (COHP)
DIAGNOSTIC
EXAMINATIONS
G. P.
SPEC
Mentally
Challenged
Program
NSDA GP
Rates
$34.40
$44.80
$60.80
$22.08
$34.51
$64.80
$92.80
$126.40
$27.97
$46.94
$40.00
$51.00
$70.00
$27.00
$43.00
DHW - details must accompany claim,
includes x-rays
01205
Emergency Exam
$34.51
$46.94
$43.00
DHW - details must accompany claim,
includes x-rays
05201
Consultation
N/A
$77.91
N/A
Examination and Diagnosis
01101
01102
01103
01202
01204
Complete Oral, Primary Dentition
Complete Oral, Mixed Dentition
Complete Oral, Permanent Dentition
Limited Oral, Previous Patient (recall)
Specific Exam
DHW - Specialist other than
Orthodontist (Details must accompany
claim.)
RADIOGRAPHS
(a) The fees are intended to include
both the technical and professional
components of an x-ray service,
however, non-readable films are not
insured.
(b) Fees for diagnostic x-rays
periapicals or bitewings should not
exceed $16.10 per child per year
(whether same or different dentist)
excluding panoramic or cephalometric
films.
(c) Procedural x-rays in connection with
Root Canal Therapy are not allowed
separately as the fees for Root Canal
Therapy include procedural x-rays.
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(d) All x-rays are to be made available to
the plan upon request and therefore
should be retained for five (5) years
following the service.
02111
02112
Radiographs, Intra-Oral, Periapical
Single film
Two films
$12.26
$16.10
$12.51
$16.42
$14.00
$19.00
02141
02142
Radiographs, Intra-Oral, Bitewing
Single Film
Two films
$12.26
$16.10
$12.51
$16.42
$14.00
$19.00
$51.51
$52.54
$56.00
$51.51
$52.54
$56.00
$30.97
$31.59
$37.00
02601 Radiographs, Panoramic - Single film
DHW - once per lifetime, only in
connection with a specific request for a
consultation with a specialist other
than an orthodontist. This service is
not payable to any provider for reasons
relating to spacing, crowding, eruption
timing, and other orthodontic related
concerns. (Details must accompany all
claims.)
02701 Radiographs, Cephalometric - Single
film
DHW - once per lifetime, only in
connection with a specific request for a
consultation with a specialist other
than an orthodontist. This service is
not payable to any provider for reasons
related to spacing, crowding, eruption
timing, and other orthodontic related
concerns. (Details must accompany all
claims.)
TESTS AND LABORATORY
EXAMINATIONS
Coverage guidelines apply - see preamble
to the COHP.
Tests, Microbiological
04101 Microbiological Test for the Determination
of Pathological Agents + L
Tests, Caries Susceptibility
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04201 Bacteriological Test for the Determination
of Dental Caries Susceptibility +L
$30.29
$30.90
$34.00
$72.36
$72.36
$72.36
$73.81
$73.81
$73.81
$83.00
$83.00
$83.00
$83.33
$85.00
$98.00
$83.33
$83.33
$85.00
$85.00
$98.00
$98.00
$30.29
$30.90
$34.00
$25.61
$26.12
$52.00
$30.97
PA
$43.45
PA
$21.00
PA
Test, Histological, Soft Tissue
04311 Biopsy, Soft Oral Tissue- by Puncture + L
04312 Biopsy, Soft Oral Tissue- by Incision + L
04313 Biopsy, Soft Oral Tissue - by Aspiration +
L
Tests, Histological, Hard Tissue
04321 Biopsy, Hard Oral Tissue - by Puncture +
L
04322 Biopsy, Hard Oral Tissue - by Incision + L
04323 Biopsy, Hard Oral Tissue - by Aspiration +
L
Tests, Cytological
04401 Cytological Smear from the Oral Cavity +
L
Tests, Pulp Vitality
04501
One Unit
CASTS, DIAGNOSTIC
DHW
(a) When diagnostic casts are
prepared, a detailed explanation must
be included on the claim.
(b) Diagnostic casts are to be
available to the Plan upon request and
accordingly, should be retained for a
period of 5 (five) years following the
service.
(c) Not payable in conjunction with
orthodontic cases and preventive
orthodontic services.
Casts, Diagnostic, Unmounted
04911
Casts, Diagnostic, Unmounted + L
04912 Casts, Diagnostic, Unmounted, Duplicate
+L
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Casts, Diagnostic, Mounted
04921
04922
04923
Casts, Diagnostic, Mounted + L
Casts, Diagnostic, Mounted using face
bow transfer + L
Casts, Diagnostic, Mounted using face
bow + occlusal records + L
$39.00
$64.00
PA
PA
$40.00
$67.00
$87.14
PA
$99.00
$15.00
$16.14
$16.00
PREVENTIVE SERVICES
The fees for preventive services assume a
one-to-one relationship between patient
and dentist. Where a service is provided
to a group at the same time, only one fee
is allowed.
Any procedure carried out by an auxiliary
is paid at the General Practitioner level.
To qualify for specialist fee, procedure
must be carried out personally by the
specialist on a properly referred patient.
Topical Fluoride Applications - coverage
guidelines apply (See preamble to the
COHP.)
12101 Fluoride treatment, topical application
POLISHING - PLEASE SEE BELOW
CARIES PREVENTION SERVICE
13101
Nutritional Counselling - One unit of
time
DHW - a series of four (4) appointments
is allowed once per lifetime of the
patient.
$25.00
$30.90
$30.00
13211
Oral Hygiene Instruction / Plaque
Control - One unit of time
$30.29
$30.29
$30.00
$20.00
$28.15
$20.00
DHW
(a) Caries Prevention Services
(13211) - allowed once in a 12 month
period
(b) Includes for DHW program rubber
cap polishing and minor scaling
procedures.
13401
Sealants, Pit and Fissure (acid etch
preparation included) - Each tooth
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Nova Scotia Dental Program — Dentists Guide
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13409
Sealants, Pit and Fissure (acid etch
preparation included) - Each additional
tooth within the same quadrant.
DHW - Limited to six and seven year
molars that meet guidelines - one
application per tooth per year. Second
sealant claimed within the same
quadrant will be paid as 13409.
Disking of Teeth, Interproximal
DHW - Maximum of 3 units per lifetime,
Primary Teeth Only
16201
One unit
16202
Two units
16203
Three units
$14.00
$19.15
$14.00
$53.81
$107.65
$161.45
$54.89
$109.80
$164.68
$58.00
$116.00
$174.00
$124.33
$169.60
$138.00
$149.00
$258.04
$151.00
$181.00
$282.20
$183.00
$160.00
$196.43
$162.00
$53.00
$59.28
$55.00
SPACE MAINTAINERS
Please note that Space Maintainers to
replace primary incisors are not
considered for coverage.
Space Maintainers, Band Type
15101
15103
15105
Space Maintainer, Band Type, Fixed,
Unilateral + L
Space Maintainer, Band Type, Fixed,
Bilateral (soldered lingual arch) + L
Space Maintainer, Band Type, Fixed,
Bilateral Tubes and Locking Wires+L
Space Maintainers, Stainless
Steel Crown Type
15201 Space Maintainer, Stainless Steel Crown
Type, Fixed + L
Space Maintainers, Maintenance
of
15601 Maintenance, Space Maintainer Appliance
RESTORATIVE SERVICES
Where at the same sitting, in order to
conserve tooth structure, two separate
restorations are performed, on the same
tooth involving a common surface, when
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 59
one restoration might have been done,
this should not be considered as one
restoration in assessing the fees.
Additional or similar restorative services
on the same tooth within 120 days of the
original service require an explanation on
the claim.
Where adjacent surfaces of a tooth are
filled at the same appointment, the fee will
be at the appropriate level for multiple
surfaces, as listed below, in the case of
tooth-colored etched/bonded restorations.
If the above conditions exist, they will be
paid at the complex level.
The replacement of an existing amalgam
restoration with tooth colored
etched/bonded restorations shall be
insured services only where the amalgam
restoration has been fractured and/or
there is recurrent caries.
CARIES/TRAUMA/PAIN
CONTROL
DHW - permanent teeth only.
Caries/Trauma/Pain Control (includes
pulp caps when necessary as a separate
procedure)
20111
First tooth
$61.86
$75.79
$85.00
Caries/Trauma/Pain Control (includes
pulp caps when necessary and use of
band for retention and support as a
separate procedure)
20121
First tooth
20131
Trauma Control - First tooth
$84.00
$32.00
$85.68
$37.00
$96.00
$35.00
$43.97
$58.98
$67.77
$85.51
$107.63
$50.09
$72.55
$82.98
$104.47
$131.72
$76.00
$99.00
$110.00
$121.00
$147.00
RESTORATIONS, AMALGAM
21111
21112
21113
21114
21115
Non-Bonded, Primary Teeth
One surface
Two surfaces
Three surfaces
Four surfaces
Five surfaces or maximum surfaces per
tooth
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21121
21122
21123
21124
21125
21211
21212
21213
21214
21215
21221
21222
21223
21224
21225
21231
21232
21233
21234
21235
21241
21242
21243
21244
21245
Bonded, Primary Teeth
One surface
Two surfaces
Three surfaces
Four surfaces
Five surfaces or maximum surfaces per
tooth
Non-Bonded, Permanent Bicuspids
and Anteriors
One surface
Two surfaces
Three surfaces
Four surfaces
Five surfaces or maximum surfaces per
tooth
Non-Bonded, Permanent Molars
One surface
Two surfaces
Three surfaces
Four surfaces
Five surfaces or maximum surfaces per
tooth
Bonded, Permanent Bicuspids and
Anteriors
One surface
Two surfaces
Three surfaces
Four surfaces
Five surfaces or maximum surfaces per
tooth
Amalgam, Bonded, Permanent Molars
One surface
Two surfaces
Three surfaces
Four surfaces
Five surfaces or maximum surfaces per
tooth
$45.23
$58.98
$67.77
$85.51
$107.63
$50.09
$72.55
$82.98
$104.47
$131.72
$78.00
$100.00
$112.00
$131.00
$161.00
$53.06
$79.61
$100.19
$129.66
$159.19
$64.82
$96.82
$122.00
$164.64
$193.85
$90.00
$119.00
$144.00
$173.00
$206.00
$60.94
$86.56
$113.43
$156.19
$207.84
$70.91
$105.63
$138.00
$191.32
$250.00
$103.00
$118.00
$159.00
$202.00
$264.00
$62.82
$79.61
$100.19
$129.66
$159.19
$64.82
$96.82
$122.19
$164.64
$193.85
$108.00
$126.00
$158.00
$179.00
$217.00
$70.36
$86.56
$113.43
$156.19
$207.84
$70.91
$105.63
$138.00
$191.32
$253.17
$121.00
$141.00
$186.00
$225.00
$277.00
Pins, Retentive per restoration (for
amalgams and tooth colored
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Nova Scotia Dental Program — Dentists Guide
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restorations)
21401
21402
21403
21404
21405
One pin
Two pins
Three pins
Four pins
Five pins or more
$15.97
$27.96
$35.39
$43.73
$50.78
$16.29
$28.52
$36.10
$44.60
$51.80
$22.00
$35.00
$40.00
$47.00
$57.00
22201
22202
22211
22212
Prefabricated, Metal, Primary Dentition
Primary Anterior
Primary Anterior - Open face
Primary Posterior
Primary Posterior - Open face
$122.50
NA
$122.50
$118.39
$155.79
NA
$155.79
$144.75
$131.00
NA
$128.00
$139.00
22301
22302
22311
Prefabricated, Metal, Permanent
Dentition
Permanent Anterior
Permanent Anterior- open face
Permanent Posterior
$122.50
NA
$122.50
$155.79
$144.75
$155.79
$146.00
NA
$128.00
RESTORATIONS,
PREFABRICATED, FULL
COVERAGE
DHW - Please note that a single surface
restoration is payable concurrently
with open-faced stainless steel crowns.
Stainless Steel Crowns - One hundred
percent (100%) of the dental tariff shall
apply to each of the first three
stainless steel crowns performed at
one sitting (for a patient under general
anaesthetic 50% of the dental tariff
shall apply 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 four or
more stainless steel crowns done at
the same sitting for a patient under
general anaesthesia. Such requests
must be accompanied by necessary xrays.
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Nova Scotia Dental Program — Dentists Guide
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22312
Permanent Posterior- open face
NA
$144.75
NA
22501
22511
Prefabricated, Plastic, Permanent
Dentition
Permanent Anterior
Permanent Posterior
$128.00
$128.00
$171.00
$171.00
$131.00
$131.00
$73.67
$96.17
$112.01
$178.31
$178.31
$89.71
$117.41
$137.20
$220.79
$220.79
$109.00
$124.00
$151.00
$199.00
$268.00
23311
23312
23313
23314
23315
Permanent Bicuspids, Bonded
One surface
Two surfaces
Three surfaces
Four surfaces
Five surfaces or maximum surfaces per
tooth
$79.15
$98.00
$131.92
$162.08
$185.32
$64.82
$96.82
$122.19
$164.64
$193.85
$130.00
$160.00
$217.00
$266.00
$305.00
23321
23322
23323
23324
23325
Permanent Molars, Bonded
One surface
Two surfaces
Three surfaces
Four surfaces
Five surfaces or maximum surfaces per
tooth
$82.92
$99.26
$135.69
$164.59
$207.84
$70.91
$105.63
$138.00
$191.32
$253.17
$133.00
$160.00
$219.00
$266.00
$334.00
Primary Anterior, Acid Etch/Bonded
One surface
$68.47
$83.77
$91.00
2341
2
Two surfaces (continuous)
$68.47
$83.77
$110.00
23413
Three surfaces (continuous)
$96.17
$117.41
$138.00
RESTORATIONS, TOOTH
COLOURED
DHW - Fee codes 23113, 23114, 23115,
23413, 23414, 23415 include
reattachment of fractured tooth
fragments.
23111
23112
23113
23114
23115
23411
Permanent, Anteriors, Acid
Etch/Bonded
One surface
Two surfaces (continuous)
Three surfaces (continuous)
Four surfaces (continuous)
Five surfaces (continuous) maximum
surfaces per tooth
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23414
23415
$146.00
$148.69
$164.59
$164.59
$151.00
$157.00
$56.64
$70.36
$86.06
$96.11
$107.63
$50.19
$72.55
$82.98
$104.47
$131.72
$90.00
$112.00
$137.00
$154.00
$160.00
Posts - Cast Metal (including core) as a
Separate Procedure
25711
Single section + L
25712
Two sections + L
25713
Three sections + L
$172.34
$233.06
PA
$244.42
$244.42
$469.48
$279.00
$378.00
PA
Posts, Cast Metal (including core)
Concurrent with Impression for Crown
25721
Single section + L
25722
Two sections + L
25723
Three sections + L
$143.00
$172.34
PA
$244.42
$244.42
$469.48
$145.00
$229.00
PA
25731
25732
25733
Posts, Prefabricated Retentive
(separate procedure)
One post
Two posts same tooth
Three posts same tooth
$109.24
$137.58
$171.50
$133.31
$133.31
$133.31
$133.00
$224.00
$280.00
25741
Posts, Prefabricated, Retentive and
Cast Core
One post and cast core + L
NA
$244.42
NA
23511
23512
23513
23514
23515
Four surfaces (continuous)
Five surfaces (continuous) maximum
surfaces per tooth
Primary Posterior, Acid Etch/Bond
Technique
One surface
Two surfaces
Three surfaces
Four surfaces
Five surfaces or maximum surfaces per
tooth
SEE PROSTHODONTICS
SECTION FOR INLAYS, ONLAYS,
AND PINS
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Page 64
25742 Two posts (same tooth) and cast core + L
25743 Three posts (same tooth) and cast core +
L
25754
Post, Prefabricated, with Core for
Crown Restoration
One post, with composite core + pins
NA
NA
$244.42
$469.48
NA
NA
$179.03
$219.13
$221.00
$404.10
PA
$458.00
NA
PA
NA
PA
NA
$117.67
NA
$145.00
NA
CROWNS
DHW NOTE: Gold, Butt Margins
(including Collarless Veneers), Custom
Shading or any esthetics included in
the lab fees are not insured. Please
submit a copy of the Lab invoice upon
completion of the services.
Permanent Crowns - payable on
permanent Anterior Teeth only - it is
recommended that pre-determination
of benefits be requested prior to
rendering services for permanent
anterior crowns. Please provide x-rays
and/or study models.
27111
27112
27113
27114
27121
27122
Crowns, Plastic, Processed
Plastic, Processed + L
$396.18
Plastic, Processed complicated
NA
(restorative, positional, and/or aesthetic) +
L
Plastic, Transitional, Indirect + L
PA
Plastic/Metal Base, Processed + L
NA
Crowns, Plastic, Direct, DHW- Not
payable in addition to permanent
Plastic, Direct, Transitional (chairside)
Transitional Restoration of Fractured
Anterior
$115.36
NA
Crowns, Porcelain/Ceramic/Polymer
Glass
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Nova Scotia Dental Program — Dentists Guide
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27201
Porcelain/Ceramic Jacket + L
$486.48
27202 Porcelain/Ceramic Jacket complicated + L
NA
Crowns, Porcelain/Ceramic Fused to
Metal
27211 Porcelain/Ceramic Fused to Metal Base +
L
27212 Porcelain/Ceramic Fused to Metal Base,
Complicated
Recementation/Rebonding,
Inlays/Onlays/Crowns/Veneers/Posts/N
atural Tooth Fragments
DHW - Maximum of 3 units per tooth.
DHW - For stainless steel crowns,
recementation is payable after 120
days following original placement by
same or different dentist.
29101
One unit of time
29102
Two units of time
29103
Three units of time
$595.46
PA
$591.00
NA
$486.48
$595.46
$591.00
PA
PA
PA
$58.12
$116.21
$174.31
$59.28
$118.53
$177.80
$68.00
$136.00
$204.00
$71.74
$71.74
$87.74
$87.74
$90.00
$107.00
$57.66
$57.66
$73.12
$73.12
$72.00
$72.00
$82.64
$128.02
$84.29
$130.58
$122.00
$187.00
ENDODONTICS
PULPOTOMY
Pulpotomy, Vital, Permanent Teeth (as
a Separate Emergency Procedure)
32221
Anterior and Bicuspid Teeth
32222
Molar Teeth
Pulpotomy, Vital, Primary Teeth
32231 Primary Tooth as a Separate Procedure
32232
Primary Tooth, Concurrent with
Restorations (but excluding final
restoration)
PULPECTOMY(as a Separate
Emergency)
32311
32312
January 2017
Pulpectomy, Permanent
Teeth/Retained Primary Teeth
One Canal
Two Canals
Nova Scotia Dental Program — Dentists Guide
Page 66
32313
32314
Three Canals
Four Canals or more
PA
PA
PA
PA
PA
PA
32321
32322
Pulpectomy, Primary Teeth
Anterior Tooth
Posterior Tooth
$75.00
$111.00
$84.29
$122.35
$77.00
$114.00
33111
33121
33131
33141
Root Canals, Permanent
Teeth/Retained Primary Teeth
One Canal
Two Canals
Three Canals
Four or more Canals
$326.42
$478.12
$642.19
$797.28
$399.57
$575.33
$785.99
$941.32
$362.00
$513.00
$668.00
$812.00
33401
33402
33403
Root Canals, Primary Teeth
One Canal
Two Canals
Three or more Canals
$123.10
$169.22
NA
$157.87
$209.18
$280.29
$153.00
$203.00
NA
33601
33602
33603
33604
Apexification/Apical closure/Induction
of Hard Tissue Repair
One Canal
Two Canals
Three Canals
Four or more Canals
$124.33
$164.62
$209.65
$376.64
$152.16
$219.58
$287.93
$433.93
$136.00
$179.00
$229.00
$409.00
33611
33612
33613
33614
Re-insertion of Dentogenic Media per
visit
One Canal
Two Canals
Three Canals
Four or more Canals
$55.42
$55.42
$55.42
$55.42
$65.32
$65.32
$65.32
$65.32
$57.00
$57.00
$57.00
$57.00
$170.50
$208.72
$204.00
ROOT CANAL THERAPY
(Includes: Clinical procedures with
appropriate radiographs, excluding final
restoration.)
APICOECTOMY/APICAL
CURETTAGE
34111
January 2017
Maxillary Anterior
One Root
Nova Scotia Dental Program — Dentists Guide
Page 67
34112
Two Roots
$243.61
$284.03
$292.00
34121
34122
34123
Maxillary Bicuspids
One Root
Two Roots
Three or more Roots
$228.00
$303.00
$379.00
$296.42
$353.90
$411.24
$233.00
$309.00
$383.00
34131
34132
34133
34134
Maxillary Molar
One Root
Two Roots
Three Roots
Four or more Roots
$242.26
$320.61
$382.63
$430.83
$296.42
$353.90
$431.81
$459.78
$261.00
$347.00
$438.00
IC
34141
34142
Mandibular Anterior
One Root
Two or more Roots
$170.50
$243.61
$208.72
$270.50
$203.00
$291.00
34151
34152
34153
Mandibular Bicuspid
One Root
Two Roots
Three or more Roots
$229.00
$303.00
$381.00
$296.42
$353.90
$411.24
$233.00
$309.00
$387.00
34161
34162
34163
Mandibular Molar
One Root
Two Roots
Three Roots
$242.26
$320.61
$382.63
$296.42
$353.90
$411.24
$288.00
$381.00
$480.00
3416
4
Four or more Roots
$430.83 $459.78
IC
RETROFILLING
34211
34212
Maxillary Anterior
One Canal
Two or more Canals
$67.78
$82.13
$82.96
$103.43
$77.00
$92.00
34221
34222
34223
34224
Maxillary Bicuspids
One Canal
Two Canals
Three Canals
Four or more Canals
$67.78
$82.13
$99.37
$111.40
$82.96
$103.43
$129.30
$145.44
$92.00
$115.00
$127.00
$137.00
34231
34232
34233
Maxillary Molar
One Canal
Two Canals
Three Canals
$69.73
$86.06
$99.37
$82.96
$103.43
$135.76
$112.00
$139.00
$153.00
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34234
Four or more Canals
$111.40
$145.44
$162.00
34241
34242
Mandibular Anterior
One Canal
Two or more Canals
$67.78
$82.13
$82.96
$103.43
$76.00
$92.00
34251
34252
34253
34254
Mandibular Bicuspids
One Canal
Two Canals
Three Canals
Four or more Canals
$67.78
$82.13
$99.37
$111.40
$82.96
$103.43
$129.30
$145.44
$91.00
$112.00
$125.00
$135.00
34261
34262
34263
34264
Mandibular Molars
One Canal
Two Canals
Three Canals
Four or more Canals
$69.73
$86.06
$99.37
$111.40
$82.96
$103.43
$129.30
$145.44
$112.00
$139.00
$153.00
$162.00
Open and Drain (Separate Emergency
Procedures)
39201
Anteriors and Bicuspids
39202
Molars
$66.00
$66.00
$71.47
$71.47
$67.00
$67.00
Opening Through Artificial Crown (In
addition to Procedures)
39211
Anterior and Bicuspids
39212
Molars
NA
$81.57
$83.20
$83.20
NA
$128.00
$53.81
$92.62
$131.41
$54.89
$94.47
$134.04
$65.00
$130.00
$195.00
$31.52
$63.03
$32.15
$64.29
$33.00
$66.00
BLEACHING, NON VITAL
DHW - Maximum of three units payable
per patient
39311
39312
39313
Bleaching Endodontically Treated
Tooth/ Teeth
One unit of time
Two units of time
Three units of time
PERIODONTAL SERVICES
Desensitization
41301
41302
DHW - Details as to rationale must
accompany claim.)
One unit of time
Two units
January 2017
Nova Scotia Dental Program — Dentists Guide
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41309
Each additional unit over two
$31.52
$32.15
$33.00
$38.95
$46.12
$65.00
$45.05
$45.05
$60.44
$60.44
$65.00
$65.00
$99.26
$132.55
NA
NA
$85.44
$60.44
$60.44
$60.44
$60.44
$60.44
$165.00
$220.00
NA
NA
$141.00
$342.90
$342.90
$430.37
$430.37
$480.00
$480.00
PERIODONTAL SPLINTING OR
LIGATION, PROVISIONAL, INTRA
CORONAL
"A" Splint (acrylic, composite or
amalgam, plus knurled wire)
Per Joint
43111
43211
43221
43231
43241
43251
43261
43271
Periodontal Splinting or Ligation,
Provisional, Extra Coronal
Acid Etch Joint Restorations - Per Joint
Acid Etch, Interproximal Enamel Splint Per Joint
Wire Ligation - Per Joint
Wire Ligation, Acrylic Covered - Per Joint
Dental Floss Ligation - Per Joint
Orthodontic Band Splint - Per Band
Cast/Soldered Splint Acid Etch/Resin
Bonded - Per Abutment + L
PROSTHETICS - REMOVABLE
Preamble - Cast Partials are not
insured services
DENTURES, PARTIAL, ACRYLIC, WITH
WROUGHT/CAST
CLASPS AND/OR RESTS
DHW - Payable only due to congenital
or accidental reasons
52301
52302
Maxillary + L
Mandibular + L
ORAL AND MAXILLOFACIAL
SURGERY
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Nova Scotia Dental Program — Dentists Guide
Page 70
SPECIAL NOTE: Certain procedures
included in this section are also
contained in the list of DHW Dental
Surgical Procedures covering all
eligible residents of the Province.
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 codes and fees
as shown in the Dental Surgical
Procedure Section.
PREAMBLE
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 two quadrants are
involved, the first two procedures will be
paid at 100% and the subsequent
procedures at 50%.
REMOVALS (EXTRACTIONS)
DHW: Extractions are insured only in
the case of : 1) unrestorable caries,
demonstrable pain, (excluding pain
associated with crowding), infection,
trauma, 2) ankylosis, 3)
supernumerary teeth.
71101
71109
Removals, Erupted Teeth
Uncomplicated
Single tooth, uncomplicated
Each additional tooth, same quadrant
Removals, Erupted Teeth Complicated
71201 Odontectomy, Erupted Tooth, Surgical
Approach
January 2017
$64.70
$43.35
$62.76
$33.00
$106.00
$71.00
$139.67
$169.98
$210.00
Nova Scotia Dental Program — Dentists Guide
Page 71
71209
Each additional tooth, same quadrant
$85.44
$85.00
$140.00
72111
72119
Removals, Impactions, Soft Tissue
Coverage
Single tooth
Each additional tooth, same quadrant
$139.67
$86.06
$169.98
$85.00
$210.00
$140.00
Removals, Impactions Involving Tissue
and/or Bone Coverage (including
removal of bone and tooth OR
sectioning and removal of tooth)
72211
Single tooth
$169.22
72219 Each additional tooth, same quadrant
$103.65
$280.09
$140.05
$253.00
$169.00
Removals, Impactions Involving Tissue
and/or Bone Coverage (including
removal of bone AND sectioning and
removal of tooth)
72221
Single tooth
$231.98
72229 Each additional tooth, same quadrant
$143.86
$311.48
$155.75
$350.00
$234.00
$51.29
$33.29
$62.76
$31.41
$82.00
$54.00
$96.13
$60.31
$117.67
$58.85
$148.00
$99.00
$199.93
$123.76
$244.66
$122.33
$303.00
$202.00
$71.74
$96.80
$117.00
$71.74
NA
$96.80
$96.80
$117.00
NA
72311
72319
Removals, (Extractions), Residual
Roots
First tooth
Each additional tooth, same quadrant
Removals, Residual Roots, Soft Tissue
Coverage
72321
First tooth
72329 Each additional tooth, same quadrant
72331
72339
Removals, Residual Roots. Bone
Tissue Coverage
First tooth
Each additional tooth, same quadrant
Surgical Incisions and Drainage and/or
Exploration, Intra-oral
75111
Intra-oral, Surgical Exploration, Soft
Tissue
75112
Intra-oral, Abscess, Soft Tissue
75113 Intra-oral, Abscess, in Major Anatomical
area with Drain
Replantation, Avulsed
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 72
Tooth/Teeth
76941
76949
DHW- includes splinting, root canal
and surgery
Replantation, first tooth
Each additional tooth
$207.31
$105.54
$215.35
$107.71
$343.00
$175.00
76951
76952
76959
Repositioning of Traumatically
Displaced Tooth
DHW - includes splinting
One unit of time
Two units of time
Each additional unit of time
$49.63
$99.26
$49.63
$47.23
$94.46
$47.23
$82.00
$164.00
$82.00
NA
$61.24
NA
NA
$61.24
NA
NA
$51.93
NA
NA
$51.93
NA
Hemorrhage, Control of
DHW - payable only if procedure
rendered by a dentist other than the
provider of the original service.
79403
Using Compression and Hemostatic
Agent
79404 Using Hemostatic Substance and Sutures
(incl. removal of bony tissue, if necessary)
Post-Surgical Care
DHW - payable only if procedure
rendered by a dentist other than the
provider of the original service.
79605 Post-Surgical Care, Alveolitis, Treatment
of (without anaesthesia)
79606 Post-Surgical Care, Alveolitis, Treatment
of (with anaesthesia)
DENTAL SURGICAL
PROGRAM
01601
Examination and Diagnosis, Surgical,
General
$61.15
DHW - In-Hospital Consult, payable
only when requested by a physician or
dentist, referral and details must be
provided on each claim.
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 73
94102
Hospital Admission
DHW - Admission to hospital where no
surgical treatment is rendered, details
must be provided on each claim.
94302
Hospital Visit
DHW - For non-surgical admitted
patients only. A maximum of 14 daily
visits are payable in connection with a
hospital admission. Notes on the
necessity of the visit must be provided
on each claim. If the patient, at any
time within the 14 days, becomes a
surgical patient, this service is no
longer payable.
$64.50
$36.27
ORAL AND MAXILLOFACIAL
SURGERY
REMOVALS (EXTRACTIONS)
71101
71109
Removals, Erupted Teeth,
Uncomplicated
Single tooth, uncomplicated
Each additional tooth, same quadrant
Removals, Erupted Teeth, Complicated
71201 Odontectomy, Erupted Tooth, Surgical
Approach, Requiring Surgical Flap and/or
Sectioning of Tooth
71209 Each additional Tooth, same quadrant
72111
72119
Removals, Impactions, Soft Tissue
Coverage
Single Tooth
Each additional Tooth, same quadrant
Removals, Impactions, Involving
Tissue and/or Bone Coverage
(including removal of bone and tooth
OR sectioning and removal of tooth)
72211
Single Tooth
72219 Each additional tooth, same quadrant
January 2017
$62.76
$33.00
$89.36
$44.71
$161.64
$80.82
$161.64
$80.82
Nova Scotia Dental Program — Dentists Guide
Page 74
Removals, Impaction, Requiring
Incision of Overlying Soft Tissue,
Elevation of a Flap, (including removal
of bone AND sectioning of the tooth for
removal)
72221
Single Tooth
72229 Each additional Tooth, same quadrant
$161.64
$80.82
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
First Tooth
72239 Each additional Tooth, same quadrant
$161.64
$80.82
72311
72319
Removals, Residual Roots, Erupted
First Tooth
Each additional tooth, same quadrant
Removals, Residual Roots, Soft Tissue
Coverage
72321
First Tooth
72329 Each additional tooth, same quadrant
$95.56
$47.78
$95.56
$47.78
72331
72339
Removals, Residual Roots. Bone
Tissue Coverage
First Tooth
Each additional tooth, same quadrant
$95.56
$47.78
72611
72619
Transplantation of Teeth
First Tooth
Each additional tooth
$312.48
$156.23
DHW - APICOECTOMY
34111
34112
Root Resection, Anterior Tooth
Root Resection, Posterior Tooth
$158.74
$238.09
REMODELING AND
RECONTOURING ORAL TISSUES
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 75
ALVEOLOPLASTY (Bone
remodeling of ridge with soft
tissue revisions)
DHW - Alveoloplasty will only be paid
as an independent procedure. If an
alveoloplasty is claimed with other
major services rendered in the same
sextant, it is not payable. If an
alveoloplasty is claimed with
extractions in the same sextant, only
the alveoloplasty will be paid.
73121 Alveoloplasty, Not in Conjunction with
Extractions - Per Sextant
$101.70
73141
73142
Remodeling of Bone
Mylohyoid Ridge Remodeling
Genial Tubercles Remodeling
$101.70
$101.70
73151
73152
73153
73154
Excision of Bone
Nasal Spine, Excision
Torus Palatinus, Excision
Torus Mandibularis, Unilateral, Excision
Torus Mandibularis, Bilateral, Excision
$152.56
$293.38
$217.61
$351.24
Removal of Bone, Exostosis, Multiple
73161
Per Quadrant
$152.56
73171
73172
Reduction of Bone Tuberosity
Unilateral, Reduction
Bilateral, Reduction
73173
Augmentation of Bone
73181 Unilateral, Pterygomaxillary Tuberosity,
Augmentation (+E - not payable by
DHW)
73182 Bilateral, Pterygomaxillary Tuberosity,
Augmentation (+E - not payable by
DHW)
73183
Unilateral, Mandibular Ridge,
Augmentation (+E - not payable by
DHW)
73184 Bilateral, Mandibular Ridge, Augmentation
(+E - not payable by DHW)
January 2017
$152.56
$228.83
$531.00
$1,053.00
$531.00
$1,061.00
Nova Scotia Dental Program — Dentists Guide
Page 76
GINGIVOPLASTY AND/OR
STOMATOPLASTY, ORAL
SURGERY
Independent Procedure
Per Sextant
73211
Miscellaneous Procedures
73222 Excision of Vestibular Hyperplasia (per
sextant)
73223 Surgical Shaving of Papillary Hyperplasia
of the Palate
73224
Excision of Pericoronal Gingiva (for
retained teeth) per tooth/implant
Removals, Tissue, Hyperplastic
73231 Tissue, Hyperplastic (includes the incision
of the mucous membrane, the dissection
and removal of hyperplastic tissue, the
replacing and adapting of the mucous
membrane) - Per sextant
73241
Mucosa, Excess (complete removal
without dissection) - Per sextant
Remodeling, Floor Of The Mouth
73301 Full Arch Lowering of the Floor of the
Mouth
73302 Partial Arch Lowering of the Floor of the
Mouth
73303
Reinsertion of the Mylohyoid Muscle
73411
73421
73431
73441
73451
73461
Vestibuloplasty
Sub-mucous - Per Sextant
Sulcus Deepening and Ridge
Reconstruction - Per sextant
With Secondary Epithelialization - Per
sextant
With Labial Inverted Flap - Per Sextant
With Skin Graft - Per Sextant
With Mucosal Graft - Per Sextant
$93.40
$140.05
$210.08
$140.05
$93.40
$93.40
$572.92
$572.92
$572.92
$151.52
$151.52
$151.52
$190.98
$190.98
$190.98
Reconstruction, Alveolar Ridge
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 77
73511 With Autogenous Bone - Per Sextant (+E
- not payable by DHW)
73521 With Alloplastic Material - Per Sextant (+E
- not payable by DHW)
73611
73621
73631
Extensions, Mucous Folds
With Secondary Epithelialization - Per
Sextant
With Skin Grafts - Per Sextant
With Mucous Grafts - Per Sextant
$312.53
$156.26
$190.98
$190.98
$190.98
SURGICAL EXCISION
74111
74112
74113
74114
74115
74116
74117
74118
74121
74122
74123
74124
74125
74126
74127
74128
Tumors, Benign, Scar Tissue,
Inflammatory or Congenital Lesions of
Soft Tissue of the Oral Cavity
1 cm and under
1 - 2 cm
2 - 3 cm
3 - 4 cm
4 - 6 cm
6 - 9 cm
9 - 15 cm
15 cm and over (DHW - complicated - by
report)
Tumors, Benign, Bone Tissue
1 cm and under
1 - 2 cm
2 - 3 cm
3 - 4 cm.
4 - 6 cm
6 - 9 cm
9 - 15 cm
15 cm and over (DHW - complicated - by
report)
Tumors, Malignant, Soft Tissue, Oral
Cavity
74211
1 cm and under
74212
1 - 2 cm
74213
2 - 3 cm
January 2017
$130.43
$130.43
$130.43
$325.81
$325.81
$325.81
$511.53
$511.53
$157.82
$157.82
$157.82
$294.98
$394.98
$394.98
$620.16
$620.16
$130.43
$130.43
$130.43
Nova Scotia Dental Program — Dentists Guide
Page 78
74214
3 - 4 cm
74215
4 - 6 cm
74216
6 - 9 cm
74217
9 - 15 cm
74218 15 cm and over (DHW - complicated - by
report)
74221
74222
74223
74224
74225
74226
74227
74228
Tumors, Malignant, Bone Tissue
1 cm and under
1 - 2 cm
2 - 3 cm
3 - 4 cm
4 - 6 cm
6 - 9 cm
9 - 15 cm
15 cm and over (DHW - complicated - by
report)
Cheiloplasty (Lip Shave)
Cheiloplasty, Partial
Cheiloplasty, Total
74301
74302
$325.81
$325.81
$325.81
$511.53
$511.53
$157.82
$157.82
$157.82
$394.98
$394.98
$394.98
$620.16
$620.16
$53.74
$161.27
Enucleation of Cyst/Granuloma,
Odontogenic and Non-Odontogenic
74611
1 cm and under
74612
1 - 2 cm
74613
2 - 3 cm
74614
3 - 4 cm
74615
4 - 6 cm
74616
6 - 9 cm
74617
9 - 15 cm
74618 15 cm and over (DHW - complicated - by
report)
$150.21
$150.21
$150.21
$150.21
$187.69
$187.69
$187.69
$294.64
74621
Marsupialization
Cyst, Marsupialization
$161.27
74631
74632
Excision of Cyst
1 cm and under
1 - 2 cm
$150.21
$150.21
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 79
74633
2 - 3 cm
74634
3 - 4 cm
74635
4 - 6 cm
74636
6 - 9 cm
74637
9 - 15 cm
74638 15 cm and over (DHW - complicated - by
report)
Surgical Incision and Drainage and/or
Exploration, Intra-Oral Soft Tissue
75111
Intra-oral, Surgical Exploration, Soft
Tissue
75112
Intra-oral, Abscess, Soft Tissue
75113 Intra-oral, Abscess, In Major Anatomical
Area with Drain
Surgical Incision and Drainage and/or
Exploration, Intra-Oral Hard Tissue
75121
Intra-oral, Abscess, Hard Tissue,
Trephination and Drainage
75122
Intra-oral, Surgical Exploration, Hard
Tissue
75123
Intra-oral, Abscess, Hard Tissue,
Trephination and Drainage in Major
Anatomical Area
Surgical Incision and Drainage and/or
Exploration, Extra-oral, Soft Tissue
75211
Extra-oral, Abscess, Superficial
75212
Extra-oral, Abscess, Deep
Surgical Incision and Drainage and/or
Exploration, Extra-oral, Hard Tissue
75221 Extra-oral, Surgical Exploration, Hard
Tissue
Surgical Incision For Removal of
Foreign Bodies
75301
Removal from Skin or Subcutaneous
Areolar Tissue
75302 Removal of Reaction Producing Foreign
Bodies
75303 Removal of Needle from Musculoskeletal
System
January 2017
$150.21
$150.21
$187.69
$187.69
$187.69
$294.64
$62.93
$62.93
$62.93
$81.55
$81.55
$81.55
$125.74
$125.74
$152.12
$140.05
$140.05
$152.56
Nova Scotia Dental Program — Dentists Guide
Page 80
Sequestrectomy (For Osteomyelitis)
75401
Intra-oral Sequestrotomy
75402
Saucerization
75403 Osteomyelitis, Non Surgical Treatment of
$236.14
$236.14
$86.24
75411
75412
75413
75414
75415
Extra-oral Sequestrotomy
3 cm and less
3 - 4 cm
4 - 6 cm
6 - 9 cm
9 cm and over
$314.83
$314.83
$472.28
$472.28
$472.28
75511
75512
75513
75514
75515
75516
75517
75518
Mandibulectomy
3 cm and less
3 - 4 cm
4 - 6 cm
6 - 9 cm
9 - 12 cm
12 - 15 cm
15 cm and over
Total Mandibulectomy
$615.51
$615.51
$615.51
$615.51
$615.51
$615.51
$966.32
$1,600.86
75611
75612
75613
75614
75615
75616
75617
75618
Maxillectomy
3 cm and less
3 - 4 cm
4 - 6 cm
6 - 9 cm
9 - 12 cm
12 - 15 cm
15 cm and over
Total Maxillectomy
$615.51
$615.51
$615.51
$615.51
$615.51
$615.51
$966.32
$1,600.86
FRACTURES, TREATMENT OF
76201
76202
76203
76204
Fractures, Reductions, Mandibular
Reduction, Mandibular, Closed
Reduction, Mandibular, Open, Simple
Reduction, Mandibular, Open, Double
Reduction, Mandibular, Open, Multiple
January 2017
$314.83
$550.89
$826.32
$1,101.73
Nova Scotia Dental Program — Dentists Guide
Page 81
76301
76302
76303
76304
76305
76401
76402
76403
Fractures, Reductions, Maxillary,
Horizontal, LeForte I
Reduction, Maxillary, Closed
Reduction, Maxillary, Open, Unilateral
Reduction, Maxillary, Open Double
Reduction, Maxillary, Open Multiple
Reduction, Compound Fracture of Maxilla
(requiring reduction and soft tissue repair)
Fractures, Reductions, Maxilla,
Pyramidal, LeForte II
Reduction, Maxillary, Closed
Reduction, Maxillary, Open, Unilateral
Reduction, Maxillary, Open, Bilateral
Fractures, Reductions, Naso-Orbital
76501
Reduction, Unilateral
76502
Reduction, Bilateral
76503 Reduction, Naso-orbital, Open, External
Approach
76504 Reduction, Naso-orbital, Open, Sinusal
Approach
76505 Reduction, Naso-orbital, Open, Orbital
Approach with Insertion of Subperiosteal
Implant
76506 Exploration of Orbital Blow-out Fracture
76507 Exploration of Orbital Blow-out Fracture
and Reconstruction with Insertion of a
Subperiosteal Implant
76601
76602
76603
76604
76605
Fractures, Reductions, Malar Bone
Reduction, Malar Bone, Closed
Reduction, Malar Bone, Open by Simple
Elevation
Reduction, Malar Bone, Open by
Osteosynthesis
Reduction, Malar Bone, Open by Sinus
Approach
Reduction, Malar Bone, Simple Fracture
(open reduction with antrostomy and
packing)
January 2017
$314.83
$550.89
$826.32
$1,101.73
$629.70
$314.83
$629.70
$629.70
$944.51
$944.51
$944.51
$944.51
$944.51
$944.51
$944.51
$157.49
$157.49
$314.83
$472.28
$472.28
Nova Scotia Dental Program — Dentists Guide
Page 82
76701
76702
76703
76704
Fractures, Reductions, Zygomatic Arch
Reduction, Zygomatic Arch, Intra-Oral
Approach
Reduction, Zygomatic Arch, Temporal
Approach
Reduction, Zygomatic - Maxillary Fracture
Dislocation, Complex. Closed Reduction
Reduction, Zygomatic - Maxillary Fracture
Dislocation, Opened Reduction
$157.49
$157.49
$314.83
$472.28
Fractures, Reductions, Craniofacial
Dysfunction, LeForte III Transverse
(specify type of procedure according to
previous code used for fracture)
76801
Closed
76802
Open
$944.51
$944.51
Fracture, Alveolar, Debridement, Teeth
Removed
76911
3 cm or less
76912
3 - 6 cm
76913
6 cm and over
$175.45
$175.45
$314.83
Reduction, Alveolar, Closed, with Teeth
(fixation extra) - not payable by DHW)
76921
3 cm or less
76922
3 - 6 cm
76923
6 - 9 cm
76924
9 cm and over
$175.45
$175.45
$314.83
$314.83
76931
76932
76933
76934
Reduction, Alveolar, Open, with Teeth
(fixation extra) - not payable by DHW)
3 cm or less
3 - 6 cm
6 - 9 cm
9 cm and over
$314.83
$314.83
$550.89
$550.89
76941
76949
Replantation, Avulsed Tooth/Teeth
(including splinting)
Replantation, first tooth
Each additional tooth
$89.36
$44.71
Repositioning of Traumatically
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 83
76951
76952
76959
Displaced Teeth
One unit of time
Two units of time
Each additional unit over two
$47.23
$94.46
$47.23
76961
76962
76963
76964
76965
76966
76967
76968
76969
Repairs, Lacerations, Uncomplicated,
Intra-oral or Extra-oral
2 cm or less
2 - 4 cm
4 - 6 cm
6 - 9 cm
9 - 12 cm
12 - 16 cm
16 - 20 cm
20 - 25 cm
25 cm and over
$62.93
$62.93
$62.93
$62.93
$62.93
$153.38
$153.38
$153.38
$153.38
76971
76972
76973
76974
76975
76976
76977
76978
76979
Repairs, Laceration, Through and
Through
2 cm or less
2 - 4 cm
4 - 6 cm
6 - 9 cm
9 - 12 cm
12 - 16 cm
16 - 20 cm
20 - 25 cm
25 cm and over
$157.49
$157.49
$157.49
$258.04
$258.04
$258.04
$258.04
$258.04
$258.04
76981
76982
76983
76984
76985
76986
76987
76988
76989
Repairs, Lacerations, Complicated
(local tissue shifts)
2 cm or less
2 - 4 cm
4 - 6 cm
6 - 9 cm
9 - 12 cm
12 - 16 cm
16 - 20 cm
20 - 25 cm
25 cm and over
$157.49
$157.49
$157.49
$258.04
$258.04
$258.04
$258.04
$258.04
$258.04
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 84
MAXILLOFACIAL DEFORMITIES,
TREATMENT OF
Osteotomy/Ostectomy, Ramus of the
Mandible
77101
Osteotomy, Subcondylar, Closed
77102
Osteotomy, Subcondylar, Open
77103
Osteotomy, Ramus of the Mandible,
Oblique, Extra-oral
77104
Osteotomy, Ramus of the Mandible,
Oblique, Intra-oral
77105
Osteotomy/Ostectomy, Body of the
Mandible
77106
Osteotomy, Coronoidectomy
77107
Osteotomy, Condylar Neck
77108 Osteotomy, Sagittal Split (DHW - Applies
to Bilateral Procedures)
77201
77202
77203
77301
77302
77303
77304
77305
77306
77307
77308
77309
77311
77312
Osteotomy, Miscellaneous
Osteotomy, Oblique with Bone Graft
Osteotomy, Inverted "L"
Osteotomy, "C"
Osteotomy, Maxilla
Osteotomy, Maxilla, Total
Osteotomy, Maxilla, Total with Bone Graft
Osteotomy, Maxilla, Leforte II with Bone
Graft
Osteotomy, Maxilla, Leforte III
Additional to the Above Osteotomy
Requiring Three Segments
Additional to the Above Osteotomy
Requiring Four Segments
Additional to the Above Osteotomy
Requiring a Cranial Flap
Closure of Cleft Fistula (alveolar)
Closure of Cleft Fistula (palatal)
Pharyngoplasty
Submucous Resection
January 2017
$551.03
$1,333.93
$1,333.93
$1,333.93
$1,333.93
$1,333.93
$1,333.93
$1,333.93
$1,600.86
$1,333.93
$1,333.93
$1,333.93
$1,600.86
$1,333.93
$1,600.86
$73.04
$109.56
$146.07
$479.88
$640.19
$384.18
$256.09
Nova Scotia Dental Program — Dentists Guide
Page 85
77411
77412
77413
77414
77421
77422
77423
77424
77425
Osteotomy, Segmental, Maxilla
Osteotomy, Segmental, Anterior
Osteotomy, Segmental, Posterior
Osteotomy, Midpalatal Split, Anterior
Osteotomy, Midpalatal Split, Complete
Osteotomy, Segmental, Mandible
Osteotomy, Segmental, Anterior with
Transfer of Mental Eminence
Osteotomy, Segmental, Anterior without
Transfer of Mental Eminence
Osteotomy, Segmental, Posterior
Osteotomy, Lower Border, Mandible
Osteotomy, Total Dento-Alveolar,
Mandible
Genioplasty
77501
Genioplasty, Sliding, Reduction or
Augmentation
77502
Genioplasty, Reduction (vertical)
77503 Genioplasty, Augmentation with Graft (see
grafting codes)
77504
Myotomy, Suprahyoid
Miscellaneous Treatment of
Maxillofacial Deformities
Corticotomy
Interdental Septotomy
Surgical Expansion of the Palate
77601
77602
77603
77701
77702
77703
77704
77705
77901
Palatorrhaphy
Palatorrhaphy, Anterior (closure of
palatine fissure)
Palatorrhaphy, Posterior
Palatorrhaphy, Total
Palatorrhaphy, with Bone Graft
Palatorrhaphy, Bone Graft to Anterior
Alveolar Ridge
Glossectomy
Glossectomy, Partial, Anterior Wedge
January 2017
$968.89
$968.89
$968.89
$968.89
$968.89
$968.89
$968.89
$968.89
$968.89
$968.89
$968.89
$968.89
$968.89
$152.56
$152.56
$968.89
$810.00
$810.00
$968.89
$968.89
$968.89
$325.81
Nova Scotia Dental Program — Dentists Guide
Page 86
77902
77903
Glossectomy, Partial, for Orthodontic
Purposes
Glossectomy, Full Posterio-Anterior
Wedge
$325.81
$325.81
77911
77912
77913
77914
77917
Cleft Surgery
Primary Unilateral Cleft Lip Repair
Secondary Unilateral Cleft Lip Repair
Primary Bilateral Cleft Lip Repair
Secondary Bilateral Cleft Lip Repair
Closure of Alveolar Cleft
$937.55
$937.55
$1,406.30
$1,406.30
$937.55
77921
77922
77923
77924
77925
Oral Nasal Fistula
Primary Closure at time of Initial Surgery
Secondary Closure with Palatal Flap
Secondary Closure with Pharyngeal Flap
Secondary Closure with Tongue Flap
Secondary Closure with Buccal Flap
$625.10
$625.10
$625.10
$625.10
$625.10
78106
Temporomandibular Joint, Dislocation,
Management of
TMJ, Dislocation, Open Reduction
TMJ, Dislocation, Closed Reduction
Uncomplicated
TMJ, Dislocation, Closed Reduction
Under General Anaesthetic
TMJ, Luxation, Reduction without
Anaesthesia
TMJ, Luxation, Reduction with
Anaesthesia
TMJ, Manipulation, under Anaesthesia
78201
78202
78203
78204
78205
78206
78207
78208
Temporomandibular Joint, Capsule,
Management of
Condyloplasty
Condylotomy
Condylectomy
Eminoplasty
Re-contour of Glenoid Fossa
Menisectomy
Plication of Meniscus
Repair of Meniscus
78101
78102
78103
78104
78105
January 2017
$393.64
$47.23
$47.23
$47.23
$47.23
$47.23
$472.28
$472.28
$472.28
$416.67
$416.67
$625.10
$833.57
$833.57
Nova Scotia Dental Program — Dentists Guide
Page 87
78209
Replacement of Meniscus
Temporomandibular Joint, Arthrotomy
for Major Reconstruction
78301
Fossa Replacement
78302
Condylar Replacement
78303
Gap Arthroplasty for Ankylosis
$833.57
$916.83
$916.83
$916.83
78501
78502
78509
Temporomandibular Joint,
Arthrocentesis (puncture and
aspiration)
One unit of time
Two units of time
Each additional unit over two
$78.74
$157.48
$78.74
78601
78602
Temporomandibular Joint,
Management by Injections
Injection, with Anti-Inflammatory Drugs
Injection with Sclerosing Agents
$78.74
$78.74
79103
79104
Salivary Glands, Treatment of
Salivary Duct, Dilation of
Salivary Duct, Insertion of Polyethylene
Tube
Salivary Duct, Sialodochoplasty
Salivary Duct, Reconstruction of
$322.53
$322.53
79111
79112
79113
Salivary Duct, Sialolithotomy
Sialolithotomy, Anterior 1/3 of Canal
Sialolithotomy, Posterior 2/3 of Canal
Sialolithotomy, External Approach
$94.46
$283.32
$377.68
79121
79122
79123
79124
79125
Salivary Gland, Excisions
Excision of Submaxillary Gland.
Excision of Sublingual Gland
Excision of Mucocele
Excision of Ranula
Marsupialization of Ranula
$377.68
$377.68
$145.24
$188.99
$188.99
79131
Salivary Gland, Removal
Salivary Gland, Removal, Parotid (sub-
$566.77
79101
79102
January 2017
$26.87
$27.45
Nova Scotia Dental Program — Dentists Guide
Page 88
total)
79132 Salivary Gland, Removal, Parotid (radical,
including facial nerve)
79211
79212
79213
79214
79215
79217
79218
Neurological Disturbances, Trigeminal
Nerve
Trigeminal Nerve, Injection for Destruction
Trigeminal Nerve, Avulsion at Periphery
Trigeminal Nerve, Total Avulsion of a
Branch
Trigeminal Nerve, Alcoholization of a
Branch
Trigeminal Nerve, Infiltration of a Branch
for Diagnosis
Trigeminal Nerve, Neurolysis or tumor
excision of trigeminal nerve branch in soft
tissue
Trigeminal Nerve, Neurolysis or tumor
excision of trigeminal nerve branch in
bone
(mandible, maxilla or orbit - not to include
osteotomy)
Neurological Disturbances, Inferior
Dental Nerve
79231 Inferior Dental Nerve, Complete Avulsio.
79232 Inferior Dental Nerve, Decompression in
the Canal
79246
79311
79312
79313
79314
Neurological Disturbances, Surgery
Excision of Tumor or Neuroma
Antral Surgery, Recovery, Foreign
Bodies
Antral Surgery, Immediate Recovery of a
Dental Root or Foreign Body from the
Antrum
Antral Surgery, Immediate Closure of
Antrum by Another Dental Surgeon
Antral Surgery, Delayed Recovery of a
Dental Root with Oral Antrostomy
Antral Surgery with Nasal Antrostomy
$755.67
$78.74
$312.77
$312.77
$78.74
$78.74
$312.77
$312.77
$312.77
$312.77
$312.77
$188.99
$152.56
$472.28
$472.28
Antral Surgery, Oro-Antral Fistula
Closure (same session)
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 89
79331
Oro-Antral Fistula Closure with Buccal
Flap.
79332 Oro-Antral Fistula Closure with Gold Plate
79333 Oro-Antral Fistula Closure with Palatal
Flap.
Antral Surgery, Oro-Antral Fistula
Closure (subsequent session)
79341 Oro-Antral Fistula Closure with Buccal
Flap
79342 Oro-Antral Fistula Closure with Gold Plate
79343 Oro-Antral Fistula Closure with Palatal
Flap .
$472.28
$472.28
$472.28
$472.28
$472.28
$472.28
HEMORRHAGE, CONTROL OF
(DHW - payable if procedure rendered
by dentist other than the provider of
original service)
79403 Hemorrhage Control, using Compression
and Hemostatic Agent
79404 Hemorrhage Control, using Hemostatic
Substance and Sutures
$50.98
$50.98
POST-SURGICAL CARE (Required by
complications and unusual
circumstances.)
DHW - excludes alveolitis, details must
accompany claim
79602 Post-Surgical Care, Minor, by Other than
Treating Dentist
$50.84
EMERGENCY OFFICE
PROCEDURES - DHW - Details
must accompany claim
79701
79702
Emergency Procedure, Tracheotomy
Emergency Procedure, CricoThyroidotomy
January 2017
Nova Scotia Dental Program — Dentists Guide
IC
IC
Page 90
CLEFT PALATE PROGRAM
01101
01102
01103
01201
01202
01204
Examination and Diagnosis
Complete, Primary Dentition
Complete, Mixed Dentition
Complete, Permanent Dentition
Limited, Oral, New Patient Examination
Limited, Oral, Previous Patient (recall)
Specific Examination,
$39.00
$39.00
$65.45
$28.91
$22.08
$34.51
$50.37
$50.37
$73.04
$35.49
$27.97
$46.94
01205
DHW - includes x-rays required to
assist in the diagnosis, details must
accompany claim
Emergency Examination
$34.51
$46.94
NA
NA
NA
$77.91
$148.00
$74.00
DHW -includes x-rays required to
assist in the diagnosis, details must
accompany claim
CONSULTATION
DHW - Specialist- In office (DHW details must accompany claim)
05201
05202
05209
One unit of time
Two units of time
Each additional unit of time
RADIOGRAPHS (including
radiographic examination and
interpretation)
PREAMBLE
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.
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 91
All x-rays are to be made available to the
Plan upon request and therefore should
be retained for five (5) years following the
service.
Radiographs, Intra-oral
02101 Pedodontic, Complete Series (minimum of
12 films incl. Bitewings)
02102 Adult, Complete Series (minimum of 16
films incl. Bitewings)
$99.97
$101.97
$99.97
$101.97
02111
02112
02113
02114
02115
02116
02117
02118
02119
02120
02121
02122
02123
02124
02125
Radiographs, Intra-Oral, Periapical
Single film
Two films
Three films
Four films
Five films
Six films
Seven films
Eight films
Nine films
Ten films
Eleven films
Twelve films
Thirteen films
Fourteen films
Fifteen films
$12.26
$16.10
$23.68
$28.29
$32.89
$37.63
$42.16
$46.84
$51.44
$56.12
$61.17
$66.65
$72.66
$79.19
$83.93
$12.51
$16.42
$24.15
$28.86
$33.55
$38.38
$43.00
$47.78
$52.47
$57.24
$62.39
$67.98
$74.11
$80.77
$85.61
02131
02132
02133
02134
Radiographs, Intra-oral, Occlusal
Single film
Two films
Three films
Four films
$29.97
$46.84
$63.70
$80.50
$30.57
$47.78
$58.00
$70.00
02141
02142
02143
02144
Radiographs, Intra-oral, Bitewing
Single film
Two films
Three films
Four films
$12.26
$16.10
$23.68
$28.29
$12.51
$16.42
$24.15
$28.86
Radiographs, Extra-oral
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 92
02201
02202
02203
02204
Single film
Two films
Three films
Four films
$29.97
$46.84
$63.70
$80.50
$30.57
$47.78
$64.97
$82.11
02301
02302
02303
02304
Radiographs, Posterio-Anterior and
Lateral Skull and Facial Bone
Single film
Two films
Three films
Sinus Examination - Maximum four films
identified as: (1) Waters (2) Calwell (3)
Lateral Skull (4) Basal
PA
PA
PA
PA
$30.57
$47.78
$64.97
$82.11
02401
02402
02409
Radiographs, Sialography
Single film
Two films
Each additional film
PA
PA
PA
PA
PA
PA
02411
02412
02419
Radiopaque Dyes, Use of, To
Demonstrate Lesions
One unit of time
Two units of time
Each additional unit over two
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
$30.57
$47.78
$64.97
$82.11
PA
PA
02509
Radiographs, Temporomandibular
Joint
Single film
Two films
Three films
Four films (minimum examination closed
and open each side)
Each additional film
02601
Radiographs, Panoramic
Single film
$51.51
$52.54
02701
02702
Radiographs, Cephalometric
Single film
Two films
$51.51
$83.87
$52.54
$85.55
02501
02502
02503
02504
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 93
02751
02752
02759
02801
02921
Radiographs, Cephalometric, Tracing
and Interpretation
One unit of time
Two units of time
Each additional unit over two
Radiographs, Interpretation
DHW - For radiographs exposed on
hospital equipment
DHW - Paid at one-half regular fee
Radiographs, Hand and Wrist
Radiographs, Hand and Wrist (as a
duplicate aid for dental treatment) per
case
Radiographs, Tomography
Single view
Two views
Three views
Four views
Each additional view over four
02931
02932
02933
02934
02939
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
TESTS AND LABORATORY
EXAMINATIONS
PREAMBLE
a) 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.
b) 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.
c) Diagnostic casts are to be available
to the Plan upon request and
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 94
accordingly, should
be retained for a period of five (5) years
following the service.
Microbiological
04101 Microbiological Test for the Determination
of Pathological Agents + L
$30.97
$31.59
Caries Susceptibility
04201 Bacteriological Test for the Determination
of Dental Caries Susceptibility + L
$30.29
$30.90
Test, Histological, Soft Tissue
04311 Biopsy, Soft Oral Tissue - by Puncture + L
04312 Biopsy, Soft Oral Tissue - by Incision + L
04313 Biopsy, Soft Oral Tissue - by Aspiration +
L
$72.36
$72.36
$72.36
$73.81
$73.81
$73.81
$83.33
$85.00
$83.33
$83.33
$85.00
$85.00
$30.29
$30.90
$25.61
$25.61
$26.12
$26.12
PA
PA
PA
PA
PA
PA
PA
PA
Test, Histological, Hard Tissue
04321 Biopsy, Hard Oral Tissue - by Puncture +
L
04322 Biopsy, Hard Oral Tissue - by Incision + L
04323 Biopsy, Hard Oral Tissue - by Aspiration +
L
Cytological
04401 Cytological Smear from the Oral Cavity +
L
04501
04509
Pulp Vitality
One unit of time
Each additional unit of time
Reports, Laboratory
Report, Microbiological by Oral
Microbiologist
04602 Report, Histological by Oral Pathologist
04603 Report, Cytological by Oral Pathologist
04604
Reports, Other
04601
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 95
TESTS AND LABORATORY
EXAMINATIONS,
MISCELLANEOUS
(All available by preauthorization)
04711
04712
04713
04714
04719
Equilibration, Casts, Diagnostic (pilot
equilibration) for extensive or
complicated restorative dentistry + L
One unit of time
Two units of time
Three units of time
Four units of time
Each additional unit over four
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
04721
04722
04723
04724
04729
Wax-up, Diagnostic (to evaluate
cosmetic and/or preparation design
and/or occlusal consideration)
(gnathological wax-up) + L
One unit of time
Two units of time
Three units of time
Four units of time
Five units of time
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
04731
04732
04733
04734
04739
Split Cast Mounting, Diagnostic + L
One unit of time
Two units of time
Three units of time
Four units of time
Five units of time
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
$15.88
$31.74
$47.63
$15.88
$16.20
$32.00
$37.00
$7.00
Interpretation of Models from Another
Source
04741
First unit of time
04749
Each additional unit of time
04801
04802
04803
04809
January 2017
Photographs, Diagnostic
Single Photograph
Two Photographs
Three Photographs
Each additional Photo over three
Nova Scotia Dental Program — Dentists Guide
Page 96
Casts, Diagnostic, Unmounted
04911
Casts, Diagnostic, Unmounted + L
04912 Casts, Diagnostic, Unmounted, Duplicate
+L
04921
04922
04923
04924
Casts, Diagnostic, Mounted
Casts, Diagnostic, Mounted + L
Casts, Diagnostic, Mounted using face
bow transfer + L
Casts, Diagnostic, Mounted using face
bow + occlusal records + L
Casts, Diagnostic, Mounted using fully
adjustable articulator + L (used with
04942)
Casts, Diagnostic, Orthodontic
04931
Casts, Diagnostic Orthodontic
(unmounted, angle trimmed and shaped)
+L
$30.97
$43.45
PA
PA
$39.00
$64.00
PA
PA
$87.14
PA
PA
PA
PA
$43.45
$30.29
$60.56
$30.90
$61.77
PREVENTIVE SERVICES
Any procedure carried out by an auxiliary
is paid at the General Practitioner level.
To qualify for specialists fee, procedure
must be carried out personally by the
specialist on a properly referred patient.
The fees for preventive services assume a
one-to-one relationship between patient
and dentist. Where service is provided to
a group at the same time, only one fee is
allowed.
DHW - Caries Prevention Service
(13211) - allowed once in a 12 month
period.
DHW - Nutritional Dietary Counselling
(13101) - a series of four (4)
appointments is allowed once per
lifetime of the patient.
POLISHING - PLEASE SEE BELOW
CARIES PREVENTION SERVICE
11111
11112
January 2017
Scaling
One unit of time
Two units of time
Nova Scotia Dental Program — Dentists Guide
Page 97
11113
11114
11115
11116
11117
11119
Three units of time
Four units of time
Five units of time
Six units of time
One-half unit of time
Each additional unit of time
$90.82
$121.10
$151.46
$181.43
$15.14
$30.29
$92.64
$123.52
$154.49
$185.06
$15.44
$30.90
Fluoride Treatments
12101 Fluoride Treatment, Topical Application
$15.00
$16.14
NUTRITIONAL COUNSELLING
Including: recording and analysis of seven
day dietary intake and consultation
DHW - a series of four (4) appointments
is allowed once per lifetime of the
patient
13101
One unit of time
$25.00
$30.90
Oral Hygiene Instruction/Plaque
Control to include: brushing and/or
flossing and /or embrasure cleaning,
includes for DHW program rubber cap
polishing and minor scaling procedures.
13211
One unit of time
$30.29
$30.90
Sealants, Pit and Fissure (acid etch
preparation included)
(DHW- Limited to six year molars that
meet guidelines - one application per
tooth per year)
13401
Each Tooth
$20.00
$28.15
Disking of Teeth, Interproximal (DHW Maximum Three Units Per Lifetime)
16201
One unit of time
16202
Two units of time
16203
Three units of time
$53.81
$107.65
$161.45
$54.89
$109.80
$164.68
CARIES PREVENTION SERVICE DHW
Recontouring of Teeth for Functional
Reasons
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 98
16301
16309
One unit of time
Each additional unit of time
Space Maintainers (Includes the design,
separation, fabrication, insertion and
where applicable initial cementation and
removal)
15101 Space Maintainer, Band Type, Fixed,
Unilateral + L
15103 Space Maintainer, Band Type, Fixed,
Bilateral (soldered lingual arch) + L
15105 Space Maintainer, Band Type, Fixed,
Bilateral Tubes and Locking Wires + L
Space Maintainers, Stainless Steel
Crown Type
15201 Space Maintainer, Stainless Steel Crown
Type, Fixed, + L
Space Maintainers, Maintenance of
15601
Maintenance, Space Maintainer
Appliance, to include adjustment and/or
recementation after 30 days from insertion
PA
PA
PA
PA
$124.33
$169.60
$149.00
$258.04
$181.00
$282.20
$160.00
$196.43
$53.00
$59.28
RESTORATIVE SERVICES
PREAMBLE
DHW NOTE:
The stipulated fees include pulp protection
and local anaesthesia.
Where at the same sitting, in order to
conserve tooth structure, two separate
restorations are performed, on the same
tooth involving a common surface, when
one restoration might have been done,
this should be considered as one
restoration in assessing the fee.
Additional or similar restorative work done
on the same tooth within four months of
the original service requires an
explanation on the claim.
Where adjacent surfaces of a tooth are
filled at the same appointment, the fee will
be at the appropriate level for multiple
surfaces, as listed below. In cases of
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 99
tooth-coloured etched/bonded restoration,
if the above conditions exist, they will be
paid at the complex level.
The replacement of an existing amalgam
restoration with tooth-coloured
etched/bonded restorations shall be an
insured service only where the amalgam
restoration has been fractured and /or
there is recurrent caries.
Stainless Steel Crowns - One hundred
percent (100%) of the dental tariff shall
apply to each of the first three stainless
steel crowns performed at one sitting for a
patient under general anaesthesia; 50% of
the dental tariff shall apply 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 four or more stainless steel
crowns done at the same sitting for a
patient under general anaesthesia. Such
requests must be accompanied by
necessary x-rays.
CARIES, TRAUMA AND PAIN
CONTROL
DHW- Permanent Teeth Only
20111
20121
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) - First Tooth
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) - First Tooth
January 2017
$61.86
$75.79
$84.00
$85.68
Nova Scotia Dental Program — Dentists Guide
Page 100
20131 Trauma Control, Smoothing of Fractured
Surfaces - First Tooth
$32.00
$37.00
21111
21112
21113
21114
21115
Non-Bonded, Primary Teeth
One Surface
Two Surfaces
Three Surfaces
Four Surfaces
Five Surfaces or maximum surfaces per
tooth
$43.97
$58.98
$67.77
$85.51
$107.63
$50.09
$72.55
$82.98
$104.47
$131.72
21121
21122
21123
21124
21125
Bonded, Primary Teeth
One Surface
Two Surfaces
Three Surfaces
Four Surfaces
Five Surfaces or maximum surfaces per
tooth
$45.23
$58.98
$67.77
$85.51
$107.63
$50.09
$72.55
$82.98
$104.47
$131.72
$53.06
$79.61
$100.19
$129.66
$159.19
$64.82
$96.82
$122.00
$164.64
$193.85
$60.94
$86.56
$113.43
$156.19
$207.84
$70.91
$105.63
$138.00
$191.32
$250.00
$62.82
$79.61
$64.82
$96.82
RESTORATIONS, AMALGAM
21211
21212
21213
21214
21215
21221
21222
21223
21224
21225
Non-Bonded, Permanent Bicuspids
and Anteriors
One Surface
Two Surfaces
Three Surfaces
Four Surfaces
Five Surfaces or maximum surfaces per
tooth
Non-Bonded, Permanent Molars
One Surface
Two Surfaces
Three Surfaces
Four Surfaces
Five Surfaces or maximum surfaces per
tooth
21231
21232
January 2017
Bonded, Permanent Bicuspids
One Surface
Two Surfaces
Nova Scotia Dental Program — Dentists Guide
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21233
Three Surfaces
21234
Four Surfaces
21235 Five Surfaces or maximum surfaces per
tooth
21241
21242
21243
21244
21245
Bonded, Permanent Molars
One Surface
Two Surfaces
Three Surfaces
Four Surfaces
Five Surfaces or maximum surfaces per
tooth
Restorations, Amalgam Cores
21301
Restorations, Amalgam Core, in
conjunction with crown
21302 Restorations, Amalgam Core, Bonded, in
conjunction with crown
Pins, Retentive per restoration (for
amalgams and tooth coloured
restorations)
One Pin
Two Pins
Three Pins
Four Pins
Five Pins or more
21401
21402
21403
21404
21405
Restorations made to a tooth
supporting an existing Partial Denture
Clasp (additional to restoration)
21501
Per Restoration
$100.19
$129.66
$159.19
$122.19
$164.64
$193.85
$70.36
$86.56
$113.43
$156.19
$207.84
$70.91
$105.63
$138.00
$191.32
$253.17
PA
PA
PA
PA
$15.97
$27.96
$35.39
$43.73
$50.78
$16.29
$28.52
$36.10
$44.60
$51.80
PA
PA
$122.50
$118.39
$122.50
$118.39
$155.79
$144.75
$155.79
$144.75
RESTORATIONS,
PREFABRICATED, FULL
COVERAGE
22201
22202
22211
22212
Prefabricated, Metal, Primary Dentition
Primary Anterior
Primary Anterior - open face
Primary Posterior
Primary Posterior - open face
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 102
22301
22302
22311
22312
Prefabricated, Metal, Permanent
Dentition
Permanent Anterior
Permanent Anterior - open face
Permanent Posterior
Permanent Posterior - open face
$122.50
$118.39
$122.50
$118.39
$155.79
$144.75
$155.79
$144.75
22501
22511
Prefabricated, Plastic, Permanent
Dentition
Permanent Anterior
Permanent Posterior
$128.00
$128.00
$171.00
$171.00
$73.67
$96.17
$112.01
$178.31
$178.31
$89.71
$117.41
$137.20
$220.79
$220.79
$178.31
$220.79
$178.31
$220.79
$79.15
$98.00
$131.92
$162.08
$185.32
$64.82
$96.82
$122.19
$164.64
$193.85
RESTORATIONS, TOOTH
COLOURED
23111
23112
23113
23114
23115
Permanent Anteriors, Acid Etch/Bond
Technique (not to be used for Veneer
Applications or Diastema Closures)
One Surface
Two Surfaces (continuous)
Three Surfaces (continuous)
Four Surfaces (continuous)
Five Surfaces (continuous), maximum
surfaces per tooth
Tooth Coloured Veneer Application
23121
Direct Chairside Prefabricated - Acid
Etch/Bond
23122 Non Prefabricated Direct Build-up - Acid
Etch/Bond
23311
23312
23313
23314
23315
Permanent Bicuspids, Acid Etch/Bond
Technique
One Surface
Two Surfaces
Three Surfaces
Four Surfaces
Five Surfaces or maximum surfaces per
tooth
Permanent Molars, Acid Etch/Bond
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 103
Technique
23321
One Surface
23322
Two Surfaces
23323
Three Surfaces
23324
Four Surfaces
23325 Five Surfaces or maximum surfaces per
tooth
23411
23412
23413
23414
23415
23511
23512
23513
23514
23515
Primary, Anterior, Acid Etch/Bond
Technique
One Surface
Two Surfaces (continuous)
Three Surfaces (continuous)
Four Surfaces (continuous)
Five Surfaces (continuous), maximum
surfaces per tooth
Primary, Posterior Acid Etch/Bond
Technique
One Surface
Two Surfaces
Three Surfaces
Four Surfaces
Five Surfaces or maximum surfaces per
tooth
Restorations, Tooth Coloured/Plastic
with Silver Fillings, Cores
23601 Restoration, Tooth Coloured, Core in
Conjunction with Crown
23602
Restoration, Tooth Coloured, Acid
Etch/Bonded, Core in Conjunction with
Crown
$82.92
$99.26
$135.69
$164.59
$207.84
$70.91
$105.63
$138.00
$191.32
$253.17
$68.47
$68.47
$96.17
$146.00
$148.69
$83.77
$83.77
$117.41
$164.59
$164.59
$56.64
$70.36
$86.06
$96.11
$107.63
$50.19
$72.55
$82.98
$104.47
$131.72
$129.33
$143.16
$129.33
$143.16
PLEASE SEE PROSTHODONTIC
SECTION FOR INLAYS, ONLAYS AND
PINS
POSTS
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 104
Posts, Cast Metal (including core) as a
Separate Procedure
25711
Single Section + L
25712
Two Sections + L
25713
Three Sections + L
$172.34
$233.06
PA
$244.42
$244.42
$469.48
Posts, Cast Metal (including core)
Concurrent with Impression for Crown
25721
Single Section + L
25722
Two Sections + L
25723
Three Sections + L
$143.00
$172.34
PA
$244.42
$244.42
$469.48
$109.24
$137.58
$171.50
$133.31
$133.31
$133.31
$172.34
$172.34
$244.42
$244.42
PA
$469.48
PA
PA
PA
PA
PA
$179.03
PA
$219.13
PA
PA
PA
PA
PA
PA
Posts, Prefabricated Retentive
(separate procedure)
One Post
Two Posts (same tooth)
Three Posts (same tooth)
25731
25732
25733
Posts, Prefabricated, Retentive and
Cast Core
25741
One Post and cast core + L
25742 Two Posts (same tooth) and cast core +
L.
25743 Three Posts (same tooth) and cast core +
L
25751
25752
25753
25754
25755
25756
25781
Post, Prefabricated, with Core for
Crown Restoration (when pins are
applicable, refer to 21401-21405 for
additional fee)
One Post with Amalgam Core + Pins
Two Post (same tooth) with Amalgam
Core + Pins
Three Posts (same tooth) with Amalgam
Core + Pins
One Post with Composite Core + Pins
Two Posts (same tooth) with Composite
Core + Pins
Three Posts (same tooth) with Composite
Core + Pins
Post Removal
One unit of time
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 105
CROWNS SINGLE UNITS (ONLY)
PREAMBLE
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 predetermination.
DHW NOTE: Gold, Butt Margins
(including Collarless Veneers), Custom
Shading or any esthetics included in
the Lab fees are uninsured. Please
submit a copy of the Lab invoice upon
completion of the services.
27111
27112
27113
27114
Crowns, Plastic, Processed
Crown, Plastic, Processed + L
$396.18
Crown, Plastic, Processed Complicated
(restorative, positional and/or esthetic) + L
PA
Crown, Plastic, Transitional, Indirect + L
PA
Crown, Plastic/Metal Base, Processed + L $486.48
Crowns, Plastic, Direct
Crown, Plastic, Direct, Transitional
(chairside)
Crown, Transitional Restoration of
Fractured Anterior
27121
27122
27201
27202
Crowns, Porcelain/Ceramic/Polymer
Glass
Crown, Porcelain/Ceramic Jacket + L
Crown, Porcelain/Ceramic Jacket
Complicated + L
Crowns Porcelain/Ceramic Fused to
Metal
27211 Crown Porcelain/Ceramic Fused to Metal
Base + L
27212 Crown Porcelain/Ceramic Fused to Metal
Base Complicated + L
January 2017
$404.10
PA
PA
$595.46
$115.36
$117.67
PA
PA
PA
PA
PA
PA
$486.48
$595.46
PA
PA
Nova Scotia Dental Program — Dentists Guide
Page 106
27213 Crown Porcelain/Ceramic Fused to Metal
Base, Screwed Directly to an Implant +L
and/or +E
Crowns, Porcelain/Ceramic, 3/4 Partial
Veneer
27221 Crown, Porcelain/Ceramic, 3/4 Partial
Veneer+ L
27222 Crown, Porcelain/Ceramic, 3/4 Partial
Veneer Complicated + L
Crowns, Metal, Cast
27301 Crown, Metal, Full Cast, Uncomplicated +
L
27302 Crown, Metal, Full Cast, Complicated
(restorative, positional ) + L
27311
27312
27313
27401
Crowns, Metal 3/4 Partial Veneer
Crown, Metal 3/4 Partial Veneer + L
Crown, Metal 3/4 Partial Veneer,
Complicated + L
Crown, Metal 3/4 Partial Veneer, with
Direct Tooth Coloured Corner + L
Crowns Made to Existing Partial
Denture Clasp (additional to crown)
One Crown
Coping, Metal/Plastic, Transfer
(thimble)
27501
As a Separate Procedure + L
27502 Each Additional Coping as a Separate
Procedure + L
27503 Concurrent with Impression for Crown + L
27504 Concurrent with Impression for Additional
Crown + L
VENEERS, LABORATORY
PROCESSED
Veneers, Porcelain/Ceramic, Acid
Etch/Bonded + L
27602
PA
PA
PA
PA
PA
PA
$441.64
$540.56
$441.64
$540.56
$486.48
$486.48
$595.46
$595.46
$486.48
$595.46
$55.42
$56.53
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
REPAIRS (Single units only, does
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 107
not include removal and
recementation)
27711
Repairs, Inlays, Onlays or Crowns,
Plastic (single units)
Repairs, Plastic, Direct
Repairs, Inlays, Onlays or Crowns,
Porcelain/Ceramic (single units)
27721
Repairs, Porcelain/Ceramic, Direct
27722 Repairs, Porcelain/Ceramic, Indirect + L
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
DHW NOTE: Gold, Butt Margins
(including Collarless Veneers), Custom
Shading or any esthetics included in
the Lab fees are uninsured. Please
submit a copy of the Lab invoice upon
completion of the services.
RESTORATIVE PROCEDURES,
OVERDENTURES
RESTORATIVE PROCEDURES,
OVERDENTURES, DIRECT
28101 Natural Tooth Preparation, Placement of
Pulp Chamber Restoration and Fluoride
application
28102 Prefabricated Attachment, as Internal or
External Overdenture Retentive Device+E
28103 Natural Tooth Preparation and Fluoride
Application, Vital Tooth
RESTORATIVE PROCEDURES,
OVERDENTURES, INDIRECT
28211
28212
January 2017
Coping Crowns, Metal Cast
Coping Crowns, Metal Cast - no
Attachment Indirect + L
Coping Crowns, Metal Cast - with
Attachment Indirect + L
Nova Scotia Dental Program — Dentists Guide
Page 108
RECEMENTATION/REBONDING,INLAY
S/ONLAYS/CROWNS/VENEERS/POSTS
/NATURAL TOOTH FRAGMENTS (single
units only) (+ L where laboratory charges
are incurred during the repair of the unit)
DHW - For stainless steel crowns,
recementation is payable after 120
days following original insertion by
same or different dentist.
DHW - Maximum of 3 units per tooth
29101
One unit of time
29102
Two units of time
29103
Three units of time
$58.12
$116.21
$174.31
$59.28
$118.53
$177.80
29401
29402
29403
29404
STAINING, PORCELAIN (chairside)
One unit of time
Two units of time
Three units of time
Four units of time
PA
PA
PA
PA
PA
PA
PA
PA
29409
Each additional unit over Four
PA
PA
$71.74
$71.74
$87.74
$87.74
$57.66
$57.66
$73.12
$71.69
$82.64
$128.02
PA
PA
$84.29
$130.58
PA
PA
ENDODONTICS
32221
32222
Pulpotomy, Permanent Teeth (as a
Separate Emergency Procedure)
Anterior and Bicuspid Teeth
Molar Teeth
Pulpotomy, Primary Teeth
32231
As a Separate Procedure
32232 Concurrent with restorations (excluding
final restoration)
32311
32312
32313
32314
January 2017
Pulpectomy, Permanent
Teeth/Retained Primary Teeth
(Separate Emergency Procedure)
One Canal
Two Canals
Three Canals
Four or more Canals
Nova Scotia Dental Program — Dentists Guide
Page 109
Pulpectomy, Primary Teeth
Anterior Tooth
Posterior Tooth
32321
32322
$75.00
$111.00
$84.29
$98.00
33111
33121
33131
33141
Permanent Teeth, Retained Primary
Teeth (includes: Clinical Procedures with
appropriate radiographs, excluding final
restorations.)
One Canal
Two Canals
Three Canals
Four or more Canals
$326.42
$478.12
$642.19
$797.28
$399.57
$575.33
$785.99
$941.32
33401
33402
33403
Primary Teeth
One Canal
Two Canals
Three or more Canals
$123.10
$169.22
$226.69
$157.87
$209.18
$280.29
33601
33602
33603
33604
Apexification/Apical Closure/Induction
of Hard Tissue Repair
One Canal
Two Canals
Three Canals
Four or more Canals
$124.33
$164.62
$209.65
$376.64
$152.16
$219.58
$287.93
$433.93
33611
33612
33613
33614
Re-insertion of Dentogenic Media per
Visit
One Canal
Two Canals
Three Canals
Four or more Canals
$55.42
$55.42
$55.42
$55.42
$65.32
$65.32
$65.32
$65.32
ROOT CANAL THERAPY
APICOECTOMY/APICAL
CURETTAGE
Maxillary Anterior
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 110
34111
34112
One Root
Two Roots
$170.50
$243.61
$208.72
$284.03
34121
34122
34123
Maxillary Bicuspids
One Root
Two Roots
Three or more Roots
$228.00
$303.00
$379.00
$296.42
$353.90
$411.24
34131
34132
34133
34134
Maxillary Molars
One Root
Two Roots
Three Roots
Four or more Roots
$242.26
$320.61
$382.63
$430.83
$296.42
$353.90
$431.81
$459.78
34141
34142
Mandibular Anterior
One Root
Two or more Roots
$170.50
$243.61
$208.72
$270.50
34151
34152
34153
Mandibular Bicuspids
One Root
Two Roots
Three or more Roots
$229.00
$303.00
$381.00
$296.42
$353.90
$411.24
34161
34162
34163
34164
Mandibular Molar
One Root
Two Roots
Three Roots
Four or more Roots
$242.26
$320.61
$382.63
$430.83
$296.42
$353.90
$411.24
$459.78
34211
34212
Maxillary Anterior
One Canal
Two or more Canals
$67.78
$82.13
$82.96
$103.43
34221
34222
34223
34224
Maxillary Bicuspids
One Canal
Two Canals
Three Canals
Four or more Canals
$67.78
$82.13
$99.37
$111.40
$82.96
$103.43
$129.30
$145.44
RETROFILLING
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 111
34231
34232
34233
34234
Maxillary Molars
One Canal
Two Canals
Three Canals
Four or more Canals
$69.73
$86.06
$99.37
$111.40
$82.96
$103.43
$135.76
$145.44
34241
34242
Mandibular Anterior
One Canal
Two or more Canals
$67.78
$82.13
$82.96
$103.43
34251
34252
34253
34254
Mandibular Bicuspids
One Canal
Two Canals
Three Canals
Four or more Canals
$67.78
$82.13
$99.37
$111.40
$82.96
$103.43
$129.30
$145.44
34261
34262
34263
34264
Mandibular Molar
One Canal
Two Canals
Three Canals
Four or more Canals
$69.73
$86.06
$99.37
$111.40
$82.96
$103.43
$129.30
$145.44
PA
PA
PA
PA
$82.33
$100.69
$66.00
$66.00
$71.47
$71.47
34601
34602
ENLARGEMENT, CANAL AND/OR
PULP CHAMBER (Preparation of Post
Space)
In previously Filled Tooth when Root
Canal Treatment Done by Another
Practitioner
In Calcified Canals
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)
Open and Drain (Separate Emergency
Procedures)
39201
Anteriors and Bicuspids
39202
Molars
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 112
Opening Through Artificial Crown (In
addition to Procedure)
39211
Anteriors and Bicuspids
39212
Molars
$81.57
$81.57
$83.20
$83.20
$53.81
$92.62
$131.41
38.79
$54.89
$94.47
$134.04
39.57
$31.52
$63.03
$31.52
$32.15
$64.29
$32.15
$111.47
$136.63
PA
$195.37
PA
$140.21
PA
$154.24
PA
$26.08
PA
PA
$26.08
$72.91
BLEACHING, NON VITAL
39311
39312
39313
39319
Bleaching Endodontically Treated
Tooth/Teeth
DHW-maximum of three units payable
per patient
One unit of time
Two units of time
Three units of time
Each Additional unit over three
PERIODONTICS
41301
41302
41309
42111
42201
42311
42321
42331
42339
42341
Desensitization - DHW - details as to
rationale must accompany claim.
One unit of time
Two units of time .
Each additional unit over two
Periodontal Surgery
Surgical Curettage, to Include Definitive
Root Planing - Per Sextant
Periodontal Surgery, Gingivoplasty - Per
Sextant
Gingivectomy, Uncomplicated - Per
Sextant
Gingivectomy, with Curettage - Per
Sextant
Gingival Fiber Incision (Supra Crestal
Fibrotomy) - Per Tooth
Each Additional Tooth
Soft Tissue Recontouring for Crown
Lengthening, Limited Recontouring of
Tissue, Per Tooth
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 113
Periodontal Surgery, Flap Approach
42411 With Osteoplasty/Ostectomy - Per Sextant
42421 With Curettage of Osseous Defect - Per
Sextant
42431 With Curettage of Osseous Defect and
Osteoplasty - Per Sextant
42441
Exploratory (for Diagnosis) - Per Site
42451 With Osteoplasty/Ostectomy for Crown
Lengthening - Per Site
42511
42512
42521
42522
42531
42541
42551
42561
42571
42581
42611
42621
Periodontal Surgery, Grafts
Soft Tissue, Pedicle (apically or coronally
positioned, lateral sliding and rotated
flaps.) - Per Site
Periosteal stimulation (in addition to
42511)
Soft Tissue, Pedicle (Coronally
Positioned) - Per Site
Periosteal stimulation (in addition to
42521)
Free Soft Tissue - Per Site
Free Soft Tissue, Pedicle, with Free Graft
Placed in Pedicle Donor Site - Per Site
Free Connective Tissue (for Root
Coverage) - Per Site
Free Connective Tissue (for Ridge
Augmentation) - Per Site
Connective Tissue, Pedicle with Free
Graft for Root Coverage - Per Site
Gingival Onlay, for Ridge Augmentation Per Site
Osseous, Autograft (including Flap Entry
and Closure and Donor Site) - Per Site
Osseous, Allograft (including Flap Entry
and Closure) - Per Site (+ E - not payable
by DHW)
Guided Tissue Regeneration (including
Re-entry)
42711 Per Site (+ E - not payable by DHW)
42811
42819
January 2017
Proximal Wedge Procedure (as a
separate procedure)
With Flap Curettage, per site
With Flap Curettage and
PA
PA
$286.43
$286.43
PA
$320.74
PA
PA
$70.57
$286.43
PA
$318.31
PA
$350.14
PA
$318.31
PA
$350.14
PA
PA
$318.31
$318.31
PA
$318.31
PA
$318.31
PA
$318.31
PA
$318.31
PA
$274.84
PA
PA
PA
PA
PA
PA
Nova Scotia Dental Program — Dentists Guide
Page 114
Ostectomy/Ostoplasty, per site
PA
PA
42821
42822
42823
42829
Post-Surgical Periodontal Treatment
Visit per Dressing Change
One unit of time
Two units of time
Three units of time
Each additional unit of time over Three
PA
PA
PA
PA
PA
PA
PA
PA
42831
42832
42833
42834
42839
Periodontal Abscess or Pericoronitis,
may include one or more of the
following procedures: Lancing,
Scaling, Curettage, Surgery or
Medication
One unit of time
Two units of time
Three units of time
Four units of time
Each additional unit of time over Four
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
$46.12
PA
PA
$60.44
$60.44
PA
PA
PA
PA
PA
$60.44
$60.44
$60.44
$60.44
$60.44
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)
Periodontal Splinting or Ligation,
Provisional, Intra Coronal
43111 "A" Splint (acrylic, Composite or amalgam,
plus knurled wire) - Per Joint
43211
43221
43231
43241
43251
43261
43271
Periodontal Splinting or Ligation,
Provisional, Extra Coronal
Acid Etch Joint Restorations - Per Joint
Acid Etch, Interproximal Enamel Splint Per Joint
Wire Ligation - Per Joint
Wire Ligation, Acrylic Covered - Per Joint
Dental Floss Ligation - Per Joint
Orthodontic Band Splint - Per Joint
Cast/Soldered Splint Acid Etch/Resin
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 115
Bonded - Per Abutment + L
Removal of Fixed Periodontal Splints
43281
One unit of time
43289
Each additional unit of time
PA
PA
PA
PA
$49.44
$98.90
$148.35
$197.81
$24.73
$49.44
$60.44
$120.89
$181.33
$241.82
$30.23
$60.44
$49.44
$98.90
$148.35
$197.81
$247.27
$296.71
$24.73
$49.44
$60.44
$120.89
$181.33
$241.82
$302.25
$362.67
$30.23
$60.44
OCCLUSION
Occlusion Adjustment/Equilibration
May require several sessions.
May be used in conjunction with basic
restorative treatment only when occlusal
adjustment/equilibration is not required as
a result of that restoration.
Not to be used in conjunction with the
delivery and post-insertion care of: fixed
or removable prosthesis (5000 & 6000
code series) by the same dentist for a
period of three months.
16511
One unit of time
16512
Two units of time
16513
Three units of time
16514
Four units of time
16517
One half unit of time
16519
Each additional unit of time over four
ROOT PLANING, PERIODONTAL
Root Planing
One unit of time
Two units of time
Three units of time
Four units of time
Five units of time
Six units of time
One half unit of time
Each additional unit of time
43421
43422
43423
43424
43425
43426
43427
43429
CHEMOTHERAPEUTIC AND/OR
ANTIMICROBIAL AGENTS
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 116
Chemotherapeutic and/or Antimicrobial
agents, Topical application
43511
One unit of time
43519
Each additional unit of time
PA
PA
PA
PA
Chemotherapeutic and/or Antimicrobial
agents, Intra-sulcular
43521
One unit of time
43529
Each additional unit of time
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
14711
14712
Appliances, TMJ, Diagnostic
Maxillary Appliance + L
Mandibular Appliance + L
PA
PA
PA
PA
14721
14722
Appliances, TMJ, Intra-oral
Repositioning
Maxillary Appliance + L
Mandibular Appliance + L
$266.33
$266.33
$325.68
$325.68
APPLIANCES, PERIODONTAL
Appliances, Periodontal (including
Bruxism appliances) (includes
Impression, Insertion and Adjustment)
14611
Maxillary Appliance + L
14612
Mandibular Appliance + L
Appliances, Maintenance,
Adjustments, Repairs (including
bruxism appliances)
One unit of time + L
Two units of time + L
Three units of time + L
Each additional unit over three
14621
14622
14623
14629
Appliances, reline (including bruxism
appliances)
14631
Reline, Direct
14632
Reline, Processed + L
APPLIANCES,
TEMPOROMANDIBULAR JOINT
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14731
14732
14733
14739
Appliances, TMJ, Periodic
Maintenance, Adjustments, Repairs
One unit of time + L
Two units of time + L
Three units of time + L
Each additional unit over three
$44.89
$89.78
$134.65
$44.89
$54.98
$109.95
$164.91
$54.98
14741
14742
Appliances, TMJ, Relines
Reline, Direct
Reline, Processed + L
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
APPLIANCES, MYOFACIAL PAIN
SYNDROME (conditions that originate
outside the temporomandibular joint, to
include: models, gnathological
determinants, adjustments and three post
insertion adjustments)
14811
Maxillary Appliance + L
14812
Mandibular Appliance + L
14821
14822
14823
14829
Periodic Maintenance, Adjustments
and Repairs
One unit of time + L
Two units of time + L
Three units of time + L
Each additional unit over three
PERIODONTAL SERVICES,
MISCELLANEOUS
Periodontal Re-evaluation
One unit of time
Two units of time
Each additional unit over two
49101
49102
49109
Periodontal Irrigation, Subgingival
49211
49219
January 2017
One unit of time
Each additional unit of time
Nova Scotia Dental Program — Dentists Guide
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PROVISIONAL NON-CODED
SERVICES
Root Separation
Forced Eruption- One Toot
Forced Eruption - More than one tooth
Rapid Extrusion - One tooth
Rapid Extrusion - More than one tooth
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Dentures, Complete, Equilibrated
(Involves remounting equilibration on a
semi-adjustable articulator)
51201
Maxillary + L
51202
Mandibular + L
51204 Liners, Resilient in addition to above + L
PA
PA
PA
$1,243.52
$1,296.19
$61.35
Dentures, Surgical, Standard
(Immediate) (includes tissue conditioner,
but does not include hard reline. Does
include three months post insertion care)
51301
Maxillary + L
51302
Mandibular + L
$562.70
$562.70
PA
PA
51601
51602
Dentures, Complete, Transitional
(Temporary)
Maxillary + L
Mandibular + L
PA
PA
$853.57
$853.57
51701
51702
Dentures, Complete, Overdenture
Maxillary + L
Mandibular + L
PA
PA
PA
PA
PROSTHETICS - REMOVABLE
DENTURES, COMPLETE (Includes:
impressions, initial and final jaw relation
records, try-in evaluation and check
records, insertion and adjustments,
including three months post insertion
care)
January 2017
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51801
51802
Dentures, Complete, Overdenture
(Immediate)
Maxillary + L
Mandibular + L
PA
PA
PA
PA
PA
PA
PA
PA
$174.55
$174.55
PA
PA
52111
52112
Dentures, Partial, Acrylic Base
(Immediate)
Maxillary + L
Mandibular + L
PA
PA
PA
PA
52301
52302
Dentures, Partial, Acrylic, with
Wrought/ Cast Clasps and/or Rests
Maxillary + L
Mandibular + L
$342.90
$342.90
$430.37
$430.37
52311
52312
Dentures, Partial, Acrylic, with
Wrought/ Cast Clasps and/or Rests
(immediate)
Maxillary + L
Mandibular + L
$342.90
$342.90
$430.37
$430.37
PA
PA
PA
PA
DENTURES, COMPLETE,
ATTACHED TO IMPLANTS
Dentures, Removable, Tissue Bone, with
Independent Attachments Secured to
Implants
51921
Maxillary + L
51922
Mandibular + L
DENTURES, PARTIAL, ACRYLIC
Dentures, Partial, Acrylic Base
(Transitional) With or Without Clasps
52101
Maxillary + L
52102
Mandibular + L
Dentures, Partial, Overdenture, Acrylic
with Cast/Wrought Clasps and/or Rests
52501
Maxillary + L
52502
Mandibular + L
January 2017
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Dentures, Partial, Overdenture, Acrylic
with Cast/Wrought Clasps and/or Rests
(immediate)
52511
Maxillary + L
52512
Mandibular + L.
PA
PA
PA
PA
PA
PA
PA
PA
PA
53201
53202
Dentures, Partial, Tooth Borne, Cast
Frame/Connector, Clasps and Rests
Maxillary + L
Mandibular + L
$489.49
$489.49
PA
PA
53401
53402
Dentures, Partial, Cast, Precision
Attachments
Maxillary + L
Mandibular + L
$694.55
$694.55
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
DENTURES, PARTIAL, CAST
WITH ACRYLIC BASE
53101
53102
53104
Dentures, Partial, Free End, Cast
Frame/Connector, Clasps and Rests
Maxillary + L
Mandibular + L
Altered Cast Impression Technique in
Conjunction with 53101, 53102 + L
Dentures, Partial, Cast, Semi Precision
Attachments
53501
Maxillary + L
53502
Mandibular + L
Dentures, Partial, Cast, Overdenture,
Removable
53701
Maxillary + L
53702
Mandibular + L
53704 Altered Cast Impression Technique done
in conjunction with 53701, 53702+L
January 2017
Nova Scotia Dental Program — Dentists Guide
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DENTURE ADJUSTMENTS
(after three months insertion or by other
than the dentist providing prosthesis)
54201
Partial or Complete Denture, Minor
One unit of time
$44.92
$54.79
PA
PA
$302.92
$302.92
$40.48
$40.48
$49.81
$49.81
Repair, Complete Denture, Impressions
Required
55201
Maxillary + L
55202
Mandibular + L
$81.71
$81.71
$99.88
$99.88
Repairs/Additions, Partial Dentures, No
Impression Required
55301
Maxillary + L
55302
Mandibular + L
$40.48
$40.48
$54.98
$54.98
55401
55402
Repairs/Additions, Partial Dentures,
Impression Required
Maxillary + L
Mandibular + L
$81.71
$81.71
$99.88
$99.88
55501
55509
Implant Retained Prosthesis,
Prophylaxis and Polishing
One unit of time + L
Each additional unit of time
PA
PA
PA
PA
Partial or Complete Denture, Remount
and Occlusal Equilibration
54301
Maxillary + L
54302
Mandibular + L
DENTURES,
REPAIRS/ADDITIONS
Repair, Complete Denture, No
Impressions Required
Maxillary + L
Mandibular + L
55101
55102
January 2017
Nova Scotia Dental Program — Dentists Guide
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DENTURES, DUPLICATION,
RELINING AND REBASING
Duplication, Complete Denture
Maxillary + L
Mandibular + L
56111
56112
PA
PA
PA
PA
56211
56212
Reline, Direct, Complete Denture
Maxillary
Mandibular
$144.41
$144.41
$147.30
$147.30
56221
56222
Reline, Direct, Partial Denture
Maxillary
Mandibular
$138.51
$138.51
$141.28
$141.28
$179.69
$179.69
$183.28
$183.28
56241
56242
Reline, Processed, Partial Denture
Maxillary + L
Mandibular + L
$105.87
$105.87
$107.99
$107.99
56261
56262
Reline, Processed, Functional
Impression Requiring Three
Appointments, Partial Denture
Maxillary + L
Mandibular + L
$179.69
$179.69
$183.28
$183.28
PA
PA
PA
PA
DENTURES, RELINING
Reline, Processed, Complete Denture
56231
Maxillary + L
56232
Mandibular + L
DENTURES, REMAKE
56411
56412
Remake, Using existing Framework,
Partial Denture
Maxillary + L
Mandibular + L
January 2017
Nova Scotia Dental Program — Dentists Guide
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DENTURES, TISSUE
CONDITIONING
Tissue Conditioning, per Appointment,
Complete Denture
56511
Maxillary + L
56512
Mandibular + L
$87.94
$87.94
$89.70
$89.70
Tissue Conditioning, per Appointment,
Partial Denture
56521
Maxillary + L
56522
Mandibular + L
$101.74
$101.74
$103.77
$103.77
$87.94
$89.70
PA
PA
PA
PA
$243.67
$243.67
PA
PA
PA
$273.63
$273.63
PA
PA
PA
Dentures, Miscellaneous Services
56601 Resilient Liner, in Relined or Rebased
Denture (in addition to reline or rebase of
denture) + L
56602 Resetting of Teeth (not including reline or
rebase of denture) + L
PROSTHODONTICS - FIXED
Fixed Bridges ( each abutment, each
retainer and each pontic, constitutes a
separate unit in a bridge, with a separate
code number)
PONTICS, BRIDGE
62101
Pontics, Cast Metal + L
62102 Pontics, Cast Metal Core with Separate
Porcelain Jacket Pontic + L
62501 Pontics, Porcelain Fused to Metal + L
62502
Pontics, Porcelain Aluminous + L
62702
Pontics, Acrylic/Plastic/Composite,
Processed Indirect (Transitional) + L
62703
Pontics, Acrylic/Plastic/Composite,
Transitional Direct + L
Recontouring of Retainers/Pontics, Per
Tooth (of existing bridgework)
January 2017
Nova Scotia Dental Program — Dentists Guide
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63001
63009
64101
One unit of time
Each additional unit of time
Master Cast, Facebow Mounting + L
PA
PA
PA
PA
PA
PA
66211
66212
66213
66219
Removal, Fixed Bridge
One unit of time + L
Two units of time + L
Three units of time + L
Each additional unit of time
$52.59
$105.17
$157.75
$52.59
$64.36
$128.69
$193.02
$64.36
66301
REPAIRS, RECEMENTATION ( + L
where laboratory charges are incurred
during repair)
One unit of time + L
$60.47
$73.81
PA
PA
PA
PA
PA
PA
PA
PA
$54.06
$54.06
$68.27
$68.27
REPAIRS, REMOVAL
REPAIRS, FIXED BRIDGE
Repairs,
Porcelain/Ceramic/Plastic/Composite,
Direct
66711
First Tooth
66719
Each additional tooth
66721
66729
Repairs, Solder Indexing to Repair
Broken Solder Joint
One unit of time + L
Each additional unit of time
FIXED BRIDGE RETAINERS
Retainers,
Acrylic/Composite/Compomer With or
Without Cast or Prefabricated Metal
Bases
67111
Plastic/Acrylic, Processed + L
67112
Plastic, Processed to Metal + L
Plastic/Acrylic, Direct (transitional
during healing, done at chairside)
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67121
67129
First Tooth
Each additional tooth
PA
PA
PA
PA
67131
67139
Plastic/Acrylic, Indirect, Processed
(transitional during healing)
First Tooth
Each additional tooth
PA
PA
PA
PA
67141
67149
Plastic/Acrylic, Indirect, Processed ,
Attached to Implants
First Implant + L
Each additional implant + L
PA
PA
PA
PA
PA
PA
PA
PA
$594.89
$169.83
PA
PA
PA
PA
PA
PA
$594.89
$169.83
PA
PA
$594.89
$169.83
PA
PA
PA
PA
$452.49
$567.67
$567.67
PA
PA
PA
PA
PA
Retainers, Porcelain/Ceramic/Polymer
Glass, Full Coverage
67201 Porcelain/Ceramic/Polymer Glass + L
67211 Porcelain/Ceramic Fused to Metal + L
67212
Stress Breaker and/or Precision
Attachments, in addition to above + L
67221
67229
Porcelain/Ceramic Fused to Metal,
Attached to Implant
First Implant + L
Each additional implant + L
Retainers, Full Cast Metal
67301
Metal Full Cast + L
67302
Stress Breaker and/or Precision
Attachments, in addition to above + L
67311
Metal 3/4 Cast + L
67312
Stress Breaker and/or Precision
Attachments, in addition to above + L
67321
Metal Inlay, Two surfaces + L
67322 Metal Inlay, Three or more surfaces + L
67331
Metal Onlay + L
67341 Metal Onlay, Acid Etch and/or Perforated,
Bonded to Abutment Tooth (Pontic extra)+
L
67351 Metal Prefabricated or Custom Cast, + L
and/or (+ E-not payable by DHW)
67359 Each additional Retainer + L and/or (+ E-
January 2017
Nova Scotia Dental Program — Dentists Guide
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not payable by DHW)
Fixed Prosthodontics,
Abutments/Retainers, Miscellaneous
Services
67501 Abutment Preparation Under Existing
Partial Denture Clasp, in addition to
retainer code+L
67502
Telescoping Crown Unit + L
67503 Implant, each Retentive Bar Attached by
Screws to Implant (67351) to retain
Removable Prosthesis (see 51920 for
prosthesis)
Fixed Prosthetics, Miscellaneous
Services
69101
Porcelain, to Replace a Substantial
Portion of Alveolar Process (in addition to
retainer and pontics) + L
69201 Splinting for Extensive or Complicated
Restorative Dentistry (per tooth)+ L
69301
69302
69303
69304
69305
69701
69702
Fixed Prosthetics, Retentive Pins (for
retainers in addition to restoration)
One pin/restoration + L
Two pins/restoration + L
Three pins/restoration + L
Four pins/restoration + L
Five pins or more/restoration + L
Fixed Prosthetics, Provisional
Coverage (In extensive or complicated
restorative dentistry)
Abutment Tooth + L
Pontic + L
PA
PA
PA
$789.84
PA
PA
PA
PA
PA
PA
$26.98
$39.66
$53.52
$71.19
$100.38
$27.52
$40.45
$54.59
$72.61
$102.39
$56.12
PA
$68.32
PA
PA
PA
FIXED PROSTHETIC FRAMEWORK,
OSSEO-INTEGRATED IMPLANT
SUPPORTED
69811
January 2017
Fixed Framework Attached with
Screws and Incorporating Teeth
(denture teeth and acrylic)
Maxillary + L
Nova Scotia Dental Program — Dentists Guide
Page 127
69812
Mandibular + L
Fixed Framework Attached with
Screws or Cement and Incorporating
Teeth (porcelain/ceramic/polymer glass
bonded to metal,
acrylic/composite/compomer
processed to metal or full metal
crowns)
69821
Maxillary + L
69822
Mandibular + L
69831
69839
Removal of Implant Screw-Retained
Prosthesis for Cleaning or Repair
One unit of time
Each additional unit of time
Reinsertion of Implant Screw-Retained
Prosthesis
69841
One unit of time + E and/or + L
69849
Each additional unit of time
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
ORAL AND MAXILLOFACIAL
SURGERY
SPECIAL NOTE
Certain procedures included in this
section are also contained in the list of
DHW Dental Surgical Procedures
covering all eligible residents of the
Province. When dental surgical
procedures are performed in hospital,
care should be taken to ensure that
claims for those services which are
January 2017
Nova Scotia Dental Program — Dentists Guide
Page 128
included on the list of Insured Dental
Surgical Procedures are submitted
with fee code and fee as shown in the
Dental Surgical Procedures Section.
DHW
Bilateral procedures done under
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 two quadrants are
involved, the first two procedures will
be paid at 100% and subsequent
procedures at 50%.
REMOVALS (EXTRACTIONS)
Unless directly related to the
developmental anomaly (supply details
with claim) uncomplicated extractions are
insured only in the case of 1) unrestorable
caries, demonstrable pain, (excluding pain
associated with crowding), infection,
trauma 2) ankylosis, and 3)
supernumerary teeth.
71101
71109
Removals, Erupted Teeth,
Uncomplicated
Single tooth, uncomplicated
Each additional tooth, same quadrant
Removals, Erupted Teeth, Complicated
71201 Odontectomy, Erupted Tooth, Surgical
Approach, Requiring Surgical Flap and/or
Sectioning of Tooth
71209 Each additional tooth, same quadrant
$64.70
$43.35
$62.76
$33.00
$139.67
$169.98
$85.44
$85.00
Removals, Impaction, Soft Tissue
January 2017
Nova Scotia Dental Program — Dentists Guide
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72111
72119
Coverage
Single Tooth
Each additional tooth, same quadrant
$139.67
$86.06
$169.98
$85.00
Removals, Impaction, Involving Tissue
and/or Bone Coverage
72211
Single Tooth
72219 Each additional tooth, same quadrant
$169.22
$103.65
$280.09
$140.05
Removals, Impaction, Requiring
Incision of Overlying Soft Tissue,
Elevation of a Flap, Removal of Bone
and Sectioning of Tooth for Removal
72221
Single Tooth
72229 Each additional tooth, same quadrant
$231.98
$143.86
$311.48
$155.75
$51.29
$33.29
$62.76
$31.41
$96.13
$60.31
$117.67
$58.85
$199.93
$123.76
$244.66
$122.33
Simple Ridge Preservation, Alloplastic
Material (+ E - Not Payable by DHW)
72411
Single Tooth
PA
PA
Surgical Exposure, Unerupted,
Uncomplicated, Soft Tissue Coverage
(Includes operculectomy)
72511
Single Tooth
72519 Each additional tooth, same quadrant
$176.84
$88.44
$225.74
$112.89
72311
72319
Removals, Residual Roots, Erupted
Single Tooth
Each additional tooth, same quadrant
Removals, Residual Roots, Soft Tissue
Coverage
72321
Single Tooth
72329 Each additional tooth, same quadrant
72331
72339
Removals, Residual Roots, Bone
Tissue Coverage
Single Tooth
Each additional tooth, same quadrant
January 2017
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72521
72529
72531
72539
72611
72621
72631
Surgical Exposure, Complex, Hard
Tissue Coverage
Single Tooth
Each additional tooth, same quadrant
Surgical Exposure, Unerupted Tooth,
with Orthodontic Attachment
Single Tooth
Each additional tooth, same quadrant
Surgical Movement of Teeth
Transplantation of Erupted Teeth - Single
Tooth
Transplantation of Unerupted Teeth Single Tooth
Repositioning, Surgical - Single Tooth
$176.84
$88.44
$225.74
$112.89
$194.82
$97.39
$238.58
$119.28
PA
PA
PA
PA
PA
PA
$71.74
$96.80
$71.74
$71.74
$96.80
$96.80
SURGICAL INCISIONS
Surgical Incision and Drainage and/or
Exploration, Intra-oral Soft Tissue
75111
Intra-oral, Surgical Exploration, Soft
Tissue
75112
Intra-oral, Abscess, Soft Tissue
75113 Intra-oral, Abscess, In Major Anatomical
Area with Drain
TREATMENT OF FRACTURES
(It is understood that the majority of
fractures will be treated in hospital and
covered under DHW Dental Surgical
Benefits. However, Independent
Consideration will be given for
fractures treated in a dental office.
Explanation should be included on the
claim form.)
FRACTURES, REDUCTIONS,
ALVEOLAR
Replantation, Avulsed Tooth/Teeth
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76941
76949
(including splinting)
Replantation, first tooth
Each additional tooth
$207.31
$105.54
$215.35
$107.71
76951
76952
76959
Repositioning of Traumatically
Displaced Teeth
One unit of time
Two units of time
Each additional unit over two
$49.63
$99.26
$49.63
$47.23
$94.46
$47.23
$49.98
$61.24
$49.98
$61.24
$42.32
$51.93
$42.32
$51.93
PA
PA
PA
PA
PA
PA
HEMORRHAGE, CONTROL OF
(DHW - Payable if procedure rendered
by dentist other than the provider of
the original service)
79403 Hemorrhage Control, using Compression
and Hemostatic Agent
79404 Hemorrhage Control, using Hemostatic
Substance and Sutures (including removal
of bony tissue, if necessary)
POST SURGICAL CARE
(DHW - Payable if procedure rendered
by dentist other than the provider of
the original service)
79605 Post-Surgical Care, Alveolitis, Treatment
of (without anaesthesia)
79606 Post-Surgical Care, Alveolitis, Treatment
of (with anaesthesia)
IMPLANTOLOGY (Includes placement of
implant, post-surgical care, uncovering
and placement of attachment by not
prosthesis)
Implants, Endosseous, Integrated
Cylindrical
79951 First Stage Surgical Placement, Maxilla
per Implant (+ E - Not payable by DHW)
79952 First Stage Surgical Placement, Mandible
per Implant (+ E - Not payable by DHW)
79953
Second Stage Exposure and
Temporization, Maxilla per Implant (+ E Not payable by DHW)
January 2017
Nova Scotia Dental Program — Dentists Guide
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79954
Second Stage Exposure and
Temporization, Mandible per Implant (+ E
- Not payable by DHW)
PA
PA
PA
PA
PA
PA
$44.92
$54.74
81113
81114
Appliances, Removable, Space
Regaining
Appliances, Maxillary, Bilateral + L
Appliances, Mandibular, Bilateral + L
$492.86
$492.86
$643.60
$643.60
81121
81122
Appliances, Removable, Cross-Bite
Correction
Appliances, Maxillary, Simple + L
Appliances, Mandibular, Simple + L
PA
PA
$1,180.34
$1,180.34
Appliances, Removable, Dental Arch
Expansion
81131
Appliances, Maxillary, Simple + L
81132
Appliances, Mandibular, Simple + L
PA
PA
PA
PA
PA
PA
PA
PA
Implants, Removal of
First Implant (uncomplicated)
First Implant (complicated)
79991
79992
ORTHODONTICS
ORTHODONTIC, OBSERVATIONS
AND ADJUSTMENTS
Recementation of Fixed Appliances (DHW - Not including brackets)
80651
One unit of time
APPLIANCES, ACTIVE, FOR TOOTH
GUIDANCE OR MINOR TOOTH
MOVEMENT
APPLIANCES, REMOVABLE
81141
81142
Appliances, Removable, Closure of
Diastemas
Appliances, Maxillary, Simple + L
Appliances, Mandibular, Simple + L
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Appliances, Removable, Alignment of
Anterior Teeth
81151
Appliances, Maxillary, Simple + L
81152
Appliances, Mandibular, Simple + L
PA
PA
PA
PA
PA
PA
$643.60
$643.60
81221
81222
Appliance, Fixed, Space Regaining,
Unilateral
Appliance, Maxillary, + L
Appliance, Mandibular, + L
PA
PA
$449.14
$449.14
81231
81232
Appliance, Fixed, Cross-Bite
Correction - Anterior
DHW - As Phase 1 Treatment
Appliance, Maxillary, + L .
Appliance, Mandibular, + L
PA
PA
$1,180.34
$1,180.34
PA
PA
PA
$1,180.34
$1,180.34
$1,180.34
PA
PA
PA
PA
APPLIANCES, FIXED OR
CEMENTED
Appliance, Fixed, Space Regaining (eg.
Lingual or Labial Arch with Molar
Bands, Tubes, Locks)
81211
Appliance, Maxillary, + L
81212
Appliance, Mandibular, + L
Appliance, Fixed, Cross-Bite
Correction - Posterior
DHW - As Phase 1 Treatment
81241
Appliance, Maxillary, + L
81242
Appliance, Mandibular, + L
81243 Appliance, Two Molar Band, Hooked and
Elastics + L
Appliance, Fixed, Dental Arch
Expansion
81251
Appliance, Maxillary, + L
81253 Appliance, Mandibular, Rapid Expansion
+L
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Appliance, Fixed, Closure of Diastemas
81261
Appliance, Maxillary, Simple + L
81262
Appliance, Mandibular, Simple + L
PA
PA
PA
PA
Appliance, Fixed, Alignment of Incisor
Teeth
81271
Appliance, Maxillary, Simple + L
81272
Appliance, Mandibular, Simple + L
PA
PA
PA
PA
Appliance, Fixed, Mechanical Eruption
Tooth/Teeth
81291
Appliance, Maxillary, + L
81292
Appliance, Mandibular, + L
PA
PA
PA
PA
PA
PA
PA
$312.61
$312.61
$312.61
PA
PA
$312.61
$312.61
PA
$5,140.45
PA
$5,648.26
PA
$6,005.26
PA
$6,362.28
APPLIANCES, RETENTION,
ORTHODONTIC RETAINING
APPLIANCES
Appliances, Removable, Retention
83101
Appliance, Maxillary, + L
83102
Appliance, Mandibular, + L
83103
Appliance, Tooth Positioned, + L
Appliances, Fixed/Cemented, Retention
83201
Appliance, Maxillary, + L
83202
Appliance, Mandibular, + L
COMPREHENSIVE
ORTHODONTIC TREATMENT
Case Type - Fixed Appliances (Includes
formal full banded treatment and
retention)
84101
84101
84201
84201
Permanent Dentition
Class I Malocclusion (DHW - nonsurgical case)
Class I Malocclusion (DHW - surgical
case)
Class II Malocclusion (DHW - nonsurgical case)
Class II Malocclusion (DHW - surgical
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case)
84301
Class III Malocclusion (DHW - nonsurgical case)
84301 Class III Malocclusion (DHW - surgical
case)
84401 Malocclusion not Requiring Complete
Banding
PA
$7,379.26
PA
$8,703.51
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Case Type - Removable Appliances
(includes removable appliance therapy
and retention: e.g.: functional
appliance for mixed and primary
dentition)
Permanent Dentition
Class I Malocclusion + L
Class II Malocclusion + L
Class III Malocclusion + L
Mixed Dentition
Class I Malocclusion + L
Class II Malocclusion + L
Class III Malocclusion + L
87101
87201
87301
88101
88201
88301
MAXILLOFACIAL PROSTHODONTICS
PROGRAM
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THE FOLLOWING SERVICES ARE
PAYABLE AT $53.90 PER 15 MINUTE
TIME UNIT.
01702
Examination and Diagnosis,
Prosthodontic, Specific
PROSTHETICS-REMOVABLE
DENTURES, COMPLETE (Includes:
Impressions, Initial and Final Jaw relation
records, Try-in evaluation and check
records, Insertion and Adjustments,
including three months post insertion
care)
51301
51302
Dentures, Complete, Equilibrated
Maxillary + L
Mandibular + L
Liners, Resilient in addition to above
Dentures, Surgical, Standard
(Immediate) (Includes tissue conditioner
and three months post insertion care, but
does not include hard reline)
Maxillary + L
Mandibular + L
51601
51602
Dentures, Complete, Transitional,
(Temporary)
Maxillary + L
Mandibular + L
51701
51702
Dentures, Complete, Overdenture
Maxillary + L
Mandibular + L
51801
51802
Dentures, Complete, Overdenture
(Immediate)
Maxillary + L
Mandibular + L
51201
51202
51204
Dentures, Removable, Tissue Borne,
with Independent Attachments Secured
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to Implants
51921
51922
Maxillary + L
Mandibular + L
DENTURES, PARTIAL, ACRYLIC
52101
52102
Dentures, Partial, Acrylic Base
(Transitional) (With or without clasps)
Maxillary + L
Mandibular + L
52111
52112
Dentures, Partial, Acrylic Base
(immediate)
Maxillary + L
Mandibular + L
52301
52302
Dentures, Partial, Acrylic, Metal
Wrought/Clasps and/or Rests
Maxillary + L
Mandibular + L
52311
52312
Dentures, Partial, Acrylic, Metal
Wrought/Cast Clasps and/or Rests
(Immediate)
Maxillary + L
Mandibular + L
Dentures, Partial, Overdenture, Acrylic,
Metal Wrought/Cast Clasps and/or
Rests
52501
Maxillary + L
52502
Mandibular + L
Dentures, Partial, Overdenture, Acrylic,
Cast/Wrought Clasps and/or Rests
(Immediate)
52511
Maxillary + L
52512
Mandibular + L
DENTURES, PARTIAL, CAST WITH
ACRYLIC BASE
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Dentures, Partial, Free End, Cast
Frame/Connector, Clasps and Rests
53101
Maxillary + L
53102
Mandibular + L
53104 Altered Cast Impression Technique in
Conjunction with 53101,53102,53103 + L
53201
53202
Dentures, Partial, Tooth Borne, Cast
Frame/Connector, Clasps and Rests
Maxillary + L
Mandibular + L
53401
53402
Dentures, Partial, Cast, Precision
Attachments
Maxillary + L
Mandibular + L
Dentures, Partial, Cast, Semi-Precision
Attachments
53501
Maxillary + L
53502
Mandibular + L
Dentures, Partial, Cast, Overdenture,
Removable
53701
Maxillary + L
53702
Mandibular + L
53704 Altered Cast Impression Technique in
Conjunction with 53701,53702,53703 + L
DENTURES, ADJUSTMENTS (after three
months insertion or by other than the
dentist providing prosthesis)
54201
Denture Adjustments (Partial or
Complete Denture) Minor
One unit of time + L
54301
54302
Denture Adjustments (Partial or
Complete Denture), Remount and
Occlusal Equilibration
Maxillary + L
Mandibular + L
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DENTURES,
REPAIRS/ADDITIONS
Repairs, Complete Denture, No
Impression Required
Maxillary + L
Mandibular + L
55101
55102
Repairs, Complete Denture, Impression
Required
55201
Maxillary + L
55202
Mandibular + L
Repairs/Addition, Partial Denture, No
Impression Required
55301
Maxillary + L
55302
Mandibular + L
55401
55402
Repairs/Addition, Partial Denture,
Impression Required
Maxillary + L
Mandibular + L
Dentures/Implant Retained Prosthesis,
Prophylaxis and Polishing
55501
One unit of time + L
55509
Each additional unit of time
DENTURES, DUPLICATION,
RELINING AND REBASING
56111
56112
Duplication, Complete Denture
Maxillary + L
Mandibular + L
DENTURES, RELINING
56211
56212
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Reline, Direct, Complete Denture
Maxillary + L
Mandibular + L
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Reline, Direct, Partial Denture
Maxillary + L
Mandibular + L
56221
56222
Reline, Processed, Complete Denture
56231
Maxillary + L
56232
Mandibular + L
56241
56242
Reline, Processed, Partial Denture
Maxillary + L
Mandibular + L
56261
56262
Reline, Processed, Functional
Impression requiring three
Appointments, Partial Denture
Maxillary + L
Mandibular + L
DENTURES, REMAKE
56411
56412
Dentures, Remake, Using Existing
Framework, Partial Denture
Maxillary + L
Mandibular + L
DENTURES, TISSUE
CONDITIONING
56511
56512
Dentures, Tissue Conditioning, per
Appointment, Complete Dentures
Maxillary + L
Mandibular + L
56521
56522
Dentures, Tissue Conditioning, per
Appointment, Partial Dentures
Maxillary + L
Mandibular + L
Dentures, Miscellaneous Services
56601 Resilient Liner, in Relined or Rebased
Denture (in addition to reline or rebase of
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denture + L)
56602 Resetting of Teeth (not including reline or
rebase of denture + L)
PROSTHESIS, MAXILLOFACIAL
57101
57102
57103
57104
57105
57106
57108
57109
57202
57203
57204
57208
57209
57301
57302
57304
57305
57308
57311
57321
57341
57342
Prosthesis, Facial
Orbital + L
Nose + L
Ear + L
Patch + L
Facial, Complex + L
Facial, Moulage Impression Complete
Ocular Conformer Prosthesis
Ocular Prosthesis
Prosthesis, Maxillofacial, Obturators
Obturator (Definitive) (prosthesis extra) +
L
Obturator (Post-surgical) (prosthesis
extra) + L
Obturator (Temporary) (prosthesis extra)
+L
Obturator Prosthesis, Modification
(relines or repairs) + L
Speech Aid Prosthesis
Prosthesis, Maxillofacial, Other
Velar (Speech) Bulb (prosthesis and
Obturator extra) + L
Velar Lift Button, Mechanical (prosthesis
and Obturator extra + L
Retention, Magnetic (prosthesis) extra +
L
Guide Plane, Condylar ( prosthesis extra)
+L
Skull Plate, Customized + L
Feeding Appliance (for infants with cleft
palate) + L
Lingual Prosthesis
Mandibular Resection Prosthesis with
Guide Flange + L
Mandibular Resection Prosthesis without
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Guide Flange + L
Prosthesis, Temporomandibular Joint
57401
Exerciser, Trismus, therapy + L
Prosthesis, Splints
57503
Gunning (Upper and Lower) + L
57504
Bar Splint, Labial and Lingual + L
57505 Scaffolding, Rhinoplastic (Nasal Stent) + L
57507
Template, Surgical + L
57508
Commissure Splint + L
Prosthesis, Stents
Ridge Extension +L
Maxillary and Mandibular + L
Skin Grafts
Mucous Membrane Grafts (Mucosal
Guard)
57601
57602
57603
57604
57651
57652
57653
57660
Prosthesis, Radiation Appliances
Radiation Vehicle Carrier + L
Radiation Protection Shield ( extra oral ) +
L
Radiation Protection Shield ( intra-oral ) +
L
Prosthesis, Stents, Decompression
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