alberta health care insurance plan...to: all dentists and billing staff amendments have been made to...

To: All dentists and billing staff

Amendments have been made to the Oral and Maxillofacial Devices and Services (OMDS) Program, effective for treatment plans approved on or after April 1, 2014.

The amendments include revision to the Program Guidelines to provide clarity, an increase to the rates listed in the OMDS Program Schedule, an update to procedure code descriptions, and the addition of a number of services to the Schedule.

Page 2 - 5 of this Bulletin include a list of the procedure codes that have been added to the OMDS Schedule.

Attachment A provides the OMDS Program Payment Guidelines.

Attachment B provides the OMDS Program List of Procedures and Prices.

The OMDS Program may provide funding for some high-cost dental services required in conjunction with an oral surgical procedure insured under the Alberta Health Care Insurance Plan. In order to qualify, the program recipients must require dental services in relation to severe oral/facial conditions caused by birth defects, jaw abnormalities (tumors), major facial trauma or temporomandibular joint (TMJ) disorder. A formal referral to the program by an Oral and Maxilliofacial Surgeon on behalf of the patient is required. Benefits are limited to payment for services such as orthodontics, prosthodontics, dental implants and pre-surgical work-up fees. The OMDS Program is the payer of last resort; all private dental insurance benefits must be utilized prior to funding being requested and an explanation of benefits must accompany the dental claim.

All dental claims must be submitted to the OMDS Program within one year of the date of service, or provision of the device.

If you have any questions about the OMDS Program, please contact the Alberta Health Dental Program Coordinator. See below for contact information. Inquiries can also be mailed to:

OMDS Program Dental Program Coordinator Alberta Health PO Box 1360 Edmonton AB T5J 2N3

Contact: Workforce Strategy Branch

Telephone: Edmonton 780-415-1475 Toll free 310-0000

Fax: 780-422-5208

Approved by: Bernard Anderson

Position: Executive Director Workforce Strategy Branch

Number: Dent 46 Date: June 9, 2014 Page: 1 of 5

Subject: Oral and Maxillofacial Devices and Services Program changes April 1, 2014

Reference: Oral and Maxillofacial Devices and Services Program

Bulletin Alberta Health Care Insurance Plan




New OMDS procedure codes for treatment plans approved on or after April 1, 2014

Procedure Code Description of Service 01200 Examination and Diagnosis, Limited Oral 01204 Examination and Diagnosis, specific examination and evaluation of a specific situation in a

localized area 02100 Radiographs, Regional/Localized 02101 Radiographs, complete series (minimum of 12 images including bitewings) 02110 Radiographs, Periapical 02114 Four images 02115 Five images 02900 Radiographs, Other 02930 Radiographs, Tomography 02933 Three views 02939 Each additional view over four 02950 Radiographic Guide (includes diagnostic wax-up with radio-opaque markers for pre-

surgical assessment of alveolar bone and vital structures as potential osseo-integrated implant site(s))

02951 Maxillary Guide 04700 Supplementary Diagnostic Procedures (interpretation only) 04720 Wax-up, Diagnostic (to evaluate cosmetic and/or preparation design and/or occlusal

considerations) (gnathological wax-up) 04721 Once unit of time 04722 Two units of time 04729 Each additional unit over four 04730 Split Cast Mounting, Diagnostic 04731 One unit of time 04732 Two units of time 04733 Three units of time 04734 Four units of time 04739 Each additional unit over four 06800 Radiographs, Computerized Axial Tomograms (CT), Positron Emission

Tomography (PET), Magnetic Resonance Images (MRI) Interpretation (includes the production of a radiographic report and may include image processing and measurements)

06810 Radiographs, computerized axial tomograms, positron emission tomograms, magnetic resonance images, interpretation, Specialists other than Radiologist

14600 Appliances, Periodontal 14610 Appliances, Periodontal (including bruxism appliance) includes impression,

insertion and insertion adjustment (no post-insertion adjustments) 14612 Mandibular Appliance 16500 Occlusion 16510 Occlusal adjustment/equilibration 16511 One unit of time 16512 Two units of time





Procedure Code Description of Service 23300 Restorations, Tooth-Colored, Permanent Posteriors – Bonded 23320 Permanent Molars 23321 Once Surface 23322 Two Surfaces 23323 Three Surfaces 25000 Restorations, Inlays, Onlays, Pins and Posts 25500 Restorations, Onlays (where one or more cusps are restored) 25531 Onlays, porcelain, ceramic, polymer glass, (Bonded) 26000 Mesostructures 26100 Mesostructures, Osseo-Integrated Implant Supported 26101 Indirect, Angulated or transmucosal pre-fabricated abutment, per implant 27000 Crowns, single units only 27120 Crowns, Plastic, Direct 27125 Crowns, Acrylic, Composite, Compomer, Direct, Provisional Implant-supported 27200 Crowns, Porcelain, Ceramic, Polymer Glass 27202 Crowns, Porcelain, Ceramic, Polymer Glass, Complicated 27205 Crowns, Porcelain, Ceramic, Polymer Glass, Implant-supported 42000 Periodontal Services, Surgical 42400 Periodontal Surgery, Flap Approach 42420 Flap Approach, with Curettage of Osseous Defect 42421 Per sextant 42700 Guided Tissue Regeneration 42701 Guided Tissue Regeneration – Non-Resorbable membrane, per site 42702 Guided Tissue Regeneration – Resorbable Membrane 42703 Guided Tissue Regeneration – Non-Resorbable membrane, surgical re-entry for

removal 51000 Denture, Complete 51700 Dentures, Complete, Overdentures, Tissue Borne, Supported by Natural Teeth

Or Implants with or without Coping Crowns, No Attachments 51711 Maxillary 51712 Mandibular 51720 Dentures, Complete, Overdentures, Tissue Borne, Supported by implants with

or without coping crowns, no attachments 51721 Maxillary 51722 Mandibular 51730 Dentures, Complete, Overdentures, Tissue Borne, Supported by a combination

of natural teeth and implants with or without coping crowns, no attachments 51731 Maxillary 51732 Mandibular





Procedure Code Description of Service 51800 Dentures, Complete, Overdentures (Immediate), Tissue Borne, Supported by natural

teeth with or without coping crowns, no attachments 51811 Maxillary 51812 Mandibular 52000 Dentures, Partial, Acrylic 52110 Dentures, Partial, Acrylic Base, (Immediate) 52111 Maxillary 52112 Mandibular 53000 Dentures, Partial, Cast with Acrylic Base 53130 Dentures, Partial, Free End, Cast Frame/Connector, Clasps and Rests

(Equilibrated) 53131 Maxillary 53132 Mandibular 54000 Dentures, Adjustments 54200 Denture Adjustments, Partial or Complete Denture, Minor 54201 One unit of time 56000 Dentures, Replication, Relining and Rebasing 56500 Dentures, Therapeutic Tissue Conditioning 56520 Dentures, Therapeutic Tissue Conditioning, Per Appointment, Partial Denture 56521 Maxillary 56522 Mandibular 57000 Prosthesis, Maxillofacial 57200 Prosthesis, Maxillofacial, Obturators 57203 Obturator: Post Maxillectomy 62000 Pontics, Bridge 62700 Pontics, Acrylic, Composite, Compomer 62702 Pontics, Acrylic, Composite, Compomer, Indirect (provisional) 63000 Recontouring of Retainers/Pontics (of existing bridgework) 63001 One unit of time 67000 Fixed Bridge Retainers 67100 Retainers, Acrylic, Composite, Compomer With, or Without Cast or Prefabricated

Metal Bases 67110 Retainers, Acrylic, Composite, Compomer, Indirect 67115 Retainers, Acrylic, Composite, Compomer, Implant-supported, Indirect 67120 Retainers, Acrylic, Composite, Compomer, Direct (Provisional During Healing,

Done at Chairside) 67125 Retainers, Acrylic, Composite, Compomer, (Provisional During Healing, Done at Chairside)

Implant-supported, Direct





Procedure Code Description of Service 67200 Retainers, Porcelain, Ceramic, Polymer Glass 67205 Retainers, Porcelain, Ceramic, Polymer Glass, Implant-supported 67210 Retainers, Porcelain, Ceramic, Polymer Glass Fused to Metal Base 67212 Retainers, Porcelain, Ceramic, Polymer Glass Fused to Metal Base, complicated 67300 Retainers, Cast Metal 67320 Retainers, Metal, Inlay 67321 Retainer, Metal Inlay, two surfaces 69000 Fixed Prosthetics, Other Services 69100 Fixed Prosthetics, Miscellaneous Services 69101 Fixed Prosthetics, Porcelain, to replace a Substantial Portion of the Alveolar Process 74400 Hard Tissue Graft to the Jaw 74401 Autograft, Maxilla or Mandible, per site 79000 Oral Surgery Procedure, Other 79900 Implantology (includes placement of implant, post-surgical care, uncovering

and placement of attachment but not prosthesis) 79930 Implant, Osseointegrated, Root Form, more than one component 79933 Surgical installation of implant with final transmucosal element, per implant 79934 Surgical re-entry, removal of healing screw and placement of healing transmucosal

element, per implant 79940 Implants, Osseointegrated, Root Form, Single component 79941 Surgical installation of implant, per implant 92000 Anaesthesia 92200 Anaesthesia, General 92215 Five units of time 92219 Each additional unit over eight 92220 Provision of Facilities, equipment and support services for general anaesthesia

when provided by a separate practitioner 92225 Five units of time 92229 Each additional unit over eight 92300 Anaesthesia, Deep Sedation 92305 Five units of time 92306 Six units of time

Dent 46 Attachment A Page 1 of 8

Oral and Maxillofacial Devices and Services (OMDS) Program Schedule Effective for treatment plans approved on or after April 1, 2014

PART A: PROGRAM GUIDELINES

OVERVIEW OF PROGRAM

The OMDS Program was designed to provide funding for high cost dental treatment required in

conjunction with an oral surgical procedure insured under the Alberta Health Care Insurance Plan

(AHCIP).

In order for a patient to be eligible for funding under the OMDS Program, the patient must require high

cost dental treatment in conjunction with an oral surgical procedure insured under the AHCIP, and have

a condition where an oral manifestation is present and conventional dental rehabilitation is not possible.

Details and further clarification of the OMDS Program is provided below.

DEFINITIONS

For the purposes of this OMDS Program:

(a) “Application” means the referral letter and Treatment Plan submitted by the oral and

maxillofacial surgeon on behalf of the Patient for funding under the OMDS Program.

(b) “Certified Specialist” means a specialist in dentistry (including oral and maxillofacial surgeon)

tasked with providing services pursuant to a Treatment Plan. A Certified Specialist must be a

regulated member of and actively registered with the Alberta Dental Association and College

(this excludes General Dentists).

(c) “Minister” means Her Majesty the Queen in Right of Alberta as represented by the Minister of

Health or his delegate.

(d) “Minister’s Consultant” means a Certified Specialist who is contracted to provide

recommendations to the OMDS Program.

(e) “Minister’s Delegate” means the Executive Director of the Workforce Strategy Branch.

(f) “OMDS Program Rates” means the rate of payment set by the Minister with respect to a

particular treatment service as set out in Part B: List of Procedures and Prices.

(g) “Patient” means the individual seeking high cost dental treatment in conjunction with an oral

surgical procedure insured under the ACHIP.

(h) “Treatment Plan” or “TP” means the course of treatment recommended by the Certified

Specialists and the oral and maxillofacial surgeon.


1. Patient Eligibility Requirements

Recipients of funding under the OMDS Program must:

(a) be registered and entitled to coverage under the AHCIP;

(b) have their Treatment Plan submitted to the OMDS Program coordinator(s) for review by the

Minister’s Consultant;

(c) receive the insured oral surgical procedure and high cost dental treatment in Alberta (unless the

insured oral surgical procedure is not available in Alberta); and

(d) have no, or have exhausted third party coverage and all other provincial or federal government

benefits with respect to the high cost dental treatment.

2. Program Eligibility Criteria

Patients may be eligible for funding under the OMDS Program provided a Certified Specialist confirms in

the Treatment Plan that the patient requires:

a) high cost dental treatment in conjunction with an oral surgical procedure insured under the

AHCIP and;

b) has one of the following conditions where an oral manifestation is evident and conventional

dental rehabilitation is not possible:

i. a severe syndromic congenital abnormality;

ii. a severe acquired abnormality (i.e., facial injury resulting in a malocclusion requiring

orthodontics, orthognathic surgery, or restorative reconstruction);

iii. ablative surgery for malignant or non-malignant disease when dental reconstruction can

safely and effectively be performed outside a multidisciplinary setting as determined by

the treating oral and maxillofacial surgeon;

iv. major avulsive trauma (i.e., avulsion injury of the dental alveolus resulting in a

demonstrative loss of three or more teeth requiring bone grafting; injury in the canine

tooth region and the repair is curvilinear; or one or two teeth lost but extensive bone

grafting techniques, such as iliac crest grafting or significant soft tissue reconstructive

procedures, are required);

v. major Temporomandibular Joint Disorder requiring surgery; or

vi. congenital oligodontia, when dental treatment is required to place critical missing teeth

to restore functionality and nutritional status.


3. Additional Conditions and Limitations

• Cancer patients must be cancer free for a period of two to five years unless the Minister’s

Delegate determines otherwise. The waiting time will be determined following consultation

with the Minister’s Consultant.

• Only dental treatment performed by a Certified Specialist is eligible for funding under the OMDS

Program.

• Cleft palate patients receiving services under the Cleft Palate Dental Indemnity Program may be

eligible for funding under the OMDS Program for services which are required in conjunction with

an insured oral surgical service and which are not currently covered under the Cleft Palate

Dental Indemnity Program as listed in their payment guidelines.

• The OMDS Program does not cover the management of dentofacial deformities that are

morphological variants from the normal facial skeleton and that can be treated with

conventional orthodontic and orthognathic procedures (i.e., mandibular and maxillary

deficiencies, mandibular and maxillary excess and chin deformities). The OMDS Program does

not cover management of bone loss in the maxilla or mandible due to long-term denture use.

4. Application Process

(a) Applications for funding under the OMDS Program must be submitted by an oral and

maxillofacial surgeon, unless otherwise provided for in (b).

(b) An Application from a specialist physician or an orthodontist may be considered where the

proposed dental treatment is orthodontic treatment only and is required in conjunction with an

insured oral surgical procedure as listed in the Schedule of Medical Benefits or the Schedule of

Oral and Maxillofacial Surgery Benefits. The referring specialist physician or orthodontist must

indicate that it is not necessary for the patient to be assessed by an oral and maxillofacial

surgeon.

(c) The Application must contain a comprehensive Treatment Plan for the Patient including all

treatments and associated treatment plans to be provided by the respective Certified Specialists

for the Patient. Where staged care is required, the submitted Treatment Plan should describe

the long and short-term treatments proposed. All Treatment Plans must include diagnostic

records unless the Minister’s Consultant determines otherwise.

(d) On receipt of the Application, confirmation of Patient AHCIP eligibility and a review of the

Application for completeness are conducted by the OMDS Program coordinator(s).

(e) Upon confirmation of AHCIP Patient coverage and a completed Application, the Treatment Plan

is forwarded to the Minister’s Consultant for review and recommendation.


(f) The Minister’s Consultant will provide recommendations to the Minister’s Delegate on whether

to approve or reject the proposed Treatment Plan. The Minister’s delegate is not bound by the

recommendations of the Minister’s Consultant.

(g) In consideration of the recommendation made by the Minister’s Consultant, the Minister’s

Delegate makes a final decision with respect to approving or rejecting the proposed Treatment

Plan.

(h) If the Treatment Plan is approved, then services performed for the Patient pursuant to the

Treatment Plan will be funded at the OMDS Program Rates as they were on the date of the

approval of the Treatment Plan.

5. Payment Parameters

(a) Funding is provided for treatment services performed post approval of the Treatment Plan.

Unless otherwise approved by the Minister’s Delegate, services provided prior to approval are

not reimbursed under the OMDS Program. Any decision to fund services provided prior to

approval of the Treatment Plan will be at the discretion of the Minister’s Delegate.

(b) The OMDS Program is payer of last resort and is designed to supplement group, individual or

any third party coverage. The OMDS Program is not an alternative to existing third party

coverage.

(c) The OMDS Program is also supplemental to any other Provincial or Federal government

benefits. The OMDS Program is not an alternative to funding under another government benefit

programs.

(d) All Treatment Plans and claims under Treatment Plans must be submitted to an existing third

party insurer or department/agency prior to submission to the OMDS Program. The only

exception to this would be instances where the Minster has entered into an apportionment

agreement with another department/agency to share costs between programs.

(e) Proof of assessment or proof of denial of payment from the third party insurer or other

program/agency must be presented when submitting claims to the OMDS Program.

(f) OMDS Program Rates will be established by the Minister’s Delegate and will be paid as set out in

Part B: List of Procedures and Prices. OMDS Program Rates payable are those stipulated as of

the date of approval of the Treatment Plan.

(g) For staged Treatment Plans, requests for funding must be made at each stage of treatment.

For example:

i. TP is approved April 1, 2014 the rates applicable for services performed under this TP

would be the April 1, 2014 rates. (“2014 Rates”). Services performed by a Certified

Specialist in July 2015 pursuant to the TP would then be paid the 2014 Rates.

ii. TP is approved April 1, 2014. New Prices come into effect on April 1, 2016. Services are

provided by a Certified Specialist in July 2016. Payment is as at the rates set out in April

1, 2014.


6. Claims for Services

(a) Claims for services provided by a Certified Specialist under a Treatment Plan must be made

within one year of the date of service or provision of device.

(b) Payment for claims beyond one year of date of service or provision of device is at the discretion

of the Minister’s Delegate. The Minister’s Delegate may consider accepting claims beyond one

year of the date of service or provision of device if, in the Minister’s Delegate discretion,

extenuating circumstances existed. Requests for extensions of time due to extenuating

circumstances must be submitted in writing to the Minister’s Delegate for consideration.

NOTE: Extenuating circumstances will apply in very few cases, for example, consideration may be

given to outdated dental claims resulting from things such as disaster (fire, flood), fraud, theft of

computer or paper records, or claims refused by the Worker’s Compensation Board.

(c) In the exceptional case where a particular service for the Patient is not payable under the Part B:

List of Procedures and Prices but, in the written recommendation of the Certified Specialist the

service is essential for the acute management of the Patient’s ongoing treatment, funding may

be considered for that service at the discretion of the Minister’s Delegate.

(d) If a dental service is deemed required by the treating Certified Specialist and is recommended

for funding approval by the Minister’s Consultant and is not listed in the OMDS Program

Schedule of Procedures and Prices, the service may be claimed as an unlisted procedure using

code 99999. Benefits for unlisted procedures will be assessed by OMDS Program coordinator(s)

by comparing the benefit claimed to the benefits listed for similar procedures requiring similar

responsibility and skill. Documentation to support the claim must be submitted by the treating

Certified Specialist.

(e) Where a service or procedure is listed in the OMDS Program Schedule of Procedures and Prices

but the price is determined “By Report” (B.R.), that price will be determined by the Minister’s

Delegate in consultation with the Minister’s Consultant and the treating Certified Specialist.

7. Changes to Treatment Plan During Course of Treatment

(a) If, during the course of treatment, circumstances arise so as to warrant substantial modification

or redevelopment of a Treatment Plan, a revised Treatment Plan must be submitted to the

OMDS Program by the Certified Specialist for the Patient. The submitting Certified Specialist

must provide rationale as to why the substantial modification or redevelopment is necessary.

(b) If, during the course of treatment, an additional service not provided for in the Treatment Plan

is warranted, the service may be funded at the discretion of the OMDS Program coordinator(s).

The Certified Specialist must provide the OMDS Program with details around the additional

service including rationale as to why the additional service was necessary.


(c) Where a revised/new Treatment Plan is submitted, any treatments already approved under the

previous Treatment Plan shall continue to be paid at the OMDS Program Rates as of the date of

the previous Treatment Plan approval.

(d) A change in OMDS Program Rates is not a reason to warrant the submission of a revised,

amended or new Treatment Plan for the Patient.

8. General Program Information

(a) Where a dental implant, prosthesis, appliance or dental device is required, the OMDS Program

covers only the initial cost of the service. Maintenance, replacements and repairs, whether due

to negligence, normal use or for any other reason, is the financial responsibility of the Patient.

(b) Coverage may be discontinued due to the Patient’s non-compliance with treatment protocols.

Dental services required due to non-compliance will not be claimable even though the original

treatment may have been funded by the OMDS Program. Patients seeking reinstatement must

provide evidence of compliance with prescribed protocols before any coverage will be

considered for future services.

(c) The Patient may be asked to undergo assessments and tests determined by the Minister’s

Delegate as necessary to ensure that the services for which funding is requested are required,

appropriate and the most cost-effective option.

(d) Funding approved for a specific dental service cannot be applied towards a cosmetic dental

procedure.

(e) In the event that any of the approved funding is not utilized by the Patient within five years from

the date of approval of the Treatment Plan, funding will be withdrawn and a new Application

must be submitted by the oral and maxillofacial surgeon on behalf of the Patient.

9. Included Benefits under the OMDS Program

Only those dental services that are required in conjunction with an insured oral surgical procedure may

be considered for coverage under the OMDS Program. Dental services eligible for funding include:

• Diagnostic, restorative, endodontic, periodontic and oral and maxillofacial surgical procedures: as

listed in the OMDS Program Schedule of Procedures and Prices when required in conjunction with

one of the conditions listed in paragraph 2(b) and when required in conjunction with an insured oral

surgical procedure or in conjunction with high cost dental reconstruction and is performed by a

Certified Specialist.


• Dental pre-surgical work-up services: three dimensional or stereolithic models, pre-surgical

models, model analysis, model surgery, prediction tracings, treatment planning, splint fabrication

and related laboratory costs, radiographs needed for assessment and treatment planning required

in preparation for an insured oral surgical procedure. These services are eligible for funding only

when they are not insured benefits under the AHCIP or are not payable by Alberta Health Services.

• Anaesthesia and Facility Fees: general anaesthesia and neurolept anaesthesia when administered

by a physician in a hospital or in an accredited non-hospital surgical facility (plus non-hospital facility

fees), when (a) neither the anaesthesia nor the oral surgical procedure is an insured benefit under

the AHCIP , (b) the non-hospital facility fee is not payable by Alberta Health Services, and (c) the

anaesthesia is required to provide one of the services that are eligible for coverage under the OMDS

Program.

• Osseointegrated dental implants: eligible for coverage only when the surgical component

(insertion) is performed by an oral and maxillofacial surgeon. The OMDS Program may provide

funding for initial placement only. No funding will be provided for replacements, repairs or

maintenance costs for any reason.

• Orthodontic Services: coverage includes all active treatment, insertion of retainers, orthodontic

records, observation appointments, radiographs and retention appointments. Multistage or

extended orthodontic treatment must be identified by the oral maxillofacial surgeon at the time of

application. Treatment plan updates will be required periodically to assess the Patient’s continuing

need for services.

• Prosthodontic Services: prosthodontic replacement of extracted teeth with dental implants only

when conventional removable prosthodontic treatment (e.g. dentures or bridges) is not deemed

adequate. The OMDS Program is responsible for initial placement of the implant and prosthesis or

appliance only. Other prosthetic treatment required in conjunction with an insured oral surgical

procedure and required to maintain oral function and nutritional status.

• Temporomandibular Joint Replacement (TMJ) Services: dental services without which a total

temporomandibular joint prosthetic replacement would not be possible including dental pre-

surgical work-up, orthodontic treatment and dental implant rehabilitation. Funding may also be

available for devices required for TMJ ankylosis and for TMJ replacement.

10. Specifically Excluded under the OMDS Program

The following are excluded from coverage under the OMDS Program:

• Prophylaxis or general dental work (cleanings, fillings);

• Treatment of pre-existing dental disease which is not directly related to one of the conditions for

inclusion in the OMDS Program (some discretion may be allowed if supported by the Certified

Specialist and the Minister’s Consultant);


• Dental or orthodontic treatment which is cosmetic or is not directly related to the provision of an

oral surgical procedure insured under the AHCIP;

• Funding approved for a dental service cannot be applied towards a more expensive or upgraded

dental service (e.g. funding approved for a crown cannot be applied to a dental implant where

implant is preferred by the Patient);

• Dental treatment required due to lack of compliance with treatment protocols prescribed by the

treating Certified Specialist;

• Services or devices which are experimental or the subject of clinical trials, are considered alternative

dental therapy, or are not endorsed by the Alberta Dental Association and College;

• Any health care goods and services which are covered under the AHCIP, or are part of an insured

service provided in a hospital or in a non-hospital surgical facility and payable by Alberta Health

Services;

• Laboratory, diagnostic, therapeutic and other services provided and payable by Alberta Health

Services;

• Services received outside of Alberta unless not available in the Province;

• Services which are eligible for coverage under Workers’ Compensation Legislation;

• Services which are provided to non-eligible patients as listed in the AHCIP;

• Treatment falling under the auspices of Alberta Health Services;

• Local anaesthesia;

• General anaesthesia and neurolept anaesthesia (and related facility fees) when provided by a

dentist;

• Replacement, repairs, maintenance costs, of OMDS Program funded dental implants, prosthetic

treatments, prosthetic devices, or dental appliances for any reason including treatment failures

unless a new condition, eligible and approved for funding in accordance with the OMDS Program

eligibility criteria, arises;

• Pre-surgical work-up for procedures that are not insured under the AHCIP and are not eligible for

funding under this Program;

• Subsistence, travel/mileage and accommodation costs for the person receiving eligible goods under

the program or anyone who accompanies that person.

Dent 46 Attachment B Page 1 of 21

Oral and Maxillofacial Devices and Services (OMDS) Program Schedule Effective for treatment plans approved on or after April 1, 2014

PART B: List of Procedures and Prices Procedure

Code

Description of Service

2014/2015

OMDS Fee

Lab Fee

Diagnostic:

Examinations and Diagnosis: Complete, Oral, to include:

(a) History, Medical and Dental.

(b) Clinical examination and diagnosis of hard and soft tissues, including: carious

lesions, missing teeth, determination of sulcular depth, gingival contours, mobility of

teeth, interproximal tooth contact relationships, occlusion of teeth, TMJ, pulp vitality

tests/analysis where necessary, and any other pertinent factors.

(c) Radiographs extra, as required.

01101

Examination and Diagnosis: Complete, Primary Dentition, to include:

(a) Extended examination and diagnosis on primary dentition, recording history,

charting, treatment planning and case presentation, including above description as per

01100.

78.95

01102

Examination and Diagnosis: Complete, Mixed Dentition, to include:

(a) Extended examination and diagnosis on mixed dentition, recording history, charting,

treatment planning and case presentation, including above description as per 01100.

(b) Eruption sequence, tooth size - jaw size assessment.

118.43

01103

Examination and Diagnosis: Complete, Permanent Dentition, to include:

(a) Extended examination and diagnosis on permanent dentition, recording history,

charting, treatment planning and case presentation, including above description as per

01100.

118.43

01200

Examinations and Diagnosis, Limited Oral

01201

Examination and Diagnosis: Limited, Oral, New Patient

Examination and Diagnosis of hard and soft tissues, including checking of occlusion and

appliances, but not including specific test/analysis as for 01100. (May include PSR)

78.95

01202

Examination and Diagnosis: Limited, Oral, Previous Patient (recall)

Examination of hard and soft tissues, including checking of occlusion and appliances,

but not including specific tests/analysis, as for 01100.

78.95

01204

Examination and Diagnosis, Specific Examination and evaluation of a specific situation

in a localized area.

78.95

01300

Examinations and Diagnosis: Stomatognathic, Dysfunctional

01301

Examination and Diagnosis: Stomatognathic Dysfunctional, Comprehensive, to include:

(a) History, medical, dental, pain/dysfunction

(b) Clinical examination to include, general appraisal, examination of head & neck,

musculoskeletal system (static & functional); intraoral examination of hard & soft

tissues, including occlusal analysis; consultation with other health care professionals,

review of previous records, including radiographs; ordering of appropriate tests/analysis

and consultations.

217.09



Code


2014/2015

OMDS Fee

Lab Fee

Examinations and Diagnosis: Periodontal

01501

Examination and Diagnosis: Periodontal, General

Recording History, Charting, Treatment Planning and Case Presentation:

(a) History, medical and dental

(b) Clinical Examination includes evaluation of topography of the gingiva and related

structures; degree of gingival inflammation; location, extent, sulcular depth; furcation

involvement, mobility of teeth; tooth contact relationships; evaluation of occlusion; TMJ;

examination of oral soft tissue pathosis; evaluation of the existing restorative and/or

prosthetic appliances; caries and pulpal vitality.

260.50

01600

Examinations and Diagnosis: Surgical

01601

Examination and Diagnosis: Surgical, General

(a) History, Medical and Dental

(b) Clinical Examination as above, may include in-depth analysis of medical status,

medication, anaesthetic and surgical risk, initial consultation with referring dentist or

physician, parent or guardian, evaluation of source of chief complaint, evaluation of

pulpal vitality, mobility of teeth, occlusal factors, TMJ, or where the patient is to be

admitted to hospital for dental procedures.

173.66

01602

Examination and Diagnosis: Surgical, Specific

86.84

01700

Examinations and Diagnosis: Prosthodontic

01701

Examination and Diagnosis: Prosthodontic, Edentulous

(a) Extended examination of the Edentulous mouth, including detailed medical and

dental history (incl. prosthetic history), visual and digital examination of the oral

structures, head and neck (incl. TMJ), lips, oral mucosa, tongue, oral pharynx, salivary

glands and lymph nodes and including evaluation for implant-supported prosthesis.

141.55

01702 Examination and Diagnosis: Prosthodontic, Specific 78.95 01703

Examination and Diagnosis: Prosthodontic, Fixed Oral Rehabilitation, to include:


(b) Clinical Examination of Hard and Soft Tissues, including carious lesions, missing

teeth, determination of sulcular depth, gingival contours, mobility of teeth, interproximal

tooth contact relationships, occlusion of teeth, TMJ, pulp vitality test/analysis, where

necessary and any other pertinent factors.

(c) Evaluation of specific sites for implant-supported or retained prosthesis.

(d) Radiographs extra, as required.

146.56

01800 Examinations and Diagnosis: Endodontic

01801

Examination and Diagnosis: Endodontic, Complete

Endodontic examination and diagnosis and/or complicated diagnosis. Recording history,

charting treatment planning and case history. Includes the following:


(b) Clinical examination and diagnosis may include vitality tests/analysis, thermal

tests/analysis, cracked tooth tests/analysis, occlusal exams, percussion, palpation,

transillumination, anaesthetic tests/analysis and mobility tests/analysis.

173.66

01802

Examination and Diagnosis: Endodontic, Specific Endodontic examination and

evaluation of a specific situation in a localized area and vitality tests/analysis.

86.84



Code


2014/2015

OMDS Fee

Lab Fee

01900

Examinations and Diagnosis: Orthodontic

01901

Examination and Diagnosis: Orthodontic, General

To include:

(a) Diagnostic models, complete intraoral radiograph series or panoramic film,

cephalograms, facial and intraoral photographs, consultation and case presentation.

434.19

260.51

01902 Examination and Diagnosis: Orthodontic, Specific 86.84

02000 Radiographs (including radiographic examination and diagnosis and interpretation)

02100

Radiographs: Regional/Localized

02101 Radiographs: Complete Series (minimum 12 images incl. bitewings) 209.95

02102 Radiographs: Complete Series (minimum of 16 images incl. bitewings) 209.95

02110

Radiographs: Periapical

02111 Single image 31.53

02112 Two images 52.52

02113 Three images 73.57

02114 Four images 116.97

02115 Five images 143.03

02130 Radiographs: Intraoral, Occlusal

02131 Single image 52.52

02600

Radiographs: Panoramic

02601 Single film 105.10

02603 3X pan x-ray 288.49

02700

Radiographs: Cephalometric

02701 Single film 125.75

02702 Two films 197.18

02750

Radiographs: Cephalometric, Tracing and Interpretation

02751 One unit of time 86.84

02752 Two units of time 173.66

02759 Each additional unit over two 86.84

02800

Radiograph: Computerized Axial Tomograms (CT), Positron Emission

Tomography (PET), Magnetic Resonance Images (MRI), Interpretation (Either the

Radiographs, CT Scans, PET Scans, MRI Scans, or the Interpretation must be received

from another source)

02801 One unit of time 82.89 02802 Two units of time 204.98 02809 Each additional unit over two 82.89 02900 Radiographs: Other 02930 Radiographs: Tomography 02933 Three views 227.07



Code


2014/2015

OMDS Fee

Lab Fee

02934 Four views 327.78 02939 Each additional view over four 106.12

02950

Radiographic Guide (includes diagnostic wax-up, with radio-opaque markers for pre-

surgical assessment of alveolar bone and vital structures as potential osseo-integrated

implant site(s))

02951 Maxillary Guide 432.73 259.64

02952 Mandibular Guide 432.73 259.64

03000

Template Surgical (includes diagnostic wax-up. Also used to locate and orient osseo-

integrated implants)

03001 Maxillary Template 82.66 49.60

03002 Mandibular Template 82.66 49.60

04700

Supplementary Diagnostic Procedures (Interpretation Only)

04720

Wax-up, Diagnostic (to evaluate cosmetic and/or preparation design and/or occlusal

considerations) (gnathological wax-up)

04721 One unit of time

97.60

58.56

04722 Two units of time 195.22 117.13

04723 Three units of time 432.73 259.64

04724 Four units of time 460.41 276.25

04729 Each additional unit over four 97.60

04730

Split Cast Mounting: Diagnostic

04731 One unit of time 97.60 04732 Two units of time 195.22 04733 Three units of time 292.83 04734 Four units of time 390.44 04739 Each additional unit over four 97.60

04740

Interpretation of Diagnostic Casts

04741 First unit of time 86.69 04749 Each additional unit of time 86.69

04800 Photographs: Diagnostic (Technical Procedure Only)

04801 Single photograph 18.75 04802 Two photographs 37.51 04803 Three photographs 56.25 04809 Each additional photograph over three 18.75

04900 Casts: Diagnostic (Technical Procedure Only)

04910 Casts: Diagnostic, Unmounted

04911 Casts: diagnostic, unmounted 155.03 93.02

04920 Casts: Diagnostic, Mounted

04921 Casts: diagnostic, mounted 112.53 67.52

04922 Casts: diagnostic, mounted, using face bow transfer 150.03 90.02

04923 Casts: diagnostic, mounted, using face bow and occlusal records 269.62 161.77



Code


2014/2015

OMDS Fee

Lab Fee

04924

Casts: diagnostic, mounted, using fully adjustable articulator (used with 04941 and

04942)

269.62

161.77

04930 Casts: Diagnostic Orthodontic

04931 Casts: diagnostic orthodontic (unmounted, angle trimmed and soaped) 150.03 90.02

04940 Casts: Diagnostic, Miscellaneous Procedures

04942

Three dimensional recordings of patient's dynamic movements for programming of fully

adjustable articulators 245.16

147.10

05000

Case Presentation/Treatment Planning

05100

Treatment Planning

(This service is only for extra time spent on unusually complicated cases or where the

patient demands unusual time in explanation or where diagnostic material is received

from another source. Usual case presentation time and usual treatment planning time

are implicit in the examination and diagnosis fee and in the radiographic interpretation

fee.)

05101 One unit of time 78.95 05102 Two units of time 157.91 05103 Three units of time 236.87 05104 Four units of time 334.72 05109 Each additional unit over four 78.95

05200 Consultation: With Patient

05201 One unit of time 78.95 05202 Two units of time 157.91 06800

Radiographs, Computerized Axial Tomograms (CT), Positron Emission

Tomography (PET), Magnetic Resonance Images (MRI) Interpretation (includes the

production of a radiographic report and may include image processing and

measurements)

06810

Radiographs, computerized axial tomograms, positron emission tomograms,

magnetic resonance images, interpretation, Oral Radiologist

402.41

06820

Radiographs, computerized axial tomograms, positron emission tomograms, magnetic

resonance images, interpretation, Specialist other than Oral Radiologist

402.41

Preventive:

13200

Oral Hygiene Instruction/Plaque Control

To include: brushing and/or flossing and/or embrasure cleaning

13210

Individual Instruction (One instructor to one patient) - Excluding Audio-Visual Time

13211 One unit of time 109.99 14600

Appliances: Periodontal (See separate codes for control of oral habits 14100,

Protective Mouth Guards 14500 and TMJ 14700 and TMJ Appliances 14800)

14610

Appliances: Periodontal (including bruxism appliance); includes impression, insertion

& insertion adjustment (no post-insertion adjustments)

14611 Maxillary appliance 454.37 272.62

14612 Mandibular appliance 454.37 272.62



Code


2014/2015

OMDS Fee

Lab Fee

16400

Recontouring of Teeth for Functional Reason (Not associated with delivery of a

single or multiple prosthesis)

16401 One unit of time 86.19 51.72

16409 Each additional unit of time 86.19 51.72

16500 Occlusion 16510

Occlusal adjustment/equilibration:

(a) May require several sessions

(b) May be used in conjunction with basic restorative treatment only when occlusal

adjustment/equilibration is not required as a result of that restoration.

(c) Not to be used in conjunction with the delivery and post-insertion care of: fixed or

removable prosthesis (50000 & 60000 code series) by the same dentist for period of

three months.

16511 One unit of time 79.13 16512 Two units of time 158.25 16513 Three units of time 237.38 Restorative: 20100 Caries, Trauma and Pain Control 20110

Caries/trauma/pain control (removal of carious lesions or existing restorations or

gingivally attached tooth fragments and placement of sedative/protective dressings,

includes pulp caps when necessary, as a separate procedure)

20111 First tooth 179.19 20119 Each additional tooth in same quadrant 179.19 20120

Caries/trauma/pain control (removal of carious lesions or existing restorations or

gingivally attached tooth fragments & placement of sedative/protective dressings,

includes pulp caps when necessary & the use of a band for retention & support, as a

separate procedure)

20121 First tooth 224.00 20129 Each additional tooth in same quadrant 224.00 20130 Trauma Control: Smoothing of Fractured Surfaces Per Tooth 20131 First tooth 42.67 20139 Each additional tooth in same quadrant 42.67 21100 Restorations: Amalgam, Primary Teeth 21110 Restorations: amalgam, non-bonded, primary teeth 21111 One surface 104.58 21112 Two surfaces 153.72 21113 Three surfaces 197.65 21114 Four surfaces 241.56 21115 Five surfaces or maximum surfaces per tooth 263.53 21120 Restorations: amalgam, bonded, primary teeth 21121 One surface 125.50 21122 Two surfaces 175.69 21123 Three surfaces 219.61 21124 Four surfaces 263.53



Code


2014/2015

OMDS Fee

Lab Fee

21125 Five surfaces or maximum surfaces per tooth 285.48

21200

Restorations, Amalgam, Permanent Teeth

21210

Restorations: Amalgam, Non Bonded, Permanent Bicuspids & Anteriors

21211 One surface 104.58 21212 Two surfaces 153.72 21213 Three surfaces 197.64 21214 Four surfaces 241.56 21215 Five surfaces or maximum surfaces per tooth 263.53

21230

Restorations: Amalgam, Bonded, Permanent Bicuspids and Anteriors

21231 One surface 125.50 21232 Two surfaces 175.69 21233 Three surfaces 219.61 21234 Four surfaces 263.53 21235 Five surfaces or maximum surfaces per tooth 285.48

21300 Restorations: Amalgam Cores

21301

Restoration: Amalgam Core, Non-bonded, in conjunction with crown or fixed bridge

retainer

219.61

21302

Restoration: Amalgam Core, Bonded, in conjunction with crown or fixed bridge retainer 241.56

21400

Pins: Retentive Per Restoration

(For amalgams and tooth coloured restorations)

21401 One pin 32.44

21402 Two pins 48.65

21403 Three pins 64.87

21404 Four pins 81.09

21405 Five pins or more 97.31

21500

Restorations Made To A Tooth Supporting An Existing Partial Denture Clasp

(Additional to restoration)

21501 Per restoration 81.09

22000

Restorations: Prefabricated, Full Coverage

22200

Restorations: Prefabricated, Metal, Primary Teeth

22201 Primary anterior 197.64

22202 Primary anterior - open face/acrylic veneer 241.56

22300

Restorations: Prefabricated, Metal, Permanent Teeth

22301 Permanent anterior 263.53

22302 Permanent anterior - open face 307.45

22400

Restorations: Prefabricated, Plastic, Primary Teeth

22401 Primary anterior 179.19



Code


2014/2015

OMDS Fee

Lab Fee

22500

Restorations: Prefabricated, Plastic, Permanent Teeth

22501 Permanent anterior 246.40 23000 Restorations, Tooth Coloured/Plastic With/Without Silver Fillings

23100 Restorations: Tooth Coloured, Permanent Anteriors, Non Bonded Technique

23110

Restorations: Permanent Anteriors, Bonded Technique (not to be used for Veneer

Applications or Diastema Closures)

23111 One surface 153.72 23112 Two surfaces (continuous) 175.69 23113 Three surfaces (continuous) 197.64 23114 Four surfaces (continuous) 241.56 23115 Five surfaces (continuous, or maximum surfaces per tooth) 285.48

23120 Restorations: Tooth Coloured, Veneer Applications

23122 Tooth coloured veneer application - Non prefabricated direct build-up - bonded 373.33

23123 Tooth coloured veneer application - Diastema closure, interproximal only, bonded 285.48

23300 Restorations: Tooth Coloured, Permanent Posteriors - Bonded Technique

23320 Permanent Molars

23321 One surface 179.34 23322 Two surfaces 256.21 23323 Three surfaces 307.44

23400

Restorations: Tooth Coloured, Primary, Anterior, Non Bonded

23410

Restorations: Tooth Coloured, Primary, Anterior, Bonded Technique

23411 One surface 153.72 23412 Two surfaces (continuous) 175.69 23413 Three surfaces (continuous) 197.64 23414 Four surfaces (continuous) 241.56 23415 Five surfaces (continuous, or maximum surfaces per tooth) 285.48

23600 Restorations: Tooth Coloured/Plastic With/Without Silver Fillings, Cores

23601

Restorations: tooth coloured, non-bonded core, in conjunction with crown or fixed bridge

retainer

256.21

23602

Restorations: tooth coloured, bonded core, in conjunction with crown or fixed bridge

retainer

307.45

25500 Restorations, Onlays (where one or more cusps are restored)

25530 Onlays: Porcelain/Ceramic/Polymer Glass (Bonded) 25531 Onlays: porcelain/ceramic/polymer glass (bonded) 768.59 461.15

25700

Posts

25710

Posts: Cast Metal, (including core) As A Separate Procedure

25711 Single section 357.33 214.40

25712 Two sections 446.66 267.99

25713 Three sections 535.98 321.59



Code


2014/2015

OMDS Fee

Lab Fee

25720

Posts: Cast Metal (Including Core) Concurrent With Impression For Crown

25721 Single section 178.65 107.19

25722 Two sections 267.98 160.79

25723 Three sections 357.33 214.40

25730 Post: Prefabricated Retentive 25731 One post 134.00 25732 Two posts same tooth 267.98 25733 Three posts same tooth 401.99 26000

Mesostructures (A separate component positioned between the head of an

implant and the final restoration, retained by either a cemented post or screw)

26100

Mesostructures, Osseo-Integrated, Implant-Supported

26101 Indirect, Angulated or transmucosal pre-fabricated abutment, per implant

290.13

174.08

26102 Indirect, custom laboratory fabricate, per implant 1006.02 603.61

27000

Crowns, Single Units Only (includes temporary protection and local anaesthetic, caries

removal, and uncomplicated restoration prior to crown preparation). Extensive

restoration requiring pins or dowels extra.

27100

Crowns: Acrylic/Composite/Compomer (With Or Without Cast Or Prefabricated

Metal Bases)

27110 Crowns: Acrylic/Composite/Compomer, Indirect

27111 Crown: acrylic/composite/compomer, indirect 714.64 428.78

27113

Crown: acrylic/composite/compomer provisional (long term), Indirect (lab

fabricated/relined intra-orally) 180.31

108.19

27120 Crowns: Acrylic/Composite/Compomer, Direct

27121 Crown: acrylic/composite/compomer, direct, provisional (chair-side) 134.00

27125 Crowns: acrylic/composite/compomer, direct, provisional implant-supported 156.79

27200 Crowns: Porcelain/Ceramic/Polymer Glass

27201 Crown: porcelain/ceramic/polymer glass 963.27 577.96

27202 Crown: porcelain/ceramic/polymer glass, complicated 1313.90 788.34

27205 Crown: porcelain/ceramic/polymer glass, implant-supported 1127.16 676.30

27210

Crowns: Porcelain/Ceramic/Polymer Glass Fused To Metal Base

27211

Crown: porcelain/ceramic/polymer glass fused to metal base

963.27

577.96

27212

Crown: porcelain/ceramic/polymer glass fused to metal base, complicated (restorative,

positional and/or aesthetic) 1666.19

999.72

27213

Crown: porcelain/ceramic fused to metal base, screwed directly to an implant without the

intervening post 1934.63

1160.78

27215 Crown: porcelain/ceramic/polymer glass fused to metal base, implant-supported

1729.08

1037.45

27220

Crowns: 3/4 Porcelain/Ceramic/Polymer Glass

27222 Crown: 3/4 porcelain/ceramic/polymer glass, complicated

921.41

552.84

27300 Crowns: Cast Metal

27301 Crown: cast metal 963.27 577.96



Code


2014/2015

OMDS Fee

Lab Fee

27310 Crown: 3/4, cast metal

27311 Crown: 3/4, cast metal 963.27 577.96

27600 Veneers: Laboratory Processed

27601 Veneers: acrylic/composite/compomer, bonded 714.64 428.78

27602 Veneers: porcelain/ceramic/polymer glass, bonded 714.64 428.78

29000

Restorative Services, Other

29300

Removal: In-lays/On-lays, Crowns, Veneers

(single units only)



29303 Three units of time 267.98

29304 Four units of time 355.20

Endodontic:

33000

Root Canal Therapy

(To include: treatment plan, clinical procedures (i.e. pulpectomy, biomechanical

preparation, chemotherapeutic treatment and obturation), with appropriate radiographs,

excluding final restoration.

33100

Root Canals: Permanent Teeth/Retained Primary Teeth

(Includes: Clinical procedures with appropriate radiographs, excluding final restoration.)

Definitions:

-Uncomplicated - Virtually straight canal penetrated by size #15 file

-Difficult Access - Limited jaw opening, unfavourable tooth inclination, through complex

restorations e.g. post/core build-ups

-Exceptional Anatomy - Canal size same as uncomplicated, but made complicated by

dens-in-dente or partially developed roots, internal/external resorption

-Calcified canals - Unable to penetrate with size #10 file and not clearly discernible on a

radiograph

-Retreatment - Retreatment of previously completed therapy

33110

Root Canals: Permanent Teeth/Retained Primary Teeth, One Canal

33111 One canal 736.17

33120 Root Canals: Permanent Teeth/Retained Primary Teeth, Two Canals

33121 Two canals 1111.34

Periodontics:

42200

Periodontal surgery, gingivoplasty (Does not include limited re-contouring to

facilitate restorative services)

42201 Per sextant

267.22

42300

Periodontal Surgery, Gingivectomy (The procedure by which gingival deformities are

reshaped and reduced to create normal and functional form, when the pocket is

uncomplicated by extension into the underlying bone; does not include limited re-

contouring to facilitate restorative services.)

42420

Flap Approach, with Curettage of Osseous Defect

42421 Per sextant 755.66



Code


2014/2015

OMDS Fee

Lab Fee

42500

Periodontal Surgery: Grafts, Soft Tissue

42560 Grafts: Free Connective Tissue (for ridge augmentation)

42561 Per site 897.70

42570

Grafts, connective tissue, pedicle with free graft for root coverage

42571 Per site 898.66

42700

Guided Tissue Regeneration

42701 Guided tissue Regeneration - Non-resorbable Membrane, Per Site 1374.84

42702 Guided tissue Regeneration - Resorbable Membrane 1374.84

42703 Guided tissue Regeneration - Non-resorbable Membrane, Surgical Re-entry for Removal 1374.84

43400 Root planing: Periodontal

43420 Root planing



49000

Periodontal Services: Miscellaneous

49100

Periodontal re-evaluation/evaluation

This follow-up service applies to the evaluation of ongoing periodontal treatment or to a

post-surgical re-evaluation performed more than one (1) month after surgery, or if

performed by another practitioner.

49101

One unit of time

64.23

Prosthodontics (removable):

51000

Denture, Complete (includes: impressions, initial & final jaw relation records, try-in

evaluation & check records, insertion & adjustments, including three month post

insertion care)

51100

Denture: Complete, Standard

51101 Maxillary 822.44 493.46

51102 Mandibular 822.44 493.46

51200 Dentures: Complete, Complex

51201 Maxillary 1944.28 1,166.57

51202 Mandibular 1944.28 1,166.57

51400

Dentures: Surgical, Complex, (immediate) (includes first tissue conditioner, but

not a processed reline)

51401 Maxillary 1839.12 1,103.47

51402 Mandibular 1839.12 1,103.47

51600

Dentures: Complete, Provisional

51601 Maxillary 548.94 329.36

51602 Mandibular 548.94 329.36



Code


2014/2015

OMDS Fee

Lab Fee

51700

Dentures: Complete, Overdentures, Tissue Borne, Supported By Natural Teeth Or

Implants With or Without Coping Crowns, No Attachments

51710

Dentures: complete, overdentures, tissue borne, supported by natural teeth with

or without coping crowns, no attachments

51711 Maxillary 854.02 512.41

51712 Mandibular 854.02 512.41

51720

Dentures: complete, overdentures, tissue borne, supported by implants with or

without coping crowns, no attachments

51721 Maxillary 854.02 512.41

51722 Mandibular 854.02 512.41

51730

Dentures: complete, overdentures, tissue borne, supported by a combination of

natural teeth and implants with or without coping crowns, no attachments

51731 Maxillary 854.02 512.41

51732 Mandibular 854.02 512.41

51800

Dentures: Complete, Overdentures, (Immediate) Tissue Borne, Supported By

Natural Teeth Or Implants With or Without Coping Crowns, No Attachments

51810

Dentures: complete, overdentures, (immediate) tissue borne, supported by natural

teeth with or without coping crowns, no attachments (includes first tissue

conditioner, but not a processed reline)

51811 Maxillary 854.02 512.41

51812 Mandibular 854.02 512.41

51900

Dentures: Complete, Overdentures, Tissue Borne, Secured by Attachments to

Natural Teeth Or Implants

51920

Dentures: Complete, Overdentures, Tissue Borne, With Independent Attachments

Secured to Implants With Or Without Coping Crowns

51921 Maxillary 4038.84 2,423.30

51922 Mandibular 3173.38 1,904.03

51950

Dentures: Complete, Overdentures, Tissue Borne, With Retention From A

Retentive Bar, Secured To Coping Crowns Supported By Implants

51951 Maxillary 6058.25 3,634.95

51952 Mandibular 6058.25 3,634.95

52000 Dentures: Partial, Acrylic

52100 Dentures: Partial, Acrylic Base (Provisional) (With or Without Clasps)

52101 Maxillary 235.24 141.15

52102 Mandibular 235.24 141.15

52110

Dentures: Partial, Acrylic Base, (immediate) (Includes First Tissue Conditioner, But

Not A Processed Reline)

52111 Maxillary 298.69 179.21

52112 Mandibular 298.69 179.21

52300

Dentures: Partial, Acrylic, With Metal Wrought/Cast Clasps And/Or Rests

52301 Maxillary 783.36 470.02



Code


2014/2015

OMDS Fee

Lab Fee

53000

Dentures: Partial, Cast With Acrylic Base

53100

Dentures: Partial, Free End, Cast Frame/Connector, Clasps & Rests

53101 Maxillary 822.44 493.46

53130

Dentures: Partial, Free End, Cast Frame/Connector, Clasps And Rests

(Equilibrated)

53131 Maxillary 2518.38 1,511.03

53132 Mandibular 2518.38 1,511.03

53200 Dentures: Partial, Tooth Borne, Cast Frame/Connector, Clasps And Rests

53201 Maxillary 822.44 493.46

53900

Dentures: Partial, Cast, Overdentures, Secured By Attachments To Natural Teeth

Or Implants

53960

Dentures: Partial, Cast, Overdentures, With Retention From A Retentive Bar,

Secured To Coping Crowns Supported By A Combination Of Natural Teeth And

Implants (see 62105 for retentive bar)

53961 Maxillary

1619.14

971.48

54000

Dentures: Adjustments (After three months insertion or by other than the dentist

providing prosthesis)

54200

Denture Adjustments: Partial Or Complete Denture, Minor

54201 One unit of time 94.59 56.75

54202 Two units of time 189.18 113.51

55400

Dentures: Repairs/Additions: Partial Denture, Impression Required

55401 Maxillary 243.64 146.19

56200 Dentures: Relining (does not include remount - see 54000 series)

56210 Dentures: Reline, Direct Complete Denture

56211 Maxillary

279.14

167.49

56212 Mandibular

279.14

167.49

56220 Denture: Reline, Direct, Partial Denture

56221 Maxillary 279.14

56222 Mandibular 279.14

56230 Denture: Reline, Processed, Complete Denture

56231 Maxillary 279.14 167.49

56232 Mandibular 279.14 167.49

56240

Denture: Reline, Processed, Partial Denture

56241 Maxillary 279.14 167.49

56400

Dentures: Remake

56410 Denture: Remake, Using Existing Framework, Partial Denture (Equilibration)

56411 Maxillary 470.02 282.01



Code


2014/2015

OMDS Fee

Lab Fee

56500

Dentures: Therapeutic Tissue Conditioning

56510 Denture: Therapeutic Tissue Conditioning, Per Appointment, Complete Denture

56511 Maxillary 171.37 102.82

56512 Mandibular 171.37 102.82

56520 Denture: Therapeutic Tissue Conditioning, Per Appointment, Partial Denture

56521 Maxillary 199.12 119.47

56522 Mandibular 199.12 119.47

57000

Prosthesis: Maxillofacial

57200

Prosthesis: Maxillofacial, Obturators

57202 Obturator: Palatal (Prosthesis Extra) 2163.67 1,298.20

57203 Obturator: Post-Maxillectomy (prosthesis extra) 134.32 to 1343.26

80.59 to 805.96

57208 Obturator Prosthesis: Modification (Relines Or Repairs) 2163.67 1,298.20

57300

Prosthesis: Maxillofacial, Other

57301 Velar bulb (prosthesis and obturator extra) 1056.89 634.13

57311 Feeding appliance (for infants with cleft palate) 1056.89 634.13

57371 Palatal life prosthesis, modification (relines or repairs) 739.82 443.89

57500 Prosthesis: Splints 57501 Stout 930.52 558.31

57503 Gunning (upper and lower) 1316.94 790.16

57506 Cast: Adjustable 1671.96 1,003.18

57507 Template, surgical 1954.17 1,172.50

57508 Commissure Splint 1750.27 1,050.16

57600 Prosthesis: Stents 57601 Ridge Extension 776.45 465.87

Prosthodontics (fixed):

62000 Pontics: Bridge 62100 Pontics: Cast Metal

62105

Pontic: Retentive bar, pre-fabricated or custom (dolder or hader) bar, attached to

implant supported retainer to retain removable prosthesis, each bar

2163.67

1,298.20

62500 Pontics: Porcelain/Ceramic/Polymer Glass 62501 Pontics: Porcelain/ceramic/polymer glass fused to metal 479.23 287.54

62502 Pontics: Porcelain/ceramic/polymer glass, aluminous 479.23 287.54

62700 Pontics: Acrylic/Composite/Compomer

62702 Pontics: Acrylic/Composite/Compomer, Indirect (Provisional) 114.46 68.67

63000 Recontouring of Retainers/Pontics (of existing bridgework)

63001 One unit of time 168.58 63009 Each additional unit of time 168.58



Code


2014/2015

OMDS Fee

Lab Fee

67000

Fixed Bridge Retainers

It is appropriate to use fixed bridge retainer codes, rather than codes for single

tooth restorations, where two or more single tooth inlays/onlays or crowns are

joined (splinted) together and do not support a pontic

67100

Retainers: Acrylic/Composite/Compomer With, Or Without Cast Or Prefabricated

Metal Bases

67110 Retainers: Acrylic, Composite/Compomer, Indirect

67115 Retainers: acrylic, composite/compomer, implant-supported indirect 801.23 480.74

67120

Retainers: Acrylic, Composite/Compomer, Direct (Provisional During Healing,

Done At Chairside)

67125

Retainer: acrylic, composite/compomer, (provisional during healing, done at chairside)

implant-supported, direct

228.91

67140 Retainers, plastic/acrylic, indirect, processed to metal, attached to implants

67141 First implant 1277.94 766.76

67200 Retainers: Porcelain/Ceramic/Polymer Glass

67201 Retainer: porcelain/ceramic/polymer glass 1044.07 626.44

67202 Retainer: porcelain/ceramic polymer glass, complicated 835.26 501.16

67205 Retainer: porcelain/ceramic/polymer glass, implant-supported 1127.16 676.30

67210 Retainers: Porcelain/Ceramic/Polymer Glass Fused To Metal Base

67211 Retainer: porcelain/ceramic/polymer glass, fused to metal base 1044.07 626.44

67212 Retainer: porcelain/ceramic/polymer glass, fused to metal base, complicated 1666.18 999.71

67215 Retainer: porcelain/ceramic/polymer glass fused to metal base, implant supported 1387.05 832.23

67220

Retainers: Porcelain/Ceramic/Polymer Glass, Partial Coverage, Bonded (External

Retention - e.g. "Maryland Bridge")

67221

Retainer: porcelain/ceramic/polymer glass, partial coverage, bonded (external retention -

e.g. "Maryland Bridge")

1277.94

766.77

67229 Each additional implant 1277.94 766.77

67300

Retainers: Cast Metal

67301 Retainers: cast metal 1044.07 626.44

67320

Retainers: Metal, Inlay (used with broken stress technique)

67321 Retainer: metal inlay, two surfaces

716.57

429.94

69000

Fixed Prosthetics: Other Services

69100

Fixed Prosthetics, Miscellaneous Services

69101

Fixed Prosthetics, Porcelain, to Replace a Substantial Portion of the Alveolar Process (in

addition to retainer and pontics)

1295.47

777.28

69700

Fixed prosthetics: Provisional Coverage (In Extensive Or Complicated Restorative

Dentistry)

69701 Abutment tooth 205.37 123.22

69702 Pontic 68.45 41.07



Code


2014/2015

OMDS Fee

Lab Fee

69800 Fixed Prosthodontic Framework: Osseo-Integrated Implant-supported

69810

Fixed Prosthodontic Framework, Osseo-Integrated, Attached With Screws And

Incorporating Teeth (Denture Teeth and Acrylic)

69811 Maxillary 11323.17 6,793.90

69812 Mandibular 9932.66 5,959.59

69820

Fixed Prosthodontic Framework, Osseo-Integrated, 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 14424.42 8,654.65

69822 Mandibular 14424.42 8,654.65

Oral and Maxillofacial Surgery

71000 Removals (Extractions): Erupted Teeth

71100 Removals: Erupted Teeth, Uncomplicated

71101 Single tooth, uncomplicated 112.23 71109 Each additional tooth, same quadrant, same appointment 112.23

71200 Removals: Erupted Teeth, Complicated

71201

Odontectomy, (extraction) erupted tooth, surgical approach, requiring surgical flap

and/or sectioning of tooth

222.17

71209 Each additional tooth, same quadrant

222.17

72000 Removals (Extractions): Surgical

72100 Removals: Impactions, Soft Tissue Coverage

72110

Removals, impaction, requiring incision of overlying soft tissue and removal of

the tooth

72111 Single tooth 201.44 72119 Each additional tooth, same quadrant 201.44

72200

Removals: Impactions, Involving Tissue And/Or Bone Coverage

72210

Removals: Impaction, Requiring Incision Of Overlying Soft Tissue, Elevation Of A

Flap And Either Removal Of Bone And Tooth Or Sectioning And Removal Of Tooth

(Partial Bone Impaction)


72220


Flap, Removal Of Bone And/Or Sectioning Of Tooth For Removal (Complete Bone

Impaction)

72221 Single tooth 402.89 72229 Each additional tooth, same quadrant 402.89 72230


Flap, Removal Of Bone And/Or Sectioning Of Tooth For Removal And/Or Presents

Unusual Difficulties And Circumstances

72231 Single tooth 549.29



Code


2014/2015

OMDS Fee

Lab Fee

72239 Each additional tooth, same quadrant 549.29

72300

Removals (Extractions): Residual Roots

72310

Removals: Residual Roots, Erupted

72311 First tooth 91.60 72319 Each additional tooth, same quadrant 91.60

72320

Removals: Residual Roots, Soft Tissue Coverage


72330

Removals: Residual Roots, Bone Tissue Coverage


72500

Surgical Exposure Of Teeth

72510

Surgical Exposure: Unerupted, Uncomplicated, Soft Tissue Coverage (Includes

Operculectomy)


72520

Surgical exposure: Complex, Hard Tissue Coverage


72530

Surgical Exposure: Unerupted Tooth, With Orthodontic Attachment


72540

Surgical Exposure: Unerupted Tooth, Soft Tissue Coverage With Positioning Of

Attached Gingivae


72550

Surgical Exposure: Unerupted Tooth, Hard Tissue Coverage With Positioning Of

Attached Gingivae


72700

Enucleation: Surgical

72710

Unerupted Tooth And Follicle


73000

Remodeling and Recontouring Oral Tissues

73100 Alveoloplasty (Bone Remodeling Of Ridge With Soft Tissue Revisions)

73150

Excision Of Bone

73152 Torus Palatinus: excision 402.89

73160

Removal Of Bone: Exostosis, Multiple

73161 Per quadrant 604.34



Code


2014/2015

OMDS Fee

Lab Fee

73200

Gingivoplasty And/Or Stomatoplasty: Oral Surgery

73210

Independent Procedure


73220

Miscellaneous Procedures

73222 Excision Of Vestibular Hyperplasia, Per Sextant 178.04

73224 Excision of pericoronal gingival (for retained tooth/implant) per tooth/implant 100.73

73230

Removal: Tissue, Hyperplastic (Includes the incision of the mucous membrane, the

dissection and removal of hyperplastic tissue, the replacing and adapting of the mucous

membrane)

73231 Per sextant

201.44

73240 Removals: Mucosa, excess (complete removal without dissection)


73500

Reconstruction: Alveolar Ridge

73520

Reconstruction: Alveolar Ridge, With Alloplastic Material


74000 Surgical Excision (Not In Conjunction With Tooth Removal, Including Biopsy)

74400 Hard Tissue Grafts to the jaw

74401 Autograft - per site - maxilla or mandible

636.63

77000 Maxillofacial Deformities: Treatment Of

77500 Genioplasty

77501 Genioplasty: sliding, reduction or augmentation 1907.84

77600 Miscellaneous Treatment Of Maxillofacial Deformities

77603 Surgical expansion of the palate 878.44

79000 Oral Surgery Procedures: Other

79900

Implantology (Includes Placement Of Implant, Post-Surgical Care, Uncovering And

Placement Of Attachment But Not Prosthesis)

79930 Implants: Ossenointegrated, Root Form, More Than One Component

79931 Surgical installation of implant with cover screw - per implant 1440.90

79932 Surgical installation of implant with healing transmucosal element - per implant 2594.86

79933 Surgical installation of implant with final transmucosal element - per implant 2594.86

79934

Surgical re-entry, removal of healing screw and placement of healing transmucosal

element, per implant 1153.96

79941 Surgical installation of implant - per implant 2594.86



Code


2014/2015

OMDS Fee

Lab Fee

Orthodontics:

80000

Orthodontic Services: Miscellaneous

80600

Orthodontic: Observations And Adjustments

Coverage includes all active treatment, insertion of retainers, orthodontic records,

observation appointments, radiographs and retention appointments. The

maximum amount payable for orthodontic treatment whether billed separately as

detailed below or by monthly billings is:

11251.05

80601

Orthodontic observation - for tooth guidance (i.e. tooth position, eruption sequence,

serial extraction supervision, etc.), per appointment

85.30

80602

Orthodontic observation and adjustment - to orthodontic appliances and/or the reduction

of proximal surfaces of teeth, per appointment

85.30

80640

Alterations To Removable Or Fixed Appliances

80641 One unit of time 85.30 51.18

80642 Two units of time 170.56 102.34

80650

Recementation Of Fixed Appliances


80660 Separation (except where included in the fabrication of an appliance)


85.30

80670

Removal Of Fixed Orthodontic Appliances

(By A Practitioner Other Than The Original Treatment Practice or Practitioner)


85.30

81000

Appliances: Active, For Tooth Guidance or Minor Tooth Movement

81100

Appliances: Removable

A maximum of eight observations or adjustment appointments may be charged for these

appliances.

81110

Appliances: Removable, Space Regaining

81111 Appliance: maxillary, unilateral 341.14 204.69

81113 Appliance: maxillary, bilateral 341.14 204.69

81120

Appliances: Removable, Cross-Bite Correction

81121 Appliance: maxillary, simple 341.14 204.69

81130

Appliances: Removable, Dental Arch Expansion


81140

Appliances: Removable, Closure Of Diastemas


81150

Appliances: Removable, Alignment Of Anterior Teeth




Code


2014/2015

OMDS Fee

Lab Fee

81200

Appliances: Fixed Or Cemented

A maximum or eight observation or adjustment appointments may be charged for these

appliances.

81210

Appliance: Fixed, Space Regaining

(e.g. Lingual Or Labial Arch With Molar Bands, Tubes, Locks)

81211 Appliance: maxillary 341.14 204.69

81220 Appliances: Fixed, Space Regaining, Unilateral


81230

Appliance: Fixed, Cross-Bite Correction - Anterior


81240

Appliances: Fixed, Cross-Bite Correction - Posterior


81243 Appliance: two-molar band, hooked and elastics 255.86 153.52

81250 Appliances: Fixed, Dental Arch Expansion


81253 Appliance: maxillary, rapid expansion 341.14 204.69

81260 Appliances: Fixed, Closure Of Diastemas


81270

Appliances: Fixed, Alignment Of Incisor Teeth


81290

Appliances: Fixed, Mechanical Eruption Of Tooth/Teeth

81291 Appliance: maxillary, impaction 341.14 204.69

81293 Appliance: maxillary, erupted 341.14 204.69

83000

Appliances: Retention, Orthodontic Retaining Appliances

83100 Appliances: Removable, Retention 83101 Appliance: maxillary 255.86 153.52

83103 Appliance: tooth positioner 255.86 153.52

83200 Appliances: Fixed/Cemented, Retention 83201 Appliance: maxillary 341.14 204.69

Adjunctive General Services:

92000

Anaesthesia

92200

Anaesthesia: General (Includes Pre-Anaesthetic Evaluation And Post-Anaesthetic

Follow-Up)

92210 General Anaesthesia 92212 Two units of time 195.39 92213 Three units of time 293.08 92214 Four units of time 390.77 92215 Five units of time 488.47 92216 Six units of time 586.16 92217 Seven units of time 683.85



Code


2014/2015

OMDS Fee

Lab Fee

92218 Eight units of time 781.54 92219 Each additional unit over eight 97.69

92220

Provision Of Facilities, Equipment And Support Services For General Anaesthesia

When Provided By A Separate Practitioner

92222 Two units of time 195.39 92223 Three units of time 293.08 92224 Four units of time 390.77 92225 Five units of time 488.47 92226 Six units of time 586.16 92227 Seven units of time 683.85 92228 Eight units of time 781.54

92229 Each additional unit over eight 97.69

92300

Anaesthesia: Deep Sedation - a controlled state of depressed consciousness

accompanied by partial loss of protective reflexes, including inability to respond

purposefully to verbal command. These states apply to any technique that has

depressed the patient beyond conscious sedation except general anaesthesia. Any

intravenous technique leading to these conditions in a patient, including

neuroleptanalgesia or anaesthesia, regardless of route of administration, would fall

within this category of service. (includes pre-anaesthetic evaluation and post

anaesthetic follow-up)

92302 Two units of time 176.82 92303 Three units of time 265.23 92304 Four units of time 353.64 92305 Five units of time 472.99 92306 Six units of time 567.58 96200 Injections: Therapeutic 96201 Intramuscular drug injection 54.74

Miscellaneous Procedures and Codes

99000

Laboratory And Expense Procedures

(this code is used in conjunction with the "+L" and "+E" designation following specific

codes in the guide. The addition of these codes are to facilitate computer or manual

input for third party claims processing, personal records and statistics, providing one

description for a specific procedure code.)

When filling out the third party claim forms, these codes must follow immediately after

the corresponding dental procedure code carried out by the dentist, so as to correlate

the lab expenses with the correct procedures.

99111

"+L" Commercial laboratory procedures (A commercial laboratory is defined as an

independent business which performs laboratory services and bills the dental practices

for these services on a case by case basis).

188.92

99555 "+E" Additional Expenses of Materials 432.73 99800 Stereolithic models (3D models) 99998 3D Model Fabricated in Alberta 2596.40 99999 Unlisted Procedures B.R. B.R.

B.R.

By Report: the fee will be determined by Alberta Health delegate in consultation

with the program dental consultant and the treating practitioner on a "by report" basis.

alberta health care insurance plan...to: all dentists and billing staff amendments have been made to...

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