Suggested Fee Guide for Dental Hygienists

January 1, 2014

©2014 Ontario Dental Hygienists’ Association All rights reserved

USER GUIDE FOR DENTAL HYGIENISTS The content, organization and management of dental hygiene care is guided by the principles of accessibility for all Canadians to comprehensive oral health care and the promotion of oral health as an integral component of general health. The purpose of this Fee Guide is to provide guidance to dental hygienists in Ontario in setting the fees that they charge for their professional services. It is a guide only; adherence to the guide is not obligatory. Each dental hygienist will set his or her fees to reflect practice realities and local circumstances and requirements. Dental hygienists must follow their code of ethics and standards of practice when determining the value of a dental hygiene service. This Fee Guide uses the CDHA National List of Service Codes© that has been produced by the Canadian Dental Hygienists Association (CDHA). The CDHA states that the National Dental Hygiene System of Service is not intended for use by dental hygienists employed within traditional dental offices or in provinces where this type of public access to dental hygiene care has not been legislated. Dental Hygiene Claim Form To protect themselves from copyright infringements, it is important that all Ontario dental hygienists who are submitting insurance claims use either the standard dental hygiene claim form attached to this Fee Guide and available on the ODHA website or if they are members of CDHA, the CDHA Dental Hygiene Claim Form. Review ODHA will periodically review the suggested fees and will submit any suggestions for the coding system to the CDHA so it can take these under advisement in its own review. Members are encouraged to submit their evidence-based feedback to the ODHA in writing. Members and third parties are reminded that the suggested fees contained in the Fee Guide were prepared by the Ontario Dental Hygienists’ Association to provide a guideline of fees considered to be fair and reasonable. The suggested fees are a guideline only. The suggested fees are not binding on any dental hygienist or third party billing for dental hygiene services, and there is no obligation to follow the suggested fees in the Fee Guide.

©2014 Ontario Dental Hygienists’ Association

All rights reserved. No part of this work covered by the publisher’s copyright may be reproduced or copied in any form or by any means (graphic, electronic or mechanical, including photocopying, recording, recording taping, or information and retrieval systems) without the written permission of the publishers.

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In this fee guide: ‘+ lab’  means that an additional laboratory expense may be assessed with the procedure code  the code for laboratory expense is 00991 ‘+ exp’  means that additional expenses such as courier costs may be assessed with the procedure code  the code for an additional expense is 00992 Code / Service

ODHA 2014 suggested fee

00100 Primary Mixed Permanent Edentulous Periodontal 00120 Routine recall Specific Emergency Periodontal, limited 00130 00200 00210 1 image 2 images 3 images 4 images 5 images 6 images 00220 1 image 2 images 3 images 4 images 5 images 6 images 7 images 8 images each additional image >8 00230 minimum 14 images 00240 1 image 00250 1 image each additional image >1

Examination/Assessment - new client 00111 00112 00113 00114 00115 Examination/Assessment – previous client 00121 00122 00123 00124 First dental hygiene visit/orientation 00131 Radiographs Intraoral bitewing 00211 00212 00213 00214 00215 00216 Intraoral periapical 00221 00222 00223 00224 00225 00226 00227 00228 00229 Intraoral, full mouth series 00231 Panoramic 00241 Cephalometric 00251 00259

$34.49 $51.74 $86.23 $34.49 $51.74 $25.16 $25.16 to $56.60 $25.16 to $56.60 $25.16 to $56.60 $16.17 $17.25 $19.94 $22.63 $25.33 $28.02 $30.72 $17.25 $19.94 $22.63 $25.33 $28.02 $30.72 $33.41 $36.11 $2.69 $71.46 $51.20 $47.48 $16.17

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00260 Duplication of radiographs 1 image 2 images 3 images 4 images 5 images 6 images 7 images 8 images each additional image >8

00261 00262 00263 00264 00265 00266 00267 00268 00269

$10.78 $11.64 $12.50 $13.37 $14.23 $15.09 $15.95 $16.81 $0.86

00270 Photographs 1 photo 2 photos 3 photos each additional photograph >3 00300 00310 bacteriological test 00320 microbiological test 00330 cytological smear vital staining direct fluorescence 00400 taking impressions fabrication/pouring/preparing casts 00500 00510 1 unit of time 2 units of time 3 units of time 4 units of time 5 units of time 6 units of time ½ unit of time each additional unit of time >6 00520 1 unit of time 2 units of time 3 units of time 4 units of time 5 units of time 6 units of time ½ unit of time each additional unit of time >6 00530 1 unit of time 2 units of time ½ unit of time each additional unit of time >2

00271 $16.17 00272 $19.40 00273 $22.63 00279 $3.23 Microbiological and histological tests Caries susceptibility 00311 $17.15 to $28.58 + lab Periodontal disease activity 00321 $17.15 to $28.58 + lab Cancer testing 00331 $34.30 + lab + exp 00332 $34.29 00333 $34.29 Study models 00401 $30.72 00402 $15.36 + lab Periodontal treatment (each unit of time is 15 minutes) Debridement 00511 $50.30 00512 $100.62 00513 $150.93 00514 $201.24 00515 $251.55 00516 $301.85 00517 $25.16 00519 $50.30 Root planning 00521 $50.30 00522 $100.62 00523 $150.93 00524 $201.24 00525 $251.55 00526 $301.85 00527 $25.16 00529 $50.30 Stain removal 00531 $29.10 00532 $58.20 00537 $14.55 00539 $29.10

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1 unit of time ½ unit of time each additional unit of time 1 unit of time 2 units of time 3 units of time 4 units of time ½ unit of time each additional unit of time >4 1 unit of time 2 units of time 3 units of time 4 units of time ½ unit of time each additional unit of time >4 1 sextant 2 sextants 3 sextants 4 sextants 5 sextants 6 sextants 1 unit of time ½ unit of time each additional unit of time 1st tooth in quadrant each additional tooth in quadrant 1 unit of time ½ unit of time each additional unit of time Topical in office Supervised, self-administered office Home - custom maxillary arch Home - custom mandibular arch Home - custom combined 1 unit of time 2 units of time 3 units of time 4 units of time ½ unit of time each additional unit of time >4

00540 Subgingival periodontal irrigation 00541 $42.42 00547 $21.21 00549 $42.42 00550 Management of oral mucosal disorders 00551 $34.30 00552 $68.61 00553 $102.90 00554 $137.21 00557 $17.15 00559 $34.30 00560 Management of oral manifestations of systemic disease 00561 $34.30 00562 $68.61 00563 $102.90 00564 $137.21 00567 $17.15 00569 $34.30 00570 Gingival curettage 00571 $25.15 00572 $50.31 00573 $75.45 00574 $100.61 00575 $125.77 00576 $150.92 00580 Intrasulcular application of chemotherapeutic agents 00581 $47.60 + exp 00582 $23.80 + exp 00583 $47.60 + exp 00600 Other oral services (each unit of time is 15 minutes) 00601 Sealants 00602 $20.12 00603 $11.44 00605 Application of anticariogenics/antimicrobials 00606 $37.72 + exp 00607 $18.86 + exp 00609 $37.72 + exp 00610 Fluoride applications 00611 $19.40 00612 $14.54 00613 $42.42 + lab 00614 $42.42 + lab 00615 $60.60 + lab 00620 Finishing restoration 00621 $29.10 00622 $58.20 00623 $87.31 00624 $116.41 00627 $14.55 00629 $29.10

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00630 preformed – maxillary arch preformed – mandibular arch preformed – maxillary & mandibular arches processed – maxillary arch processed – mandibular arch processed – maxillary & mandibular arches 00638 labeling removable prosthesis 00640 1 unit of time 2 units of time ½ unit of time each additional unit of time >2 00650 1 unit of time 2 units of time 3 units of time ½ unit of time each additional unit of time >3 00660 maxillary arch mandibular arch maxillary and mandibular arch 00665 1st tooth in quadrant each added tooth same quadrant 00670 1 unit of time 2 units of time 3 units of time ½ unit of time each additional unit of time >3 00680 1 unit of time ½ unit of time each additional unit of time 00690 1 unit of time ½ unit of time each additional unit of time 00700 00710 1 unit of time 2 units of time 3 units of time 4 units of time ½ unit of time each additional unit of time >4

Mouth protectors 00631 00632 00633 00634 00635 00636

$21.56 + exp $21.56 + exp $32.34 + exp $80.84 + lab $80.84 + lab $97.01 + lab

00638

$37.72 + exp

00641 00642 00647 00649

$37.72 $75.45 $18.86 $37.72

00651 00652 00653 00657 00659

$43.22 + exp $86.44 + exp $129.65 + exp $21.62 + exp $43.22 + exp

Labeling removable prosthesis Desensitization

Bleaching vital teeth in office

Bleaching vital teeth at home 00661 $129.34 + lab + exp 00662 $129.34 + lab + exp 00663 $188.62 + lab + exp Placement temporary restorations 00666 $54.54 00667 $27.87 Recementation 00671 $54.54 00672 $109.08 00673 $163.62 00677 $27.27 00679 $54.54 Pulp vitality testing 00681 $35.57 00687 $17.78 00689 $35.57 Denture/removable prosthesis prophylaxis and polishing 00691 $43.11 + lab 00697 $21.56 + lab 00699 $43.11 + lab Pain management (each unit of time is 15 minutes) Electronic dental anaesthesia 00711 $35.57 00712 $39.13 00713 $42.68 00714 $46.24 00717 $29.82 00719 $3.56

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00720 Local anaesthesia regional block trigeminal division block supraperiosteal infiltration

00721 00722 00723

$12.93 $12.93 $12.93

00731 00732 00733 00734 00737 00739 Nitrous oxide, conscious sedation 00741 00742 00743 00744 00747 00749 Education and habit modification (each unit of time is 15 minutes) Counseling for diet 00811 00812 00813 00814 00817 00819 Counseling for tobacco use cessation 00821 00822 00823 00824 00827 00829 Counseling for oral self-exam 00831 00832 00833 00834 00837 00839 Instruction in oral self care 00841 00842 00843 00844 00847 00849

$35.57 $39.13 $42.68 $46.24 $29.82 $3.56

00730 Acupuncture 1 unit of time 2 units of time 3 units of time 4 units of time ½ unit of time each additional unit of time >4 00740 1 unit of time 2 units of time 3 units of time 4 units of time ½ unit of time each additional unit of time >4 00800 00810 1 unit of time 2 units of time 3 units of time 4 units of time ½ unit of time each additional unit of time >4 00820 1 unit of time 2 units of time 3 units of time 4 units of time ½ unit of time each additional unit of time >4 00830 1 unit of time 2 units of time 3 units of time 4 units of time ½ unit of time each additional unit of time >4 00840 1 unit of time 2 units of time 3 units of time 4 units of time ½ unit of time each additional unit of time >4

$53.89 $107.79 $161.68 $215.57 $26.95 $53.89

$37.72 $75.45 $113.17 $150.90 $18.86 $37.72 $37.72 $75.45 $113.17 $150.90 $18.86 $37.72 $37.72 $75.45 $113.17 $150.90 $18.86 $37.72 $37.72 $75.45 $113.17 $150.90 $18.86 $37.72

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1 unit of time 2 units of time 3 units of time 4 units of time ½ unit of time each additional unit of time >4 1 unit of time 2 units of time each additional unit of time >2 1 unit of time 2 units of time ½ unit of time each additional unit of time >2 1 unit of time 2 units of time ½ unit of time each additional unit of time >2 Home visit Institutional visit Emergency home visit Emergency institutional visit 1 unit of time 2 units of time 3 units of time 4 units of time each additional unit of time >4 + lab + exp

00850 Group presentations (including preparation) 00851 $37.72 00852 $75.45 00853 $113.17 00854 $150.90 00857 $18.86 00859 $37.72 00860 Oral myofunctional therapy 00861 $51.83 00862 $103.66 00863 $51.83 00900 Outcome evaluation (each unit of time is 15 minutes) 00910 Evaluation of dental hygiene care 00911 $37.72 00912 $75.45 00917 $18.86 00919 $37.72 00920 Professional communications / case presentations 00921 $37.72 00922 $75.45 00927 $18.86 00929 $37.72 00950 Mobile services 00951 $31.44 to $62.89 00952 $31.44 to $62.89 00953 $47.43 to $88.93 00954 $47.43 to $88.93 00960 Exceptional client 00961 $55.00 00962 $110.00 00963 $165.00 00964 $220.00 00969 $55.00 00990 Laboratory and expense services 00991 00992

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Top section of form is completed by dental hygienist : DENTAL HYGIENE PRACTICE

Last name:

CLIENT

First name: Address: Unit/Apt#:

City:

Prov:

Postal Code:

For additional notes, assessment, special considerations:

Standard Dental Hygiene Claim Form

CDHO Registration #

I hereby assign my benefits payable from this claim to the dental hygienist identified here and authorize payment directly to him/her.

Name: Address: Suite#:

City:

Prov:

Postal Code:

Telephone:

Fax:

____________________________________ (signature of subscriber)

I understand that the fees listed in this claim may not be covered by my plan or may exceed the benefits of my plan. I acknowledge that I am responsible for the total fee shown below to the dental hygienist identified above and further acknowledge that the said fee is accurate. I agree to the release by the dental hygienist of any information necessary with respect to this claim to my insurance company or plan administrator. ____________________________________________________________________ (signature of client/parent/guardian)

Service provided: Date of service day

mo

yr

Description of service provided

Intl. Tooth code

Procedure code

Dental hygienist’s fee

This is an accurate statement of services performed and the total fee dues and payable:

Laboratory or Expense charge

Total

Total fee for service

————————————————————————————— CDHO reg’n# —————————(dental hygienist signature) Employee/Plan member/Subscriber Information: Group policy/plan# Employer

Division/section#

Employee/plan member/subscriber name (please print) Certificate#/S.I.N.#/ID#

Insurer/agency/plan

Employee/member/subscriber date of birth

day

mo

year

Client Information: Relationship to employee/plan member/subscriber

Client date of birth day

Are any of the services provided under any other Group Insurance, Dental, WSIB or Government Plan? Is any of the required treatment as the result of an accident?

mo

year

(if not self) □ yes If yes, plan name and # □ no □ yes If yes, provide details separately □ no

If child: □ student Name of school

□ disabled

I hereby authorize the release of any information or records requested in respect of this claim to the insurer/plan administrator and certify that the information given is true, accurate and complete to the best of my knowledge. ___________________________________________________________ _________________________ signature of employee/plan member/subscriber date