Dental Hygiene

Services Fee Guide

2024

Prepared by:

1079 Wellington Ave, Winnipeg, MB R3E 3E8

 Manitoba Dental Hygienists Association
2024 Dental Hygiene Services Fee Guide

Prepared and published by the Manitoba Dental Hygienists Association (MDHA).

MDHA provides this guide as a reference document only for dental hygiene practitioners. MDHA
encourages practitioners to consider the many factors of their individual business when
determining the fees, they will charge in their practice. Dental hygienists may choose to use the
fees in this guide or may choose to set fees that differ from this guide. MDHA supports and
encourages this diversity in the marketplace.
This guide is created for the use of members of the (MDHA). Other hygienists or organizations
wishing to use the information in this document may only do so with written permission from the
MDHA.
All Rights Reserved. No part of this publication may be reproduced in whole or in part or by any
means now or later developed, or copied, fixed, stored or recorded in any material form or in any
manner including by any electronic, mechanical or other means, or in or into any information
storage and retrieval system, or used in any database or machine-readable form or to create any
work that is based upon or derived from any part of the publication, without the prior written
permission of the MDHA.

GUIDELINES FOR USE

1. This is a comprehensive fee guide for the use of all Manitoba Dental Hygienists
Association members. All codes within this fee guide are not necessarily
applicable to every dental hygienist. It is the ethical, moral and legal responsibility
of dental hygienists utilizing these codes to do so in a manner not conflicting with
provincial regulations. Dental hygienists should ensure the services which they
provide and bill for are included within their scope of practice. For any questions
or concerns regarding your scope of practice, please contact the College of Dental
Hygienists of Manitoba.
2. The MDHA organized the service codes in relation to the five phases of care: assessment,
dental hygiene diagnosis, treatment planning, treatment, and evaluation. Dental hygiene
services have been classified into the following categories:
00100 – 00499 assessment, dental hygiene diagnosis, and treatment planning
00500 – 00999 dental hygiene treatment and evaluation
3. Specific service codes may refer to UNITS OF TIME or other charges. These are defined
as follows:
“Unit of Time” – each unit of time is fifteen (15) minutes
“IC” – independent consideration
“ + L” – an additional laboratory expense may be assessed
“ + E” – an additional fee may be added for extra expenses incurred
4. Where a specific service code indicates a “tooth number” is required, the 2-digit
International System of tooth numbering is to be applied. The first digit indicates the
quadrant, the second digit indicates the tooth within the quadrant.

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First Digit Assignment

Permanent Teeth: Deciduous Teeth:

Quadrant “1” – maxillary right Quadrant “5” – maxillary right

“ “2” – maxillary left “ “6” – maxillary left

“ “3” – mandibular left “ “7” – mandibular left

“ “4” – mandibular right “ “8” – mandibular right

Second Digit Assignment

The first tooth at the midline of the arch is assigned tooth number “1”. Counting continues
to the third molar assigned tooth number “8”. As an example, the permanent maxillary
right first bicuspid would be assigned tooth number “14”.
Supernumerary teeth should be assigned tooth number “99”.

Sextant Assignment:
The dental arch can be divided into six relatively equal sections. Sextant assignment can
be used for recording periodontal charting or for treatment.

Sextant 1: tooth numbers 18‒14

Sextant 2: tooth numbers 13‒23
Sextant 3: tooth numbers 24‒28
Sextant 4: tooth numbers 38‒34
Sextant 5: tooth numbers 33‒43
Sextant 6: tooth numbers 44‒48

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Dental Hygiene Claim Form

To protect themselves from copyright infringements, it is important that all Manitoba

dental hygienists that are members of CDHA who are submitting insurance claims use the
CDHA Dental Hygiene Claim Form available on the CDHA website.

http://files.cdha.ca/Profession/CDHA_UIN_Claim_Form.pdf

Notes:

The Reassessment/Recall Examination (Assessment) (00121 Previous Client) is provided

for clients who have already undergone treatment and have been placed on a regular recall
schedule for maintenance and control.

The Specific and/or Limited Examination (00122) is meant to be used for the evaluation of a
specific oral situation or an incomplete dental hygiene examination performed under
compromised situations (e.g., where a complete and comprehensive exam could not be
performed due to extenuating circumstances). Please note that this code can be used for new or
for previous clients.

It is only differentiated from the “Emergency Examination” in that the latter is a specific evaluation
under emergency conditions, such as the investigation of pain and/or acute infection.

It is a misuse of the fee guide to charge for more units of time during an appointment than the
total time the client was seated and attended by the dental hygienist. It is appropriate to bill for
all the time that the dental hygienist takes to provide oral care. Additionally, the procedure code
used must accurately reflect the service provided.

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SECTION 1: 00100 – 00499 ASSESSMENT, DENTAL HYGIENE DIAGNOSIS,
AND TREATMENT PLANNING
00100 COMPLETE DENTAL HYGIENE EXAMINATION AND DIAGNOSIS (ASSESSMENT)

Primary 00111 43.01

Mixed 00112 64.50

Permanent 00113 109.03

Edentulous 00114 49.32

Periodontal 00115 52.84

Case Presentation/Treatment Planning 00116 43.01

Notes:
00100 Complete Dental Hygiene Examination and Diagnosis (Assessment) includes:
a) History – personal, medical, dental, oral health risk factors
b) Vital signs – may include blood pressure, pulse, temperature
c) Extra oral examination of the head and neck includes temporomandibular joint,
lymph nodes, symmetry and skin lesions.
d) Intra oral examination includes examining the lips, oral mucosa, frena, hard and soft
palate pillars, oropharnyx, tongue, floor of the mouth and salivary flow and
assessment of edentulous arches.
e) Dental hygiene examination includes developmental anomalies, risk assessment for
caries and carious lesions, existing restorations, missing teeth, rotations, diastemas,
contacts, occlusal relationships, parafunctional habits, attrition, abrasion, abfraction,
erosion, pulp vitality, sensitivity and discomfort. The dental hygiene examination may
include collaboration and/or referral with an oral health care provider.
f) Periodontal assessment includes risk assessment for periodontal disease, bleeding
upon probing, medications, local contributing risk factors, history of periodontitis,
gingival health, sulcus depths, adequacy of attached gingiva, gingival inflammation,
signs of disease progression: recession, clinical attachment level, furcation
involvement, tooth mobility, occlusal trauma, mucogingival conditions, and may
include radiograph interpretation and referral as necessary.
g) Oral self care assessment includes oral hygiene and possibly microbiological
assessment, general health activities and nutrition related to oral health.
Radiographs are not included. Radiographs are described in section 00200.
The dental hygienist may not use more than one examination from section 00100 at the
same visit (i.e. cannot use both 00113 and 00115).

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00111 Dental Hygiene Examination (Assessment): Complete: Primary Dentition to include:

Full mouth dental hygiene examination and dental hygiene diagnosis on primary
dentition, recording medical and dental history, charting, treatment planning and case
presentation, including above description as per 00100.

00112 Dental Hygiene Examination (Assessment): Complete: Mixed Dentition to include:

Full mouth dental hygiene examination and dental hygiene diagnosis on mixed dentition,
recording medical and dental history, charting, treatment planning and case
presentation, including above description as per 00100.
Eruption sequence, tooth size-jaw size assessment.

00113 Dental Hygiene Examination (Assessment): Complete: Permanent Dentition to

include:
Full mouth dental hygiene examination and dental hygiene diagnosis on permanent
dentition, recording medical and dental history, charting, treatment planning and case
presentation, including above description as per 00100.

00114 Dental Hygiene Examination (Assessment): Complete: Edentulous (maxilla and

mandible)
Full mouth dental hygiene examination and dental hygiene diagnosis of edentulous
arches, recording medical and dental history, charting, treatment planning and case
presentation, including above description as per 00100.

00115 Dental Hygiene Examination (Assessment): Complete: Periodontal

Full mouth dental hygiene examination and dental hygiene diagnosis (with emphasis on
periodontal issues), recording medical and dental history, charting, treatment planning
and case presentation, including above description as per 00100.

00116 Case Presentation/Treatment Planning

This service is for extra time spent on unusually complicated cases, for occasions when
the client demands unusual time in explanation or for when 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.

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00120 DENTAL HYGIENE EXAMINATION AND DIAGNOSIS (ASSESSMENT)

Reassessment/recall 00121 35.20

Emergency 00123 43.01

Periodontal limited 00124 35.20

Specific 00125 49.31

Limited, New Client 00126 49.31

Notes:
00121 Dental Hygiene Examination (Assessment): Reassessment/Recall (Previous Client)
Review and updating of all previously collected assessment data, analysis of revised
assessment data, evaluation of previous interventions, modification of intervention plans
and programs based on outcome measures, changing needs and new information, and
case presentation. Update of services listed in 00100.
00123 Dental Hygiene Examination (Assessment): Emergency
Dental hygiene examination and dental hygiene diagnosis under emergency conditions
for the investigation of discomfort and/or infection in a localized area.
00124 Dental Hygiene Examination (Assessment): Periodontal, Limited, Previous Client
Dental hygiene examination and dental hygiene diagnosis for the investigation of
discomfort and/or infection of a specific area(s) of the periodontium.
00125 Dental Hygiene Examination (Assessment): Specific
Dental hygiene examination, evaluation, and dental hygiene diagnosis of a specific oral
situation (new or existing client)
00126 Dental Hygiene Examination (Assessment): New Client
Dental hygiene examination, evaluation, and dental hygiene diagnosis under situations
where a complete exam is not performed. May include PSR. (Not to be used in lieu of
00125 or 00121).

00130 FIRST DENTAL HYGIENE VISIT/ORIENTATION

First dental hygiene visit/orientation 00131 33.13

Notes:
Oral assessment for clients up to the age of 3 years inclusive. Assessment to include
family dental history, dietary/feeding practices, oral habits, oral hygiene, fluoride exposure.
Anticipatory guidance with parent/guardian to be conducted.

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00200 RADIOGRAPHS AND PHOTOGRAPHS

Intraoral bitewing

Single image 00211 21.24

Two images 00212 29.24

Three images 00213 37.27

Four images 00214 45.32

Five images 00215 53.34

Six images 00216 58.48

Intraoral periapical

Single image 00221 21.24

Two images 00222 29.24

Three images 99223 37.27

Four images 00224 45.32

Five images 00225 53.34

Six images 00226 58.48

Seven images 00227 64.25

Eight images 00228 69.97

Each additional image > 8 00229 5.73

Intraoral full mouth series

Minimum of 14 images 00231 115.51

Panoramic

Panoramic image 00241 77.30

Cephalometric

One image 00251 62.51

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 Two images 00259 84.86

Duplication of radiographs

Single image 00261 10.32

Two images 00262 15.02

Three images 00263 19.75

Four images 00264 24.43

Five images 00265 29.13

Six images 00266 33.84

Seven images 00267 38.54

Eight images 00268 43.23

Each additional image > 8 00269 4.70

00270 VISUAL IMAGING (PHOTOGRAPHS AND VIDEOS) EXCLUDING RADIOGRAPHS,

FOR PURPOSES OF DENTAL HYGIENE DIAGNOSIS

1 photo 00271 18.11

2 photos 00272 27.41

3 photos 00273 36.69

Video 00278 18.11

Each additional photograph >3 00279 9.30

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00300 TESTS/ANALYSIS AND LABORATORY PROCEDURES/INTERPRETATION
Tests and laboratory procedures including, but not limited to, the evaluation and identification of
mucosal changes, presence of pathogens, caries or suspected caries. (Includes interpretation of
findings).

Note: Procedure codes in this section should be used only when indicated by clinical history and
after an appropriate head and neck examination have been completed. (ie. Head & neck exam,
caries risk assessment, periodontal assessment).

Caries Susceptibility Test (technical procedure only)

Bacteriological Test for the Determination of Dental 00311 48.97 +L

Caries Susceptibility ( + Lab)

Periodontal disease activity

Microbiological test for the determination of pathological 00321 48.97 +L

agents

Cancer testing (technical procedure only)

Cytological smear from the oral cavity 00331 49.31 +L +E

Vital Staining of Oral Mucosal Tissues 00332 49.31 +L +E

Direct fluorescence of oral mucosal tissues: direct

visualization of alterations to autofluorescence in the
00333 37.93
oral cavity

Non-Ionizing Scanning Procedure

Procedure to detect & monitor stages throughout the caries or suspected caries process,
which involves quantifying, monitoring, ad recording changes in enamel, dentin and
cementum. (Includes dental hygiene diagnosis ad interpretation of findings).

One unit of time 00341 50.60

Two units of time 00342 101.19

One half unit of time 00347 25.30

Each unit over two units of time 00349 50.60

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00400 STUDY MODELS (FOR DIAGNOSTIC PURPOSES)

Impressions of Maxilla and/or Mandible 00401 53.45 +L

Fabrication/pouring and preparing casts 00402 46.11 +L

SECTION 2: 00500 – 00999 DENTAL HYGIENE TREATMENT AND EVALUATION

00500 PERIODONTAL TREATMENT

Debridement

1 unit of time 00511 52.96

2 units of time 00512 105.87

3 units of time 00513 158.92

4 units of time 00514 211.95

5 units of time 00515 264.92

6 units of time 00516 323.17

½ unit of time 00517 26.50

Each additional unit of time >6 00519 52.96

Notes:
May include supra and/or subgingival scaling and/or subgingival deplaquing.

Root planning

1 unit of time 00521 52.96

2 units of time 00522 105.87

3 units of time 00523 158.95

4 units of time 00524 211.95

5 units of time 00525 264.92

6 units of time 00526 323.18

½ unit of time 00527 26.50

Each additional unit of time >6 00529 52.96

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 Notes:
The definitive instrumentation of the root surface resulting in the removal of cementum and
dentin that is rough, and/or permeated by calculus or contaminated with toxins or
microorganisms. The objective is to remove these contaminants while preserving the
integrity of the root structure.

Stain removal

1 unit of time 00531 41.31

2 units of time 00532 83.90

½ unit of time 00537 20.65

Each additional unit of time >2 00539 41.31

Notes:
May include manual or mechanical methods, prophylaxis, ultrasonic, etc.

Subgingival periodontal irrigation

1 unit of time 00541 63.31

½ unit of time 00547 31.64

Each additional unit of time 00549 63.31

Notes:
Targeted lavage and subgingival delivery of a chemotherapeutic agent into a periodontal
pocket.

Management of oral mucosal disorders

1 unit of time 00551 90.34

2 units of time 00552 180.66

3 units of time 00553 250.16

4 units of time 00554 333.53

½ unit of time 00557 54.19

Each additional unit of time >4 00559 84.78

Notes:
Includes education and counselling for disorders such as lichen planus, aphthous stomatis.

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00560 Management of Oral Manifestations of Systemic Disease

1 unit of time 00561 48.52

2 units of time 00562 97.01

3 units of time 00563 145.52

4 units of time 00564 194.05

½ unit of time 00567 24.24

Each additional unit of time >4 00569 48.52

Notes:
Includes education and counselling for oral manifestations of systemic diseases, such as
diabetes and lupus erythematosus, or for complications arising from chemotherapy or radiation
therapy, such as upper respiratory infections and pernicious anemia.

00570 Gingival Curettage

One sextant 00571 35.57

Two sextants 00572 71.12

Three sextants 00573 106.70

Four sextants 00574 142.26

Five sextants 00575 177.83

Six sextants 00576 213.40

Notes:
Intentional removal of inflamed soft tissue that lines the wall of a pocket in conjunction with
subgingival instrumentation—non surgical.

00580 Chemotherapeutic/Photodisinfection Therapy

1 unit of time 00581 IC +E

½ unit of time 00582 IC +E

Each additional unit of time 00583 IC +E

Notes:
Site specific delivery of a medication or photodisinfection therapy used to control periodontal
infection.
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00600 ADDITIONAL ORAL HEALTH SERVICES
Sealants

1st tooth in quadrant 00602 32.11

Each additional tooth in quadrant 00603 16.06

Notes:
Tooth number must be indicated on claim form.

Application of anticariogenics/antimicrobial agents

1 unit of time 00606 50.91 +E

½ unit of time 00607 25.44 +E

Each additional unit of time 00609 50.91 +E

Notes:
Applied to hard tissue to suppress caries or to destroy or hinder the growth of
microorganisms.

Fluoride applications

Fluoride Treatment – Topical - Varnish 00611 30.12

Supervised, self-administered, in office 00612 28.54

Home – custom maxillary arch 00613 67.96 +L

Home – custom mandibular arch 00614 67.96 +L

Home – custom combined 00615 72.11 +L

Fluoride Treatment – Topical – All other products 00616 30.12

applied in office

Finishing restoration
May include polishing/finishing, removal of overhangs, refining marginal ridges and occlusal
surfaces, etc. Note: Not to be used at the initial placement of restoration.

1 unit of time 00621 49.08

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 2 units of time 00622 98.18

3 units of time 00623 147.25

4 units of time 00624 196.37

½ unit of time 00627 24.54

Each additional unit of time >4 00629 49.08

Notes:
May include polishing/finishing, removal of overhangs, refining marginal ridges and occlusal
surfaces, etc.

Fabrication of sports guards

Preformed – maxillary arch 00631 46.22

Preformed – mandibular arch 00632 46.22

Preformed – maxillary & mandibular arches 00633 92.44

Custom – maxillary arch 00634 73.40 +L

Custom – mandibular arch 00635 73.40 +L

Custom – maxillary & mandibular arch 00636 146.81

Notes:
May include the taking of impressions and the preparation of study models for the purpose of
fabricating a mouth guard and subsequent insertion, fitting and education/instruction.

Labeling removal prosthesis

Labeling removable prosthesis 00638 40.31

Desensitization of teeth

1 unit of time 00641 59.12

2 units of time 00642 118.14

½ unit of time 00647 29.54

Each additional unit of time >2 00649 59.08

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 Notes:
May involve the application of chemotherapeutic agents or the use of a variety of therapeutic
procedures. More than one appointment or application may be necessary.

Whitening of vital teeth in office

1 unit of time 00651 84.78

2 units of time 00652 169.55

3 units of time 00653 254.70

½ unit of time 00657 55.60

Each additional unit of time >3 00659 84.78

Whitening of vital teeth at home

Maxillary arch 00661 IC +LE

Mandibular arach 00662 IC +LE

Maxillary and mandibular arch 00663 IC +LE

Notes:
Includes the fabrication of bleaching trays, product system for home use and follow-up care.

00665 Placement of Preventive, Therapeutic and/or Temporary Restorations

First Tooth, IST: Removal of soft debris (plaque and/or

food particles) from the lesion and placement of
00666
fluoride-releasing material, such as glass ionomer
105.28
cement
Each additional tooth in the same quadrant – all
00667
procedures 87.85

First Tooth, All other preventive, therapeutic and/or

temporary restorations 00669
105.28

Notes:
Tooth number must be indicated on the claim form.

000675 Resin Infiltration

One Surface 00676 64.90

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 Each additional surface over one 00677 33.71

Placement of an infiltrating resin material for the purpose of filling the sub-surface porosity of
an incipient, non-cavitated lesion for the purpose of strengthening, stabilizing and/or limiting
the progression of the lesion

Pulp vitality testing

1 unit of time 00681 67.43

2 unit of time 00682 33.71

Each additional unit of time 00689 67.49

Dentures/removable oral prosthesis, debridement and stain removal

1 unit of time 00691 83.38 +L

½ unit of time 00697 51.41 +L

Each additional unit of time 00699 83.38 +L

Notes:
Including implant retained.

00700 ORAL PAIN MANAGEMENT

Electronic dental anaesthesia

1 unit of time 00711 48.65

2 units of time 00712 91.74

3 units of time 00713 134.82

4 units of time 00714 178.05

½ unit of time 00717 34.74

Each additional unit of time >4 00719 48.65

Notes:
Not to be used in conjunction with treatment procedures.

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 Local anaesthesia

Regional block 00721 26.50

Trigeminal division block 00722 26.50

Supraperiosteal infiltration 00723 26.50

Notes:
Not to be used in conjunction with treatment procedures.

Acupuncture

1 unit of time 00731 48.00

2 units of time 00732 52.80

3 units of time 00733 57.59

4 units of time 00734 62.39

½ unit of time 00737 24.00

Each additional unit of time >4 00739 48.00

Nitrous oxide oxygen, conscious sedation

1 unit of time 00741 62.60

2 units of time 00742 94.05

3 units of time 00743 125.47

4 units of time 00744 156.89

½ unit of time 00747 31.32

Each additional unit of time >4 00749 31.42

00800 EDUCATION AND HABIT MODIFICATION

Counselling for diet as related to oral health

1 unit of time 00811 37.51

2 units of time 00812 75.02

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 3 units of time 00813 112.51

4 units of time 00814 150.02

½ unit of time 00817 18.75

Each additional unit of time >4 00819 37.51

Notes:
Includes recording and analysis of dietary intake and consultation.

Counselling for tobacco use cessation

1 unit of time 00821 37.51

2 units of time 00822 75.02

3 units of time 00823 112.51

4 units of time 00824 150.02

½ unit of time 00827 18.75

Each additional unit of time >4 00829 37.51

Counselling for oral self-examination

1 unit of time 00831 37.51

2 units of time 00832 75.02

3 units of time 00833 112.51

4 units of time 00834 150.01

½ unit of time 00837 18.75

Each additional unit of time >4 00839 37.51

Notes:
Client–dental hygienist interaction to provide detailed instructions on self-examination
techniques that allow the client to monitor changes in his or her extra or intraoral condition.

Instruction in oral self care

1 unit of time 00841 37.51

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 2 units of time 00842 75.02

3 units of time 00843 112.51

4 units of time 00844 150.01

½ unit of time 00847 18.75

Each additional unit of time >4 00849 37.51

Notes:
Individual instruction (one instructor to one client and/or caregiver) that may include, but is
not limited to, brushing and/or flossing and/or embrasure cleaning.

Group presentations: Note, this is not an insurance billable service.

1 unit of time 00851 IC

2 units of time 00852 IC

3 units of time 00853 IC

4 units of time 00854 IC

½ unit of time 00857 IC

Each additional unit of time >4 00859 IC

00900 PERIODONTAL OUTCOME EVALUATION

Notes:

The reassessment of periodontal health as a follow up to ongoing dental hygiene

care/therapy. May include evaluation of conditions such as NUG, post surgery sites, etc.

Evaluation of dental hygiene care/therapy

1 unit of time 00911 47.26

2 units of time 00912 83.38

½ unit of time 00917 27.79

Each additional unit of time >2 00919 47.26

Professional communications / Treatment Planning (client, family, and members of

the health care team)

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 1 unit of time 00921 IC+E

2 units of time 00922 IC+E

½ unit of time 00927 IC+E

Each additional unit of time >2 00929 IC+E

Notes:
May include family members, institution and/or other members of health care team. Only to
be used in particularly complex or time intensive cases.

Mobile dental hygiene services

Home visit (scheduled, non-emergency) 00951 82.57

Institutional visit (scheduled, non-emergency) 00952 82.57

Emergency home visit (non-scheduled) 00953 82.57

Emergency institutional visit (non-scheduled) 00954 87.75

Notes:
May include, but is not limited to, mobile dental hygiene services being delivered to a single
client in their primary place of residence (e.g. private home or care facility) in addition to
procedures performed.

00960 MANAGEMENT OF EXCEPTIONAL CLIENT

1 unit of time 00961 41.74

2 units of time 00962 155.58

3 units of time 00963 233.36

4 units of time 00964 311.13

Each additional unit of time over four 00969 77.79

Notes:
These codes take into consideration the extra time needed to provide dental hygiene interventions.
Only to be used in particularly complex or time-intensive cases.

Missed or cancelled appointments

In Office or Virtual Appointment, with insufficient notice 00981 30.05

Mobile Appointment, with insufficient notice 00982 30.05

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00970 CONSULTATION WITH CLIENT

1 unit of time 00971 77.79

2 units of time 00972 155.58

Each additional unit over two 00973 77.79

00990 MANAGEMENT DURING A PANDEMIC OR PUBLIC HEALTH CRISIS

Provision of enhanced personal protective materials for 00993

non-aerosol generating procedures 18.03

Provision of enhanced personal protective materials for 00994

aerosol generating procedures 24.04

Note: Personal Protective Equipment includes gowns, masks, hair and shoe coverings, face
shields, etc

5000-5009 OROFACIAL MYOFUNCTIONAL THERAPY

Examination and Diagnosis: Stomatognathic,

05001 IC
Dysfunctional, Comprehensive, to include:
(a) Client’s history, including medical, dental,
pain/dysfunction
(b) Clinical examination, including general appraisal,
examination of head and neck, musculoskeletal system
(static and functional); intraoral examination of hard
and soft tissues, including OMT occlusal analysis;
consultation with other health care professionals;
review of previous records, including radiographs,
photographs, videos, and consultations
Examination and Diagnosis: Stomatognathic,
05002 IC
Dysfunctional, Limited
Clinical examination under situations where a complete
assessment is not performed
Examination and Diagnosis: Stomatognathic
05003 IC
Dysfunctional, Limited (audio/video)
Virtual clinical examination under situations where a
complete assessment is not performed
Orofacial Myofunctional Therapy Examination:
05004 IC

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 Reassessment (Previous Client) Review and updating
of previously collected assessment data; analysis of
revised assessment data; modifications to orofacial
myofunctional therapy plans and programs based on
outcome measures, changing needs, new information,
and case presentation
Orofacial Myofunctional Therapy Examination:
05005 IC
Reassesment (previous client) (Audio/video
appointment). Review and updating of previously
collected assessment data; analysis of revised
assessment data; modifications to orofacial
myofunctional therapy plans and programs based o
outcome measures, changing needs, new information,
and case presentation.

05010 OROFACIAL MYOFUNCTIONAL THERAPY

For neuromuscular re-education exercises that support the development of optimal structure
and function of the orofacial complex to address orofacial myofunctional disorders (OMDs).
OMDs include, but are not limited to, abnormal orofacial rest posture of the tongue, lips, and/or
mandible; open mouth posture; atypical swallowing/forward tongue movement; inefficient/
insufficient chewing; inefficient breastfeeding; noxious oral habits; orofacial and jaw
parafunctions; and concomitant systemic symptoms such as sleep interruptions (snoring, sleep
apnea).

First unit of time per visit 05011 77.79

Two units of time 05012 155.59

Each additional unit of time over two 05019 77.79

05020 OROFACIAL MYOFUNCTIONAL THERAPY (AUDIO/VIDEO)

For virtual neuromuscular re-education exercises that support the development of optimal
structure and function of the orofacial complex addressing orofacial myofunctional disorders
(OMDs). OMDs include, but are not limited to, abnormal orofacial rest posture of the tongue,
lips, and/or mandible; open mouth posture; atypical swallowing/forward tongue movement;
inefficient/ insufficient chewing; inefficient breastfeeding; noxious oral habits; orofacial and jaw
parafunctions; and concomitant systemic symptoms such as sleep interruptions (snoring, sleep
apnea).

First unit of time per visit 05021 77.79

Two units of time 05022 155.59

Each additional unit of time over two 05029 77.79

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05090 POSTAGE COSTS FOR SHIPPING OROFACIAL MYOFUNCTIONAL THERAPY
RELATED MATERIALS

Flat Rate 05090 18.03

Material Expense 05091 IC

(includes cost of therapy kits)

5300 COUNSELLING FOR TOBACCO USE CESSATION (AUDIO/VIDEO APPOINTMENT)

One unit of time 05301 77.79

Two units of time 05302 155.58

Three units of time 05303 233.38

Four units of time 05304 311.18

One-half unit of time 05307 38.90

Each additional unit of time over four 05309 77.79

5310 COUNSELLING FOR ORAL SELF-EXAMINATION (AUDIO/VIDEO APPOINTMENT)

Client-dental hygienists’ virtual interaction to provide detailed instructions on self-examination
techniques that allow the client to monitor changes in his or her extra-or intraoral condition.

One unit of time 05311 77.79

Two units of time 05312 155.58

Three units of time 05313 233.38

Four units of time 05314 311.18

One-half unit of time 05317 38.90

Each additional unit of time over four 05319 77.79

5320 INSTRUCTION ON ORAL SELF-CARE (AUDIO/VIDEO APPOINTMENT)

Individual virtual instruction (one instructor to one client and/or caregiver) that may include, but
is not limited to, brushing and/or flossing and/or embrasure cleaning.

One unit of time 05321 77.79

Two units of time 05322 155.58

Each additional unit of time over two 05329 77.79

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05330 GROUP PRESENTATIONS (AUDIO/VIDEO APPOINTMENT)
Note – This is not an insurance billable service

One unit of time 05331 77.79

Two units of time 05332 155.58

Three units of time 05333 233.38

Four units of time 05334 311.18

One-half unit of time 05337 38.90

Each additional unit of time over four 05339 77.79

05340 CASE PREDATION/TREATMENT PLANNING (INDIVIDUAL CLIENT) (AUDIO/VIDEO

APPOINTMENT)
This service is for extra time spent on unusually complicated cases, for occasions when the
client demands unusual time in explanation or for when 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.

One unit of time 05341 77.79

Two units of time 05342 155.58

Three units of time 05343 233.38

Each additional unit of time over three 05349 77.79

05350 CASE PRESENTATION/TREATMENT PLANNING (Client, Family, and Members of

the Health Care Team) (audio/video appointment)
May include family members, institutions and/or other members of the health care team. Only
to be used in particularly complex or time-intensive cases.

One unit of time 05351 77.79

Two units of time 05352 155.58

One-half unit of time 05357 38.09

Each additional unit of time over two 05359 77.79

05360 MANAGEMENT OF ORAL MUCOSAL DISORDERS (audio/video appointment)

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Includes virtual education and counselling for disorders such as lichen planus or aphthous
stomatitis.

One unit of time 05361 77.79

Two units of time 05362 155.58

One-half unit of time 05367 38.90

Each additional unit of time over two 05359 77.79

05370 MANAGEMENT OF ORAL MANIFESTATIONS OF SYSTEMIC DISEASE (audio/video

appointment)
Includes virtual education and counselling for oral manifestations of system diseases such as
diabetes and lupus erythematosus, or for complications arising from chemotherapy or radiation
therapy, such as upper respiratory infections and pernicious anemia.

One unit of time 05371 77.79

Two units of time 05372 155.58

One-half unit of time 05377 38.90

Each additional unit of time over two 05379 77.79

05380 DENTAL HYGIENE EXAMINATION

Emergency: Virtual dental hygiene examination and 05380

dental hygiene diagnosis under emergency conditions
for the investigation of discomfort and/or infection in a
localized area. 81.48

Specific: Virtual dental hygiene examination, 05381

evaluation, and dental hygiene diagnoses of a specific
oral situation (new or existing client) 81.48

05461 PRESCRIPTION, EMERGENCY DRUGS

e.g. For a Periodontal Abscess 05461 43.41

05463 DISPENSING, NON-EMERGENCY DRUGS

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e.g. Fluoride, Vitamins, Other Drugs/Medication 05463 43.41

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