`DENTAL BENEFIT GRID

INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

DENTAL BENEFIT GRID

INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
GENERAL PRACTITIONERS
DIAGNOSTIC SERVICES
Examination Services
01205 Emergency Examination No 100% of the Emergency examinations are covered once every six months
provincial/territorial per dental office.
(PT) Dental Fee Guides
Radiographs
02111-02125 Periapical No 100% of the •Periapical and bitewing radiographs to a maximum of 16
02141-02146 Bitewing provincial/territorial (PT) Dental radiographs per lifetime (any combination).
02601 Panoramic Fee Guides. •One panoramic radiograph limited to once per lifetime.
External: If requested - radiographs must be clear, discernible,
and properly labeled. Digital X-rays are acceptable. Intraoral
photographs in addition to radiographs are acceptable but
must be labeled with macros noted on teeth with decay.

RESTORATIVE SERVICES
Caries, Trauma and Pain Control
20111-20119 Removal of carious lesions or No 100% of the
existing restorations or gingivally provincial/territorial (PT) Dental
attached tooth fragment and Fee Guides.
placement of sedative/protective
dressings, includes pulp caps, when
necessary, as a separate procedure
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Caries, Trauma and Pain Control
20121-20129 Removal of carious lesions or existing No 100% of the
restorations or gingivally attached provincial/territorial (PT) Dental
tooth fragment and placement of Fee Guides.
sedative/protective dressings,
includes pulp caps when necessary,
and the use of a band for retention
and support, as a separate procedure
20131-20139 Trauma control, smoothing of No 100% of the
fractured surfaces provincial/territorial (PT) Dental
Fee Guides.
20141-20149 Pulp capping direct performed in No 100% of the
conjunction with permanent provincial/territorial (PT) Dental
restoration Fee Guides.
Restorations
21111-21115 Amalgam, non-bonded, primary No* 100% of the •Restorations will be paid on a continuous surface basis only.
teeth provincial/territorial (PT) Dental •Replacement restorations are not eligible within a 12 Teeth with extensive bone loss,
Fee Guides. consecutive month period. mobility, gross decay into the pulp
•Molar teeth are limited to the cost of an equivalent bonded chamber /horns, furcation
or non-bonded amalgam restoration. involvement, and apical
•Restorations are covered to a maximum of $2000.00 per radiolucencies, will be considered not
calendar year without prior approval. fit for restoration and be declined.
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Restorations
21121-21125 Amalgam, bonded, primary teeth No* 100% of the •Restorations will be paid on a continuous surface basis only.
provincial/territorial (PT) Dental •Replacement restorations are not eligible within a 12 Teeth with extensive bone loss, mobility,
Fee Guides. consecutive month period. gross decay into the pulp chamber
•Molar teeth are limited to the cost of an equivalent bonded /horns, furcation involvement, and
or non-bonded amalgam restoration. apical radiolucencies, will be considered
•Restorations are covered to a maximum of $2000.00 per not fit for restoration and be declined.
calendar year without prior approval.
21211-21215 Amalgam, non-bonded, permanent No* 100% of the •Restorations will be paid on a continuous surface basis only.
bicuspids and anterior teeth provincial/territorial (PT) Dental •Replacement restorations are not eligible within a 12 Teeth with extensive bone loss, mobility,
Fee Guides. consecutive month period. gross decay into the pulp chamber
•Molar teeth are limited to the cost of an equivalent bonded /horns, furcation involvement, and
or non-bonded amalgam restoration. apical radiolucencies, will be considered
•Restorations are covered to a maximum of $2000.00 per not fit for restoration and be declined.
calendar year without prior approval.

21221-21225 Amalgam, non-bonded, permanent No* 100% of the •Restorations will be paid on a continuous surface basis only.
molars provincial/territorial (PT) Dental •Replacement restorations are not eligible within a 12 Teeth with extensive bone loss, mobility,
Fee Guides. consecutive month period. gross decay into the pulp chamber
•Molar teeth are limited to the cost of an equivalent bonded /horns, furcation involvement, and
or non-bonded amalgam restoration. apical radiolucencies, will be considered
•Restorations are covered to a maximum of $2000.00 per not fit for restoration and be declined.
calendar year without prior approval.

21231-21235 Amalgam, bonded, permanent No* 100% of the •Restorations will be paid on a continuous surface basis only.
bicuspids and anterior teeth provincial/territorial (PT) Dental •Replacement restorations are not eligible within a 12 Teeth with extensive bone loss, mobility,
Fee Guides. consecutive month period. gross decay into the pulp chamber
•Molar teeth are limited to the cost of an equivalent bonded /horns, furcation involvement, and
or non-bonded amalgam restoration. apical radiolucencies, will be considered
•Restorations are covered to a maximum of $2000.00 per not fit for restoration and be declined.
calendar year without prior approval. .
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Restorations
21241-21245 Amalgam, bonded, permanent No* 100% of the •Restorations will be paid on a continuous surface basis
molars provincial/territorial (PT) Dental only. Teeth with extensive bone loss, mobility,
Fee Guides. •Replacement restorations are not eligible within a 12 gross decay into the pulp chamber /horns,
consecutive month period. furcation involvement, and apical
•Molar teeth are limited to the cost of an equivalent radiolucencies, will be considered not fit
bonded or non-bonded amalgam restoration. for restoration and be declined.
•Restorations are covered to a maximum of $2000.00 per
calendar year without prior approval.
23101-23105 Tooth coloured, non-bonded, No* 100% of the •Restorations will be paid on a continuous surface basis
permanent anterior teeth provincial/territorial only. Teeth with extensive bone loss, mobility,
(PT) Dental Fee Guides •Replacement restorations are not eligible within a 12 gross decay into the pulp chamber /horns,
consecutive month period. furcation involvement, and apical
•Molar teeth are limited to the cost of an equivalent radiolucencies, will be considered not fit
bonded or non-bonded amalgam restoration. for restoration and be declined.
•Restorations are covered to a maximum of $2000.00 per
calendar year without prior approval.

23111-23112 Tooth coloured, bonded (not to be No* 100% of the provincial/territorial •Restorations will be paid on a continuous surface basis
used for veneer applications or (PT) Dental Fee Guides only. Teeth with extensive bone loss, mobility,
diastema closures), permanent •Replacement restorations are not eligible within a 12 gross decay into the pulp chamber /horns,
anterior teeth consecutive month period. furcation involvement, and apical
•Molar teeth are limited to the cost of an equivalent radiolucencies, will be considered not fit
bonded or non-bonded amalgam restoration. for restoration and be declined.
•Restorations are covered to a maximum of $2000.00 per
calendar year without prior approval.
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Restorations
23211-23215 Tooth coloured/plastic, non-bonded, No* 100% of the provincial/territorial •Restorations will be paid on a continuous surface basis
with/without silver fillings, (PT) Dental Fee Guides only. Teeth with extensive bone loss, mobility,
permanent bicuspids •Replacement restorations are not eligible within a 12 gross decay into the pulp chamber /horns,
consecutive month period. furcation involvement, and apical
•Molar teeth are limited to the cost of an equivalent radiolucencies, will be considered not fit
bonded or non-bonded amalgam restoration. for restoration and be declined.
•Restorations are covered to a maximum of $2000.00 per
calendar year without prior approval.

23221-23225 Tooth coloured/plastic, non-bonded, No* 100% of the provincial/territorial •Restorations will be paid on a continuous surface basis
with/without silver fillings, (PT) Dental Fee Guides only. Teeth with extensive bone loss, mobility,
permanent molars •Replacement restorations are not eligible under this gross decay into the pulp chamber /horns,
program within a 12 consecutive month period. furcation involvement, and apical
•Molar teeth are limited to the cost of an equivalent radiolucencies, will be considered not fit
bonded or non-bonded amalgam restoration. for restoration and be declined.
•Restorations are covered to a maximum of $2000.00 per
calendar year without prior approval.

23311-23315 Tooth coloured, bonded, permanent No* 100% of the •Restorations will be paid on a continuous surface basis
bicuspids provincial/territorial only. Teeth with extensive bone loss, mobility,
(PT) Dental Fee Guides •Replacement restorations are not eligible within a 12 gross decay into the pulp chamber /horns,
consecutive month period furcation involvement, and apical
•Molar teeth are limited to the cost of an equivalent radiolucencies, will be considered not fit
bonded or non-bonded amalgam restoration. for restoration and be declined.
•Restorations are covered to a maximum of $2000.00 per
calendar year without prior approval.
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Restorations
23321-23325 Tooth coloured, bonded, permanent No* 100% of the •Restorations will be paid on a continuous surface basis
molars provincial/territorial only. Teeth with extensive bone loss, mobility,
(PT) Dental Fee Guides •Replacement restorations are not eligible within a 12 gross decay into the pulp chamber /horns,
consecutive month period furcation involvement, and apical
•Molar teeth are limited to the cost of an equivalent radiolucencies, will be considered not fit
bonded or non-bonded amalgam restoration. for restoration and be declined.
•Restorations are covered to a maximum of $2000.00 per
calendar year without prior approval.

23401-23405 Tooth coloured, non-bonded, No* 100% of the •Restorations will be paid on a continuous surface basis
primary anterior provincial/territorial only. Teeth with extensive bone loss, mobility,
(PT) Dental Fee Guides •Replacement restorations are not eligible within a 12 gross decay into the pulp chamber /horns,
consecutive month period furcation involvement, and apical
•Molar teeth are limited to the cost of an equivalent radiolucencies, will be considered not fit
bonded or non-bonded amalgam restoration. for restoration and be declined.
•Restorations are covered to a maximum of $2000.00 per
calendar year without prior approval.

23411-23415 Tooth coloured, bonded, primary No* 100% of the •Restorations will be paid on a continuous surface basis
anterior provincial/territorial only. Teeth with extensive bone loss, mobility,
(PT) Dental Fee Guides •Replacement restorations are not eligible within a 12 gross decay into the pulp chamber /horns,
consecutive month period furcation involvement, and apical
•Molar teeth are limited to the cost of an equivalent radiolucencies, will be considered not fit
bonded or non-bonded amalgam restoration. for restoration and be declined.
•Restorations are covered to a maximum of $2000.00 per
calendar year without prior approval.
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Restorations
23501-23505 Tooth coloured/plastic with/without No* 100% of the •Restorations will be paid on a continuous surface basis
silver fillings, non-bonded, primary provincial/territorial only. Teeth with extensive bone loss, mobility,
posterior (PT) Dental Fee Guides •Replacement restorations are not eligible within a 12 gross decay into the pulp chamber /horns,
consecutive month period furcation involvement, and apical
•Molar teeth are limited to the cost of an equivalent radiolucencies, will be considered not fit
bonded or non-bonded amalgam restoration. for restoration and be declined.
•Restorations are covered to a maximum of $2000.00 per
calendar year without prior approval.

23511-23515 Tooth coloured/plastic with/without No* 100% of the •Restorations will be paid on a continuous surface basis
silver fillings, bonded, primary provincial/territorial only. Teeth with extensive bone loss, mobility,
posterior (PT) Dental Fee Guides •Replacement restorations are not eligible within a 12 gross decay into the pulp chamber /horns,
consecutive month period furcation involvement, and apical
•Molar teeth are limited to the cost of an equivalent radiolucencies, will be considered not fit
bonded or non-bonded amalgam restoration. for restoration and be declined.
•Restorations are covered to a maximum of $2000.00 per
calendar year without prior approval.

Extractions
71101-71109 Removals, erupted teeth, No 100% of the Limited to GP rate except for Oral Surgeons and
uncomplicated provincial/territorial Pedodontists.
(PT) Dental Fee Guides
71201-71209 Odontectomy, erupted tooth, Yes 100% of the Limited to GP rate except for Oral Surgeons and All complicated extractions require
surgical approach, requiring surgical provincial/territorial Pedodontists. radiographs for justification of level of
flap and/or sectioning of tooth. (PT) Dental Fee Guides difficulty.
71211- 71219 Requiring elevation of flap, removal Yes 100% of the Limited to GP rate except for Oral Surgeons and All complicated extractions require
of bone and may include sectioning provincial/territorial Pedodontists. radiographs for justification of level of
of tooth for removal of tooth (PT) Dental Fee Guides difficulty.
72111-72119 Removals, impactions, requiring Yes 100% of the provincial/ Limited to GP rate except for Oral Surgeons and All complicated extractions require
incision of overlying soft tissue and territorial Pedodontists. radiographs for justification of level of
removal of tooth (PT) Dental Fee Guides difficulty.
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Extractions
72211-72219 Removals, impactions, requiring Yes 100% of the Limited to GP rate except for Oral Surgeons and All complicated extractions require
incision of overlying soft tissue, provincial/territorial Pedodontists. radiographs for justification of level of
elevation of a flap and EITHER (PT) Dental Fee Guides difficulty.
removal of bone and tooth OR
sectioning of tooth removal
72221-72229 Removal, impaction, requiring Yes 100% of the Limited to GP rate except for Oral Surgeons and All complicated extractions require
incision of overlying soft tissue, provincial/territorial Pedodontists. radiographs for justification of level of
elevation of flap, removal of bone (PT) Dental Fee Guides difficulty.
AND sectioning of tooth for removal

72231-72239 Removals, impactions, requiring Yes 100% of the Limited to GP rate except for Oral Surgeons and All complicated extractions require
incision of overlying soft tissue, provincial/territorial Pedodontists. radiographs for justification of level of
elevation of a flap, removal of bone (PT) Dental Fee Guides difficulty.
AND/OR sectioning of tooth for
removal AND/OR presents unusual
difficulties and circumstances
72241 Coronectomy (deliberate vital root Yes 100% of the Limited to GP rate except for Oral Surgeons and All complicated extractions require
retention of unerupted mandibular provincial/territorial Pedodontists. radiographs for justification of level of
molar) (PT) Dental Fee Guides difficulty.
72242 Coronectomy (deliberate vital root Yes 100% of the Limited to GP rate except for Oral Surgeons and All complicated extractions require
retention to prevent complications provincial/territorial Pedodontists radiographs for justification of level of
associated with extraction) (PT) Dental Fee Guides difficulty.
72311-72319 Removals, residual roots, erupted Yes 100% of the provincial/territorial Limited to GP rate except for Oral Surgeons and All complicated extractions require
(PT) Dental Fee Guides Pedodontists. radiographs for justification of level of
difficulty.
72321-72329 Removals, residual roots, soft tissue Yes 100% of the provincial/territorial Limited to GP rate except for Oral Surgeons and All complicated extractions require
coverage (PT) Dental Fee Guides Pedodontists. radiographs for justification of level of
difficulty.
72331-72339 Removals, residual roots, bone tissue Yes 100% of the provincial/territorial Limited to GP rate except for Oral Surgeons and All complicated extractions require
coverage (PT) Dental Fee Guides Pedodontists. radiographs for justification of level of
difficulty.
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Extractions
72801-72809 Removal of fractured cusp as a No 100% of the provincial/territorial Limited to GP rate except for Oral Surgeons and All complicated extractions require
separate procedure, not in (PT) Dental Fee Guides Pedodontists radiographs for justification of level of
conjunction with surgical or difficulty.
restorative procedures on the same
tooth

79401-79404 Primary Hemorrhage, Control No 100% of the provincial/territorial Limited to GP rate except for Oral Surgeons and
(PT) Dental Fee Guides Pedodontists

Periodontics
42831-42839 Periodontal abscess or pericoronitis, No 100% of the provincial/territorial Limited to GP rate except for Oral Surgeons and
includes any of the following (PT) Dental Fee Guides Pedodontists
procedures: lancing, scaling,
curettage, surgery or medication
PROSTHODONTIC SERVICES
Dentures, Complete
51101-51103 Dentures, complete, standard Yes 100% of the provincial/territorial •Complete dentures are limited to one upper and one Must be edentulous.
(PT) Dental Fee Guides lower per lifetime.
•All complete dentures are limited to the cost of a
transitional denture.
51201-51203 Dentures, complete, complex Yes 100% of the provincial/territorial •Complete dentures are limited to one upper and one Must be edentulous.
(PT) Dental Fee Guides lower per lifetime.
•All complete dentures are limited to the cost of a
transitional denture.
51301-51303 Dentures, complete, surgical, Yes 100% of the provincial/territorial •Complete dentures are limited to one upper and one Must be edentulous.
standard (immediate) (PT) Dental Fee Guides lower per lifetime.
•All complete dentures are limited to the cost of a
transitional denture.
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Dentures, Complete
51601-51603 Dentures, complete, provisional Yes 100% of the provincial/territorial •Complete dentures are limited to one upper and one Must be edentulous.
(PT) Dental Fee Guides lower per lifetime.
•All complete dentures are limited to the cost of a
transitional denture.
51611-51613 Dentures, complete , surgical, Yes 100% of the provincial/territorial •Complete dentures are limited to one upper and one Must be edentulous.
provisional (immediate) (PT) Dental Fee Guides lower per lifetime.
•All complete dentures are limited to the cost of a
transitional denture.

Dentures, Partial
52101-52103 Dentures, partial, acrylic base Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
(provisional) (with or without clasps) (PT) Dental Fee Guides lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
52111-52113 Dentures, partial, acrylic base Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
(immediate) (includes first tissue (PT) Dental Fee Guides lifetime. teeth are not covered.
conditioner, but not a processed •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
reline) denture. the prosthesis.
52121-52123 Dentures, partial, acrylic base, Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
provisional (immediate) (with or (PT) Dental Fee Guides lifetime. teeth are not covered.
without clasps) (includes first tissue •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
conditioner, but not a processed denture. the prosthesis.
reline)
52201-52203 Dentures, partial, acrylic, resilient Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
retainer (PT) Dental Fee Guides lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Dentures, Partial
52211-52213 Dentures, partial, acrylic, resilient Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
retainer (immediate) (includes first (PT) Dental Fee Guides lifetime. teeth are not covered.
tissue conditioner, but not a •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
processed reline) denture. the prosthesis.
52301-52303 Dentures, partial, acrylic, with metal Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
wrought/cast clasps and/or rests (PT) Dental Fee Guides lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
52311-52313 Dentures, partial, acrylic, with metal Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
wrought/cast clasps and/or rests (PT) Dental Fee Guides lifetime. teeth are not covered.
retainer (immediate) (includes first •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
tissue conditioner, but not a denture. the prosthesis.
processed reline)
52401-52403 Dentures, partial, acrylic, with metal Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
wrought palatal/lingual bar and (PT) Dental Fee Guides lifetime. teeth are not covered.
clasps and/or rests •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
52411-52413 Dentures, partial, acrylic, with metal Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
wrought palatal/lingual bar and (PT) Dental Fee Guides lifetime. teeth are not covered.
clasps and/or rests (immediate) •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
(includes first tissue conditioner, but denture. the prosthesis.
not a processed reline.)
52511-52513 Dentures, partial (flexible, non metal, Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
non acrylic) (PT) Dental Fee Guides lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
53101-53103 Dentures, partial, free end, cast Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
frame/connector, clasps and rests (PT) Dental Fee Guides lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Dentures, Partial
53111-53113 Dentures, partial, free end, cast Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
frame/connector, clasps and rests (PT) Dental Fee Guides lifetime. teeth are not covered.
(immediate) (includes first tissue •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
conditioner, but not a processed denture. the prosthesis.
reline)
53201-53203 Dentures, partial, tooth borne, cast Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
frame/connector, clasps and rests (PT) Dental Fee Guides lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
53211-53213 Dentures, partial, tooth borne, cast Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
frame/connector, clasps and rests (PT) Dental Fee Guides lifetime. teeth are not covered.
(immediate) (includes first tissue •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
conditioner, but not a processed denture. the prosthesis.
reline)
53401-53403 Dentures, partial, cast, precision Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
attachments (PT) Dental Fee Guides lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
53501-53503 Dentures, partial, cast, semi- Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
precision attachments (PT) Dental Fee Guides lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
53611-53613 Dentures, partial, stress breaker Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
53621-53623 attachments (PT) Dental Fee Guides lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
Dentures, Repairs
55101-55102 Dentures, repairs, complete, no No 100% of the provincial/territorial Limited to one upper and one lower per lifetime.
impression required (PT) Dental Fee Guides
55201-55203 Dentures, repairs, complete, No 100% of the provincial/territorial Limited to one upper and one lower per lifetime.
impression required (PT) Dental Fee Guides
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Dentures, Repairs
55301-55302 Dentures, repairs/additions, partial, No 100% of the provincial/territorial Limited to one upper and one lower per lifetime.
no impression required (PT) Dental Fee Guides
55401-55403 Dentures, repairs/additions, partial, No 100% of the provincial/territorial Limited to one upper and one lower per lifetime.
impression required (PT) Dental Fee Guides
Dentures, Relining
56211-56213 Dentures, reline, direct, complete No 100% of the provincial/territorial Limited to one upper and one lower per lifetime.
(PT) Dental Fee Guides
56221-56223 Denture, reline, direct, partial No 100% of the provincial/territorial Limited to one upper and one lower per lifetime.
(PT) Dental Fee Guides
56231-56233 Denture, reline, processed, complete No 100% of the provincial/territorial Limited to one upper and one lower per lifetime.
(PT) Dental Fee Guides
56241-56243 Denture, reline, processed, partial No 100% of the provincial/territorial Limited to one upper and one lower per lifetime.
(PT) Dental Fee Guides
56251-56253 Denture, reline, processed, functional No 100% of the provincial/territorial Limited to one upper and one lower per lifetime.
impression requiring three (PT) Dental Fee Guides
appointments, complete
56261-56263 Denture, reline, processed, functional No 100% of the provincial/territorial Limited to one upper and one lower per lifetime.
impression requiring three (PT) Dental Fee Guides
appointments, partial
General Anaesthesia
92210-92218 Anaesthesia, general Yes 100% of the provincial/territorial •Limited to four units per lifetime for children under age 13.
(PT) Dental Fee Guides •Limited to eight units per lifetime for age 13 and over.

Drugs/Medication, Dispensing
96100 Prescriptions, emergency No 100% of the provincial/territorial Limited to GP rate except for Oral Surgeons and
(PT) Dental Fee Guides Pedodontists
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Denturists
Examinations
10010-10104 Examination No Pays equal to emergency Emergency examinations are covered once every six
examination. months per dental office.
Dentures, Complete
31110 Complete maxillary – precision Yes 100% of the •Complete dentures are limited to one upper and one Must be edentulous.
equilibrated/complex provincial/territorial lower per lifetime.
(PT) Denturists Fee Guide •All complete dentures are limited to the cost of a
transitional denture.
31120 Complete mandibular – precision Yes 100% of the •Complete dentures are limited to one upper and one Must be edentulous.
equilibrated/complex provincial/territorial lower per lifetime.
(PT) Denturists Fee Guide •All complete dentures are limited to the cost of a
transitional denture.
31310 Complete maxillary – standard Yes 100% of the •Complete dentures are limited to one upper and one Must be edentulous.
provincial/territorial lower per lifetime.
(PT) Denturists Fee Guide •All complete dentures are limited to the cost of a
transitional denture.
31320 Complete mandibular – standard Yes 100% of the •Complete dentures are limited to one upper and one Must be edentulous.
provincial/territorial lower per lifetime.
(PT) Denturists Fee Guide •All complete dentures are limited to the cost of a
transitional denture.
31111 Complete maxillary – precision Yes 100% of the •Complete dentures are limited to one upper and one Must be edentulous.
equilibrated/complex provincial/territorial lower per lifetime.
(immediate/surgical) (PT) Denturists Fee Guide •All complete dentures are limited to the cost of a
transitional denture.
31121 Complete mandibular - precision Yes 100% of the •Complete dentures are limited to one upper and one Must be edentulous.
equilibrated/complex provincial/territorial lower per lifetime.
(immediate/surgical) (PT) Denturists Fee Guide •All complete dentures are limited to the cost of a
transitional denture.
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Dentures, Complete
31311 Complete maxillary - standard Yes 100% of the •Complete dentures are limited to one upper and one Must be edentulous.
(immediate/surgical) provincial/territorial lower per lifetime.
(PT) Denturists Fee Guide •All complete dentures are limited to the cost of a
transitional denture.
31321 Complete mandibular - standard Yes 100% of the •Complete dentures are limited to one upper and one Must be edentulous.
(immediate/surgical) provincial/territorial lower per lifetime.
(PT) Denturists Fee Guide •All complete dentures are limited to the cost of a
transitional denture.
31510 Complete maxillary - transitional Yes 100% of the •Complete dentures are limited to one upper and one Must be edentulous.
provincial/territorial lower per lifetime.
(PT) Denturists Fee Guide •All complete dentures are limited to the cost of a
transitional denture.
31520 Complete mandibular - transitional Yes 100% of the •Complete dentures are limited to one upper and one Must be edentulous.
provincial/territorial lower per lifetime.
(PT) Denturists Fee Guide •All complete dentures are limited to the cost of a
transitional denture.
31511 Complete maxillary – transitional Yes 100% of the •Complete dentures are limited to one upper and one Must be edentulous.
(immediate/surgical) provincial/territorial lower per lifetime.
(PT) Dental Fee Guides •All complete dentures are limited to the cost of a
transitional denture.
31521 Complete mandibular – transitional Yes 100% of the •Complete dentures are limited to one upper and one Must be edentulous.
(immediate/surgical) provincial/territorial lower per lifetime.
(PT) Dental Fee Guides •All complete dentures are limited to the cost of a
transitional denture.
Dentures, Reline(s) Complete
32110 Complete maxillary – lab processed No 100% of the Limited to one upper and one lower per lifetime.
heat cured provincial/territorial
(PT) Denturists Fee Guide
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Dentures, Reline(s) Complete
32120 Complete mandibular – lab No 100% of the Limited to one upper and one lower per lifetime.
processed heat cured provincial/territorial
(PT) Denturists Fee Guide
32215 Complete maxillary – lab processed No 100% of the Limited to one upper and one lower per lifetime.
self-polymerized provincial/territorial
(PT) Denturists Fee Guide
32225 Complete mandibular – lab No 100% of the Limited to one upper and one lower per lifetime.
processed self-polymerized provincial/territorial
(PT) Denturists Fee Guide

Denture, Repair(s) Complete

36110 Complete maxillary - no impression No 100% of the provincial/territorial Limited to one upper and one lower per lifetime.
(PT) Denturists Fee Guide
36120 Complete mandibular – no No 100% of the provincial/territorial Limited to one upper and one lower per lifetime.
impression (PT) Denturists Fee Guide
36210 Complete maxillary - with impression No 100% of the provincial/territorial Limited to one upper and one lower per lifetime.
(PT) Denturists Fee Guide
36220 Complete mandibular – with No 100% of the provincial/territorial Limited to one upper and one lower per lifetime.
impression (PT) Denturists Fee Guide
Dentures, Partials
41110 Partial maxillary - precision Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
equilibrated/complex - free-end - cast (PT) Denturists Fee Guide lifetime. teeth are not covered.
with clasps and/or rests •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41120 Partial mandibular - precision Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
equilibrated/complex - free-end - cast (PT) Denturists Fee Guide lifetime. teeth are not covered.
with clasps and/or rests •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Dentures, Partials
41111 Partial maxillary - precision Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
equilibrated/complex – free-end - (PT) Denturists Fee Guide lifetime. teeth are not covered.
cast with clasps and/or rests •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
(immediate/surgical) denture. the prosthesis.
41121 Partial mandibular - precision Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
equilibrated/complex – free-end - (PT) Denturists Fee Guide lifetime. teeth are not covered.
cast with clasps and/or rests •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
(immediate/surgical) denture. the prosthesis.
41115 Partial maxillary - standard - free-end Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
- cast with clasps and/or rests (PT) Denturists Fee Guide lifetime. teeth are not covered.
(immediate/surgical) •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41125 Partial mandibular - standard – free- Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
end - cast with clasps and/or rests (PT) Denturists Fee Guide lifetime. teeth are not covered.
(immediate/surgical) •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41114 Partial maxillary - standard - free-end Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
- cast with clasps and/or rests (PT) Denturists Fee Guide lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41124 Partial mandibular - standard – free- Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
end - cast with clasps and/or rests (PT) Denturists Fee Guide lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41215 Partial maxillary - standard – tooth Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
borne - cast with clasps and/or rests (PT) Denturists Fee Guide lifetime. teeth are not covered.
(immediate/surgical) •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41225 Partial mandibular - standard – tooth Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
borne - cast with clasps and/or rests (PT) Denturists Fee Guide lifetime. teeth are not covered.
(immediate/surgical) •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Dentures, Partials
41216 Partial maxillary - precision Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
equilibrated/complex – tooth borne - (PT) Denturists Fee Guide lifetime. teeth are not covered.
cast with clasps and/or rests •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41226 Partial mandibular - precision Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
equilibrated/complex – tooth borne - (PT) Denturists Fee Guide lifetime. teeth are not covered.
cast with clasps and/or rests •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41254 Partial maxillary - standard – tooth Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
borne - cast with clasps and/or rests (PT) Denturists Fee Guide lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41264 Partial mandibular - standard – tooth Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
borne - cast with clasps and/or rests (PT) Denturists Fee Guide lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.

41913 Partial maxillary – non-acrylic Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
(PT) Denturists Fee Guide lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41923 Partial mandibular – non-acrylic Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
(PT) Denturists Fee Guide lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41610 Partial maxillary - standard - acrylic Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
base with clasps and/or rests or (PT) Denturists Fee Guide lifetime. teeth are not covered.
resilient retainers •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Dentures, Partials
41620 Partial mandibular - standard - acrylic Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
base with clasps and/or rests (PT) Denturists Fee Guide lifetime. teeth are not covered.
or resilient retainers •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41611 Partial maxillary – standard – acrylic Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
base with clasps and/or rests or (PT) Denturists Fee Guide lifetime. teeth are not covered.
resilient retainers •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
(immediate/surgical) denture. the prosthesis.
41621 Partial mandibular – standard – Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
acrylic base with clasps and/or rests (PT) Denturists Fee Guide lifetime. teeth are not covered.
or resilient retainers •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
(immediate/surgical) denture. the prosthesis.
41612 Partial maxillary - standard - acrylic Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
base no clasps (PT) Denturists Fee Guide lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41622 Partial mandibular - standard - acrylic Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
base no clasps (PT) Denturists Fee Guide lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture the prosthesis.

41613 Partial maxillary -standard - acrylic Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
base without clasps (PT) Denturists Fee Guide lifetime. teeth are not covered.
(immediate/surgical) •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41623 Partial mandibular -standard - acrylic Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
base without clasps (PT) Denturists Fee Guide lifetime. teeth are not covered.
(immediate/surgical) •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Dentures, Partials
41710 Partial maxillary – transitional - Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
acrylic base with clasps and/or resets (PT) Denturists Fee Guide lifetime. teeth are not covered.
or resilient •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41720 Partial mandibular – transitional - Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
acrylic base with clasps and/or resets (PT) Denturists Fee Guide lifetime. teeth are not covered.
or resilient •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41711 Partial maxillary – transitional - Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
acrylic base with clasps and/or resets (PT) Denturists Fee Guide lifetime. teeth are not covered.
or resilient retainers •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
(immediate/Surgical) denture. the prosthesis.
41721 Partial mandibular – transitional - Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
acrylic base with clasps and/or resets (PT) Denturists Fee Guide lifetime. teeth are not covered.
or resilient retainers •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
(immediate/surgical) denture. the prosthesis.
41712 Partial maxillary –transitional - acrylic Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
base no clasps (PT) Denturists Fee Guide lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41722 Partial mandibular –transitional - Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
acrylic base no clasps (PT) Denturists Fee Guide lifetime. teeth are not covered.
•All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41713 Partial maxillary – transitional - Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
acrylic base without clasps (PT) Denturists Fee Guide lifetime. teeth are not covered.
(immediate/surgical) •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
41723 Partial mandibular – transitional - Yes 100% of the provincial/territorial •Partial dentures limited to one upper and one lower per •Partial dentures to replace only posterior
acrylic base without clasps (PT) Denturists Fee Guide lifetime. teeth are not covered.
(immediate/surgical) •All partial dentures are limited to the cost of a transitional • Sufficient support to stabilize and retain
denture. the prosthesis.
`DENTAL BENEFIT GRID
INTERIM FEDERAL HEALTH PROGRAM – All PTs except QC

Dental Code Benefit Description Prior Payment Rules Limitations Criteria

Approval
Required
Dentures, Reline(s) Partial
42210 Partial maxillary – lab processed – No 100% of the provincial/territorial Limited to one upper per lifetime.
self-polymerized (PT) Denturists Fee Guide
42220 Partial mandibular – lab processed – No 100% of the provincial/territorial Limited to one lower per lifetime.
self-polymerized (PT) Denturists Fee Guide
Dentures, Repair(s) Partial
46110 Partial maxillary - no impression No 100% of the provincial/ Limited to one upper per lifetime.
territorial
(PT) Denturists Fee Guide
46120 Partial mandibular - no impression No 100% of the provincial/ Limited to one lower per lifetime.
territorial
(PT) Denturists Fee Guide
46210 Partial maxillary - with impression No 100% of the provincial/ Limited to one upper per lifetime.
territorial
(PT) Denturists Fee Guide
46220 Partial mandibular - with impression No 100% of the provincial/ Limited to one lower per lifetime.
territorial
(PT) Denturists Fee Guide