dentistry price list - october 1, 2014 · 2019. 3. 18. · generated 2014/07/29 part c - price list...

ALBERTA HEALTH CARE INSURANCE PLAN

Dentistry

Price List

As Of

01 October 2014

© Government of Alberta

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ALBERTA HEALTH CARE INSURANCE PLAN Page i Generated 2014/07/29 TABLE OF CONTENTS As of 2014/10/01 I. CERTAIN DIAGNOSTIC AND THERAPEUTIC PROCEDURES . . . . . . . . . . . . . . . . . 1 01 NONOPERATIVE ENDOSCOPY . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 01.0 Nonoperative endoscopy of respiratory tract . . . . . . . . . . . . . . . 1 01.3 Other nonoperative endoscopy . . . . . . . . . . . . . . . . . . . . . . 1 03 CLINICAL EVALUATION AND EXAMINATION . . . . . . . . . . . . . . . . . . . . . 2 03.0 Diagnostic interview and evaluation or consultation . . . . . . . . . . . 2 13 OTHER NONOPERATIVE PROCEDURES . . . . . . . . . . . . . . . . . . . . . . . . 3 13.4 Injection or infusion of other therapeutic or prophylactic substance . . 3 13.5 Other injection or infusion of other therapeutic or prophylactic substance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 13.9 Other miscellaneous diagnostic and therapeutic procedures . . . . . . . . 3 II. OPERATIONS ON THE NERVOUS SYSTEM . . . . . . . . . . . . . . . . . . . . . . . 3 15 OTHER OPERATIONS ON SKULL, BRAIN, AND CEREBRAL MENINGES . . . . . . . . . . . 3 15.0 Cranioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 17 OPERATIONS ON CRANIAL AND PERIPHERAL NERVES . . . . . . . . . . . . . . . . . 4 17.0 Incision, division, and excision of cranial and peripheral nerves . . . . 4 17.1 Destruction of cranial and peripheral nerves . . . . . . . . . . . . . . 5 17.2 Suture of cranial and peripheral nerves . . . . . . . . . . . . . . . . . 5 17.3 Freeing of adhesions and decompression of cranial and peripheral nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 17.5 Transposition of cranial and peripheral nerves . . . . . . . . . . . . . 7 17.7 Injection into peripheral nerve . . . . . . . . . . . . . . . . . . . . . 8 VI. OPERATIONS ON NOSE, MOUTH, AND PHARYNX . . . . . . . . . . . . . . . . . . . . 9 33 OPERATIONS ON NOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 33.0 Control of epistaxis . . . . . . . . . . . . . . . . . . . . . . . . . . 9 33.4 Submucous resection of nasal septum . . . . . . . . . . . . . . . . . . . 9 33.6 Reduction of nasal fracture . . . . . . . . . . . . . . . . . . . . . . 10 33.7 Repair and plastic operations on the nose . . . . . . . . . . . . . . . 12 34 OPERATIONS ON NASAL SINUSES . . . . . . . . . . . . . . . . . . . . . . . . 13 34.1 Intranasal antrotomy . . . . . . . . . . . . . . . . . . . . . . . . . 13 34.6 Repair and plastic operation of nasal sinus . . . . . . . . . . . . . . 14 35 REMOVAL AND RESTORATION OF TEETH . . . . . . . . . . . . . . . . . . . . . . 16 35.0 Forceps extraction of tooth (multiple) (single) . . . . . . . . . . . . 16


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ALBERTA HEALTH CARE INSURANCE PLAN Page ii Generated 2014/07/29 TABLE OF CONTENTS As of 2014/10/01 36 OTHER OPERATIONS ON TEETH, GUMS, AND ALVEOLI . . . . . . . . . . . . . . . 16 36.3 Excision of dental lesion of jaw . . . . . . . . . . . . . . . . . . . 16 36.6 Application of orthodontic appliance . . . . . . . . . . . . . . . . . . 19 36.7 Other orthodontic operation . . . . . . . . . . . . . . . . . . . . . . 20 36 OTHER OPERATIONS ON TEETH, GUMS AND ALVEOLI . . . . . . . . . . . . . . . . 21 36.9 Other dental operations . . . . . . . . . . . . . . . . . . . . . . . . 21 37 OPERATIONS ON TONGUE . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 37.1 Partial glossectomy . . . . . . . . . . . . . . . . . . . . . . . . . . 21 37.2 Complete glossectomy . . . . . . . . . . . . . . . . . . . . . . . . . 22 37.4 Repair and plastic operations on tongue . . . . . . . . . . . . . . . . 22 37.8 Invasive diagnostic procedures on tongue . . . . . . . . . . . . . . . 22 37.9 Other operations on tongue . . . . . . . . . . . . . . . . . . . . . . 23 38 OPERATIONS ON SALIVARY GLANDS AND DUCTS . . . . . . . . . . . . . . . . . . 23 38.0 Incision of salivary gland or duct . . . . . . . . . . . . . . . . . . 23 38.1 Excision of lesion of salivary gland . . . . . . . . . . . . . . . . . 24 38.2 Sialoadenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 38.9 Other operations on salivary gland or duct . . . . . . . . . . . . . . 25 39 OTHER OPERATIONS ON MOUTH AND FACE . . . . . . . . . . . . . . . . . . . . 26 39.0 Drainage of face or floor of mouth . . . . . . . . . . . . . . . . . . 26 39.1 Incision of palate . . . . . . . . . . . . . . . . . . . . . . . . . . 27 39.2 Excision of lesion or tissue of palate . . . . . . . . . . . . . . . . 27 39.4 Plastic repair of mouth (internal) . . . . . . . . . . . . . . . . . . 28 39.5 Palatoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 39.8 Invasive diagnostic procedures on oral cavity . . . . . . . . . . . . . 31 39.9 Other operations on mouth and face . . . . . . . . . . . . . . . . . . 31 41 OPERATIONS ON PHARYNX . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 41.3 Plastic operation on pharynx . . . . . . . . . . . . . . . . . . . . . 32 43 OTHER OPERATIONS ON LARYNX AND TRACHEA . . . . . . . . . . . . . . . . . . 33 43.1 Temporary tracheostomy . . . . . . . . . . . . . . . . . . . . . . . . 33 46 OPERATIONS ON CHEST WALL, PLEURA, MEDIASTINUM, AND DIAPHRAGM . . . . . . . 33 46.0 Incision of chest wall and pleura . . . . . . . . . . . . . . . . . . . 33 VIII. OPERATIONS ON THE CARDIOVASCULAR SYSTEM . . . . . . . . . . . . . . . . . 34 51 OTHER OPERATIONS ON VESSELS . . . . . . . . . . . . . . . . . . . . . . . . 34


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ALBERTA HEALTH CARE INSURANCE PLAN Page iii Generated 2014/07/29 TABLE OF CONTENTS As of 2014/10/01 51.9 Other operations on vessels . . . . . . . . . . . . . . . . . . . . . . 34 XV. OPERATIONS ON THE MUSCULOSKELETAL SYSTEM . . . . . . . . . . . . . . . . . . 34 88 OPERATIONS ON FACIAL BONES AND JOINTS . . . . . . . . . . . . . . . . . . . 34 88.0 (Closed) reduction of facial fractures . . . . . . . . . . . . . . . . 34 88.1 Open reduction of facial fractures . . . . . . . . . . . . . . . . . . 37 88.2 Incision of facial bone without division . . . . . . . . . . . . . . . 45 88.4 Partial ostectomy of facial bone, except mandible . . . . . . . . . . . 56 88.5 Excision and reconstruction of mandible . . . . . . . . . . . . . . . . 57 88.6 Temporomandibular arthroplasty . . . . . . . . . . . . . . . . . . . . 57 88.7 Other facial bone repair and osteoplasty . . . . . . . . . . . . . . . 63 88.8 Invasive diagnostic procedures on facial bones . . . . . . . . . . . . 66 88.9 Other operations on facial bones and joints . . . . . . . . . . . . . . 66 89 INCISION, EXCISION, AND DIVISION OF OTHER BONES . . . . . . . . . . . . . . 69 89.0 Sequestrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 90 OTHER OPERATIONS ON BONES EXCEPT FACIAL BONES . . . . . . . . . . . . . . . 70 90.6 Removal of internal fixation device . . . . . . . . . . . . . . . . . . 70 92 INCISION AND EXCISION OF JOINT STRUCTURES . . . . . . . . . . . . . . . . . 70 92.4 Synovectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 93 REPAIR AND PLASTIC OPERATIONS ON JOINT STRUCTURES . . . . . . . . . . . . . 70 93.9 Other operations on joints . . . . . . . . . . . . . . . . . . . . . . 70 95 OPERATIONS ON MUSCLES, TENDONS, FASCIA, AND BURSA, EXCEPT HAND . . . . . . 71 95.0 Incision of muscle, tendon, fascia and bursa . . . . . . . . . . . . . 71 XVII. OPERATIONS ON SKIN AND SUBCUTANEOUS TISSUE . . . . . . . . . . . . . . . . 72 98 OPERATIONS ON SKIN AND SUBCUTANEOUS TISSUE . . . . . . . . . . . . . . . . 72 98.1 Excision of skin and subcutaneous tissue . . . . . . . . . . . . . . . 72 98.3 Relaxation of scar or contracture of skin . . . . . . . . . . . . . . . 73 98.5 Flap or pedicle graft . . . . . . . . . . . . . . . . . . . . . . . . . 75 98.6 Plastic operations on lip and external mouth . . . . . . . . . . . . . 76 XVIII. PROCEDURES NOT ELSEWHERE CLASSIFIED . . . . . . . . . . . . . . . . . . . 77 99 PROCEDURES NOT ELSEWHERE CLASSIFIED . . . . . . . . . . . . . . . . . . . . 77 99.0 Ill-defined operations . . . . . . . . . . . . . . . . . . . . . . . . 77


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ALBERTA HEALTH CARE INSURANCE PLAN Page 1 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 I. CERTAIN DIAGNOSTIC AND THERAPEUTIC PROCEDURES 01 NONOPERATIVE ENDOSCOPY 01.0 Nonoperative endoscopy of respiratory tract ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT -------------------------------------------------------------------------------------------------- 01.01DA 94.15 BMI BMIANE Y Increase By 25% M+ BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 102.50 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 01.05DA 143.01 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 108.57 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 01.3 Other nonoperative endoscopy -------------------------------------------------------------------------------------------------- 01.32D 142.47 BMI BMIANE Y Increase By 25% M+ BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 107.37 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 01.39A 287.74 BMI BMIANE Y Increase By 25% M+ BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 107.27 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 2 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 01.39A (cont'd) CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 03 CLINICAL EVALUATION AND EXAMINATION 03.0 Diagnostic interview and evaluation or consultation -------------------------------------------------------------------------------------------------- 03.01DC 35.05 V -------------------------------------------------------------------------------------------------- 03.01DJ 48.40 V -------------------------------------------------------------------------------------------------- 03.01DK 71.64 V -------------------------------------------------------------------------------------------------- 03.01DM 84.55 V -------------------------------------------------------------------------------------------------- 03.03DA 45.41 TELE TELES Y Increase Base By V -------------------------------------------------------------------------------------------------- 03.03DB 27.04 LEVL ORPAH1 Replace Base 27.04 V LEVL ORPAH2 Replace Base 19.51 LEVL ORSGH1 Replace Base 27.04 LEVL ORSGH2 Replace Base 19.51 LMTS TOC Y Increase Base By -------------------------------------------------------------------------------------------------- 03.03DC 119.74 V -------------------------------------------------------------------------------------------------- 03.03DD 133.37 V -------------------------------------------------------------------------------------------------- 03.03DE 267.77 V -------------------------------------------------------------------------------------------------- 03.03DN 89.00 V -------------------------------------------------------------------------------------------------- 03.03DP 30.31 V -------------------------------------------------------------------------------------------------- 03.03DQ 30.31 V -------------------------------------------------------------------------------------------------- 03.04DA 82.25 SUBD HAEV Y Increase Base By 39.17 V SUBD HAEVWK Y Increase Base By 39.17 SUBD HANTAM Y Increase Base By 134.20 SUBD HANTPM Y Increase Base By 134.20 -------------------------------------------------------------------------------------------------- 03.05DA 84.48 V -------------------------------------------------------------------------------------------------- 03.05DB 81.21 V -------------------------------------------------------------------------------------------------- 03.05DC 194.93 V -------------------------------------------------------------------------------------------------- 03.05DD 81.21 V -------------------------------------------------------------------------------------------------- 03.05DE 57.81 CALL M15 V 1-40 For Each Call Pay Base At 100% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 -------------------------------------------------------------------------------------------------- 03.07DA 47.91 SURC DEV Y Increase By 89.10 V SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 TELE TELES Y Increase Base By


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ALBERTA HEALTH CARE INSURANCE PLAN Page 3 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT -------------------------------------------------------------------------------------------------- 03.08D 75.53 SKLL ORPA Replace Base 97.97 V SKLL ORSG Replace Base 97.97 SKLL PROS Replace Base 97.97 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 TELE TELES Y Increase Base To 120% -------------------------------------------------------------------------------------------------- 03.08DK 122.48 SURC DEV Y Increase By 89.10 V SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 TELE TELES Y Increase Base To 120% -------------------------------------------------------------------------------------------------- 13 OTHER NONOPERATIVE PROCEDURES 13.4 Injection or infusion of other therapeutic or prophylactic substance -------------------------------------------------------------------------------------------------- 13.4 B 73.61 LVP LVP75 Y Reduce Base To 75% M+ -------------------------------------------------------------------------------------------------- 13.5 Other injection or infusion of other therapeutic or prophylactic substance -------------------------------------------------------------------------------------------------- 13.59DE 139.23 LVP LVP75 Y Reduce Base To 75% M -------------------------------------------------------------------------------------------------- 13.59DF 70.00 LVP LVP75 Y Reduce Base To 75% M -------------------------------------------------------------------------------------------------- 13.59DH 26.93 LVP LVP75 Y Reduce Base To 75% M -------------------------------------------------------------------------------------------------- 13.59DJ 29.40 CALL NBRSER M 1 For Each Call Pay Base At 100% 2-3 For Each Call Pay Base At 75% LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 13.59DK 67.49 CALL NBRSER M 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 13.9 Other miscellaneous diagnostic and therapeutic procedures -------------------------------------------------------------------------------------------------- 13.99DE 218.16 CALL H1M15 M 1 For Each Call Pay Base At 100% 2-12 For Each Call Increase By 54.53 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- II. OPERATIONS ON THE NERVOUS SYSTEM 15 OTHER OPERATIONS ON SKULL, BRAIN, AND CEREBRAL MENINGES 15.0 Cranioplasty -------------------------------------------------------------------------------------------------- 15.03A 374.65 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 300.35 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54


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ALBERTA HEALTH CARE INSURANCE PLAN Page 4 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 15.03A (cont'd) ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP ADD Y Replace Base 100% LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 17 OPERATIONS ON CRANIAL AND PERIPHERAL NERVES 17.0 Incision, division, and excision of cranial and peripheral nerves -------------------------------------------------------------------------------------------------- 17.08L 193.50 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 137.30 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 17.08M 257.97 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 137.30 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 © Government of Alberta

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ALBERTA HEALTH CARE INSURANCE PLAN Page 5 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 17.08M (cont'd) SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 17.08N 257.97 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 137.30 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 17.1 Destruction of cranial and peripheral nerves -------------------------------------------------------------------------------------------------- 17.1 E 239.98 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 107.27 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 17.2 Suture of cranial and peripheral nerves -------------------------------------------------------------------------------------------------- 17.2 E 1409.37 BMI BMIANE Y Increase By 25% 14


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ALBERTA HEALTH CARE INSURANCE PLAN Page 6 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 17.2 E (cont'd) BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 566.37 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 17.2 F 239.17 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 163.04 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 17.2 G 715.78 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 257.44 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17


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ALBERTA HEALTH CARE INSURANCE PLAN Page 7 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 17.2 G (cont'd) CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 17.2 H 959.25 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 429.07 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 17.3 Freeing of adhesions and decompression of cranial and peripheral nerves -------------------------------------------------------------------------------------------------- 17.32D 1162.49 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 257.44 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 17.5 Transposition of cranial and peripheral nerves


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ALBERTA HEALTH CARE INSURANCE PLAN Page 8 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT -------------------------------------------------------------------------------------------------- 17.5 C 557.60 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 137.30 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 17.7 Injection into peripheral nerve -------------------------------------------------------------------------------------------------- 17.7 A 239.87 BMI BMIANE Y Increase By 25% M+ BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 107.27 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 17.7 B 73.61 BMI BMIANE Y Increase By 25% M+ BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 107.27 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 17.7 C 218.38 BMI BMIANE Y Increase By 25% M+ BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 108.57 ROLE ANEST Y Replace Base 18.10 © Government of Alberta

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ALBERTA HEALTH CARE INSURANCE PLAN Page 9 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 17.7 C (cont'd) ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- VI. OPERATIONS ON NOSE, MOUTH, AND PHARYNX 33 OPERATIONS ON NOSE 33.0 Control of epistaxis -------------------------------------------------------------------------------------------------- 33.02DA 220.81 BMI BMIANE Y Increase By 25% M BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 137.30 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 33.02DB 53.79 BMI BMIANE Y Increase By 25% M BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 145.88 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 33.05DA 541.80 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 180.21 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 33.4 Submucous resection of nasal septum -------------------------------------------------------------------------------------------------- 33.4 B 288.93 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 120.14


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ALBERTA HEALTH CARE INSURANCE PLAN Page 10 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 33.4 B (cont'd) ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP ADD Y Replace Base 100% -------------------------------------------------------------------------------------------------- 33.6 Reduction of nasal fracture -------------------------------------------------------------------------------------------------- 33.61B 124.01 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 107.27 ROLE ANEST Y Replace Base 18.10 VANE ADDA Replace 120.73 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP ADD Y Replace Base 100% -------------------------------------------------------------------------------------------------- 33.62C 405.23 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 180.21 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP ADD Y Replace Base 100% -------------------------------------------------------------------------------------------------- 33.62E 405.23 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 180.21 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54


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ALBERTA HEALTH CARE INSURANCE PLAN Page 11 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 33.62E (cont'd) ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP ADD Y Replace Base 100% -------------------------------------------------------------------------------------------------- 33.62DA 417.37 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 145.88 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 33.62DB 1112.55 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 377.58 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP ADD Y Replace Base 100%


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ALBERTA HEALTH CARE INSURANCE PLAN Page 12 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 33.7 Repair and plastic operations on the nose ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT -------------------------------------------------------------------------------------------------- 33.76DA 240.76 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 137.30 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 33.76DB 196.38 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 128.72 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 33.76DC 202.78 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 128.72 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 33.76DD 321.31 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 137.30 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 33.76DE 463.71 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 163.04 ROLE ANEST Y Replace Base 18.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 13 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 33.76DE (cont'd) ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 33.76DF 541.73 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 171.63 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 33.76DG 363.53 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 137.30 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 33.76DH 705.16 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 308.93 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 34 OPERATIONS ON NASAL SINUSES 34.1 Intranasal antrotomy -------------------------------------------------------------------------------------------------- 34.1 B 107.96 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 107.27 ROLE ANEST Y Replace Base 18.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 14 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 34.1 B (cont'd) ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP ADD Y Replace Base 100% -------------------------------------------------------------------------------------------------- 34.6 Repair and plastic operation of nasal sinus -------------------------------------------------------------------------------------------------- 34.61A 370.00 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 156.19 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 34.61B 471.96 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 154.46 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 34.61C 370.00 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 156.19


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ALBERTA HEALTH CARE INSURANCE PLAN Page 15 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 34.61C (cont'd) ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 34.61D 370.00 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 154.46 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 34.61E 370.00 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 154.46 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 34.61F 370.00 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 164.86 ROLE ANEST Y Replace Base 18.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 16 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 34.61F (cont'd) ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 35 REMOVAL AND RESTORATION OF TEETH 35.0 Forceps extraction of tooth (multiple) (single) -------------------------------------------------------------------------------------------------- 35.0 DA 27.96 BMI BMIANE Y Increase By 25% M BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 107.37 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 36 OTHER OPERATIONS ON TEETH, GUMS, AND ALVEOLI 36.3 Excision of dental lesion of jaw -------------------------------------------------------------------------------------------------- 36.3 B 135.92 BMI BMIANE Y Increase By 25% 4 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 107.37 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 36.3 C 409.02 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 144.76


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ALBERTA HEALTH CARE INSURANCE PLAN Page 17 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 36.3 C (cont'd) ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 36.3 D 204.54 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 162.86 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 36.3 E 151.68 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 108.47 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 36.3 M 298.86 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 162.86 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17


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ALBERTA HEALTH CARE INSURANCE PLAN Page 18 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 36.3 M (cont'd) SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 36.3 F 450.54 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 182.22 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 36.3 G 644.33 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 196.85 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 36.3 H 485.79 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 199.05 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 36.3 J 615.44 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 171.63 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% © Government of Alberta

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ALBERTA HEALTH CARE INSURANCE PLAN Page 19 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 36.3 J (cont'd) ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 36.3 K 889.79 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 253.33 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 36.3 L 889.79 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 216.93 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 36.6 Application of orthodontic appliance -------------------------------------------------------------------------------------------------- 36.6 A 373.03 BMI BMIANE Y Increase By 25% 14


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ALBERTA HEALTH CARE INSURANCE PLAN Page 20 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 36.6 A (cont'd) BMI BMISRG Y Increase By 25% BMI BMI2AN Y Increase By 25% ROLE ANE Y Replace Base 275.00 ROLE SA Y Replace Base 92.23 ROLE 2ANES Y Replace Base 21.70 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 50% 2ANU 2ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 21.70 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Increase By 150.20 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 36.7 Other orthodontic operation -------------------------------------------------------------------------------------------------- 36.7 A 133.00 BMI BMIANE Y Increase By 25% M BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 108.57 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 36.7 B 64.64 BMI BMIANE Y Increase By 25% M BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 108.57 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59


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ALBERTA HEALTH CARE INSURANCE PLAN Page 21 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 36.7 B (cont'd) SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 36 OTHER OPERATIONS ON TEETH, GUMS AND ALVEOLI 36.9 Other dental operations -------------------------------------------------------------------------------------------------- 36.99DA 102.10 BMI BMISRG Y Increase By 25% R CALL NBRSER 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 25.53 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 -------------------------------------------------------------------------------------------------- 37 OPERATIONS ON TONGUE 37.1 Partial glossectomy -------------------------------------------------------------------------------------------------- 37.1 DA 270.86 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 136.81 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 37.1 DB 424.34 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 255.38 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 22 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 37.1 DB (cont'd) SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 37.2 Complete glossectomy -------------------------------------------------------------------------------------------------- 37.2 D 980.86 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 566.37 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 37.4 Repair and plastic operations on tongue -------------------------------------------------------------------------------------------------- 37.49A 130.65 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 120.14 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 37.8 Invasive diagnostic procedures on tongue -------------------------------------------------------------------------------------------------- 37.81D 41.97 BMI BMIANE Y Increase By 25% M+ BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 108.47 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17


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ALBERTA HEALTH CARE INSURANCE PLAN Page 23 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 37.81D (cont'd) SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 37.9 Other operations on tongue -------------------------------------------------------------------------------------------------- 37.91DA 47.91 BMI BMIANE Y Increase By 25% M BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 108.47 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 37.91DB 216.83 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 108.57 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 37.99B 213.44 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 144.76 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 38 OPERATIONS ON SALIVARY GLANDS AND DUCTS 38.0 Incision of salivary gland or duct -------------------------------------------------------------------------------------------------- 38.0 B 40.89 BMI BMIANE Y Increase By 25% 4 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 108.57 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84


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ALBERTA HEALTH CARE INSURANCE PLAN Page 24 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 38.0 B (cont'd) SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 38.0 C 145.35 BMI BMIANE Y Increase By 25% 4 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 108.57 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 38.0 D 114.86 BMI BMIANE Y Increase By 25% 4 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 107.37 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 38.1 Excision of lesion of salivary gland -------------------------------------------------------------------------------------------------- 38.19A 40.89 BMI BMIANE Y Increase By 25% M BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 108.47 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-3 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 38.19B 135.92 BMI BMIANE Y Increase By 25% 4 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 107.27 ROLE ANEST Y Replace Base 18.10 © Government of Alberta

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ALBERTA HEALTH CARE INSURANCE PLAN Page 25 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 38.19B (cont'd) ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 38.19D 409.02 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 147.51 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 38.2 Sialoadenectomy -------------------------------------------------------------------------------------------------- 38.21DA 439.41 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 164.86 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 38.9 Other operations on salivary gland or duct -------------------------------------------------------------------------------------------------- 38.91A 54.74 BMI BMIANE Y Increase By 25% 4 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 107.27 ROLE ANEST Y Replace Base 18.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 26 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 38.91A (cont'd) ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39 OTHER OPERATIONS ON MOUTH AND FACE 39.0 Drainage of face or floor of mouth -------------------------------------------------------------------------------------------------- 39.0 A 151.68 BMI BMIANE Y Increase By 25% 4 BMI BMISRG Y Increase By 25% BMI BMI2AN Y Increase By 25% ROLE ANE Y Replace Base 144.76 ROLE 2ANES Y Replace Base 21.70 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% 2ANU 2ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 21.70 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.0 B 531.48 BMI BMIANE Y Increase By 25% 4 BMI BMISRG Y Increase By 25% BMI BMI2AN Y Increase By 25% ROLE ANE Y Replace Base 144.76 ROLE SOSS Y Replace Base 285.54 ROLE 2ANES Y Replace Base 21.70 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% 2ANU 2ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 21.70 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.0 C 54.74 BMI BMIANE Y Increase By 25% 4 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 143.16 ROLE ANEST Y Replace Base 18.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 27 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 39.0 C (cont'd) ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.1 Incision of palate -------------------------------------------------------------------------------------------------- 39.1 A 54.74 BMI BMIANE Y Increase By 25% 4 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 107.27 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.2 Excision of lesion or tissue of palate -------------------------------------------------------------------------------------------------- 39.21B 151.68 BMI BMIANE Y Increase By 25% 4 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 144.76 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.21C 108.86 BMI BMIANE Y Increase By 25% 4 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 144.76 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17


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ALBERTA HEALTH CARE INSURANCE PLAN Page 28 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 39.21C (cont'd) SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.4 Plastic repair of mouth (internal) -------------------------------------------------------------------------------------------------- 39.41 55.94 BMI BMIANE Y Increase By 25% 4 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 108.47 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 CALL CM2.5D 1 For Each Call Pay Base At 100% 2-12 For Each Call Increase By 28.37 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.5 Palatoplasty -------------------------------------------------------------------------------------------------- 39.52E 834.84 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 163.04 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.52F 969.31 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 188.79 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 © Government of Alberta

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ALBERTA HEALTH CARE INSURANCE PLAN Page 29 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 39.52F (cont'd) SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.52H 969.31 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 197.37 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.52J 969.31 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 197.37 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.52DA 1453.34 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 326.09 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59


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ALBERTA HEALTH CARE INSURANCE PLAN Page 30 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 39.52DA (cont'd) SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 39.52DB 638.75 BMI BMIANE Y Increase By 25% 14 BMI BMISRG Y Increase By 25% BMI BMI2AN Y Increase By 25% ROLE ANE Y Replace Base 475.00 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ROLE 2ANES Y Replace Base 21.70 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% 2ANU 2ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 21.70 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.52DC 648.97 BMI BMIANE Y Increase By 25% 14 BMI BMISRG Y Increase By 25% BMI BMI2AN Y Increase By 25% ROLE ANE Y Replace Base 475.00 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ROLE 2ANES Y Replace Base 21.70 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% 2ANU 2ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 21.70 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.59B 1366.98 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 317.51 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 31 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 39.59B (cont'd) SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.8 Invasive diagnostic procedures on oral cavity -------------------------------------------------------------------------------------------------- 39.83C 54.74 BMI BMIANE Y Increase By 25% 4 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 108.57 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.83D 145.97 BMI BMIANE Y Increase By 25% 4 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 138.83 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.9 Other operations on mouth and face -------------------------------------------------------------------------------------------------- 39.91DB 43.84 BMI BMIANE Y Increase By 25% M BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 107.27 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.91DC 216.83 BMI BMIANE Y Increase By 25% M BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25%


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ALBERTA HEALTH CARE INSURANCE PLAN Page 32 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 39.91DC (cont'd) ROLE ANE Y Replace Base 108.57 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.92A 331.03 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 108.57 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 39.99B 427.88 BMI BMIANE Y Increase By 25% G BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 145.88 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 39.99C 195.98 BMI BMISRG Y Increase By 25% G -------------------------------------------------------------------------------------------------- 41 OPERATIONS ON PHARYNX 41.3 Plastic operation on pharynx -------------------------------------------------------------------------------------------------- 41.3 C 439.77 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 171.63 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 © Government of Alberta

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ALBERTA HEALTH CARE INSURANCE PLAN Page 33 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 41.3 C (cont'd) ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 43 OTHER OPERATIONS ON LARYNX AND TRACHEA 43.1 Temporary tracheostomy -------------------------------------------------------------------------------------------------- 43.1 DA 393.36 BMI BMIANE Y Increase By 25% M BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 120.14 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 43.1 DB 227.85 BMI BMIANE Y Increase By 25% M BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 120.14 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 46 OPERATIONS ON CHEST WALL, PLEURA, MEDIASTINUM, AND DIAPHRAGM 46.0 Incision of chest wall and pleura -------------------------------------------------------------------------------------------------- 46.04DA 58.57 BMI BMIANE Y Increase By 25% M BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 107.27 ROLE ANEST Y Replace Base 18.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 34 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 46.04DA (cont'd) ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- VIII. OPERATIONS ON THE CARDIOVASCULAR SYSTEM 51 OTHER OPERATIONS ON VESSELS 51.9 Other operations on vessels -------------------------------------------------------------------------------------------------- 51.98B 531.48 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 138.83 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- XV. OPERATIONS ON THE MUSCULOSKELETAL SYSTEM 88 OPERATIONS ON FACIAL BONES AND JOINTS 88.0 (Closed) reduction of facial fractures -------------------------------------------------------------------------------------------------- 88.02C 277.75 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 107.27 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 50% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 50% CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP50 Y Reduce Base To 50% -------------------------------------------------------------------------------------------------- 88.03B 383.84 BMI BMIANE Y Increase By 25% 14


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ALBERTA HEALTH CARE INSURANCE PLAN Page 35 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.03B (cont'd) BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 173.55 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 50% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 50% CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP50 Y Reduce Base To 50% -------------------------------------------------------------------------------------------------- 88.04C 281.76 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 180.95 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 50% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Increase By 150.20 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP50 Y Reduce Base To 50% -------------------------------------------------------------------------------------------------- 88.04DB 542.89 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 347.09 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89


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ALBERTA HEALTH CARE INSURANCE PLAN Page 36 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.04DB (cont'd) CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.04DC 1226.40 BMI BMIANE Y Increase By 25% 14 BMI BMISRG Y Increase By 25% BMI BMI2AN Y Increase By 25% ROLE ANE Y Replace Base 900.00 ROLE SA Y Replace Base 92.23 ROLE 2ANES Y Replace Base 21.70 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% 2ANU 2ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 21.70 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.09B 255.75 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 161.06 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 50% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 50% CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP50 Y Reduce Base To 50%


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ALBERTA HEALTH CARE INSURANCE PLAN Page 37 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 88.1 Open reduction of facial fractures ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT -------------------------------------------------------------------------------------------------- 88.12DB 657.60 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 446.23 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.12DC 985.60 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 597.14 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.12DD 1227.65 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 789.48 ROLE ANEST Y Replace Base 18.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 38 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.12DD (cont'd) ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.12F 397.66 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 162.86 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.12G 397.66 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 145.88 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 39 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.12G (cont'd) SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.12H 397.66 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 145.88 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.12J 397.66 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 145.88 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 40 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.12J (cont'd) SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.13DC 1313.59 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 1149.89 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.13F 821.83 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 214.53 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-3 For Each Call Pay Base At 100% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Increase By 205.44 3-3 For Each Call Increase By 205.44 MAX 1232.71 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.13J 1080.15 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 635.02 ROLE ANEST Y Replace Base 18.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 41 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.13J (cont'd) ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.14DA 348.39 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 394.74 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.14DB 565.50 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 463.39 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59


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ALBERTA HEALTH CARE INSURANCE PLAN Page 42 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT -------------------------------------------------------------------------------------------------- 88.14DC 639.82 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 503.28 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.14J 810.45 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 433.86 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.14K 1080.15 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 642.12 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89


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ALBERTA HEALTH CARE INSURANCE PLAN Page 43 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.14K (cont'd) SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.14L 1313.59 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 662.12 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.16DB 1313.59 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 789.48 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.16C 428.41 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 171.63 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54


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ALBERTA HEALTH CARE INSURANCE PLAN Page 44 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.16C (cont'd) ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.16D 520.32 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 171.63 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.19DA 1313.59 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 961.11 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89


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ALBERTA HEALTH CARE INSURANCE PLAN Page 45 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.19DA (cont'd) SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.2 Incision of facial bone without division -------------------------------------------------------------------------------------------------- 88.29C 543.68 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 326.09 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29E 1783.36 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 1132.73 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29F 1783.36 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 607.40 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 © Government of Alberta

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ALBERTA HEALTH CARE INSURANCE PLAN Page 46 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.29F (cont'd) SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29H 1783.36 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 600.69 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29M 1783.36 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 590.54 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29T 2015.08 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 600.69 ROLE ANEST Y Replace Base 18.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 47 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.29T (cont'd) ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29U 1783.36 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 1181.08 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29V 1783.36 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 633.33 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75%


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ALBERTA HEALTH CARE INSURANCE PLAN Page 48 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT -------------------------------------------------------------------------------------------------- 88.29X 1783.36 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 1046.92 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29Y 1783.36 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 1064.08 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29DB 2175.32 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 789.48 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 49 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.29DB (cont'd) SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.29DC 2351.67 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 858.13 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.29DD 1783.36 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 687.62 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.29DE 2175.32 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 789.48 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17


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ALBERTA HEALTH CARE INSURANCE PLAN Page 50 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.29DE (cont'd) SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.29DF 2015.08 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 652.18 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.29DG 2378.15 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 751.60 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.29CA 1783.36 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 659.47 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 51 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.29CA (cont'd) SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29DA 2175.32 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 652.18 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29N 2377.83 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 1390.17 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29FA 2575.99 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 1544.63 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 © Government of Alberta

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ALBERTA HEALTH CARE INSURANCE PLAN Page 52 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.29FA (cont'd) SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29GA 1783.36 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 557.78 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29HA 1783.36 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 1064.08 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29TA 1783.36 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 617.85 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54


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ALBERTA HEALTH CARE INSURANCE PLAN Page 53 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.29TA (cont'd) ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29MA 1783.36 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 600.69 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29NA 119.90 BMI BMIANE Y Increase By 25% M BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 154.46 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29PA 287.76 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25%


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ALBERTA HEALTH CARE INSURANCE PLAN Page 54 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.29PA (cont'd) ROLE ANE Y Replace Base 143.16 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29QA 119.90 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 137.30 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29RA 119.90 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 137.30 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29SA 119.90 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25%


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ALBERTA HEALTH CARE INSURANCE PLAN Page 55 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.29SA (cont'd) BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 145.88 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29DH 64.03 BMI BMIANE Y Increase By 25% 14 BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 107.27 LVP ADD Y Replace Base 100% -------------------------------------------------------------------------------------------------- 88.29DJ 350.98 BMI BMIANE Y Increase By 25% 14 BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 107.27 LVP ADD Y Replace Base 100% -------------------------------------------------------------------------------------------------- 88.29DP 664.30 BMI BMIANE Y Increase By 25% 14 BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 107.27 LVP ADD Y Replace Base 100% -------------------------------------------------------------------------------------------------- 88.29DQ 88.57 BMI BMISRG Y Increase By 25% 14 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 100% LVP ADD Y Replace Base 100% -------------------------------------------------------------------------------------------------- 88.29DK 181.53 BMI BMIANE Y Increase By 25% 14 BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 107.27 LVP ADD Y Replace Base 100% -------------------------------------------------------------------------------------------------- 88.29DL 320.68 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 128.72 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59


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ALBERTA HEALTH CARE INSURANCE PLAN Page 56 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.29DL (cont'd) LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29DM 705.73 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 205.95 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.29DN 1026.52 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 291.76 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.4 Partial ostectomy of facial bone, except mandible -------------------------------------------------------------------------------------------------- 88.4 DA 1144.42 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 411.90 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 © Government of Alberta

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ALBERTA HEALTH CARE INSURANCE PLAN Page 57 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.4 DA (cont'd) SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.5 Excision and reconstruction of mandible -------------------------------------------------------------------------------------------------- 88.51DA 1226.40 BMI BMIANE Y Increase By 25% 14 BMI BMISRG Y Increase By 25% BMI BMI2AN Y Increase By 25% ROLE ANE Y Replace Base 900.00 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ROLE 2ANES Y Replace Base 21.70 2ANU 2ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 21.70 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.6 Temporomandibular arthroplasty -------------------------------------------------------------------------------------------------- 88.6 C 431.64 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 128.72 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% RECO OPEN Y Replace Base 913.67 RECO OPEN2 Y Replace Base 1598.94 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17


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ALBERTA HEALTH CARE INSURANCE PLAN Page 58 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.6 C (cont'd) SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.6 J 913.67 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 180.21 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.6 FA 335.72 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 180.21 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% RECO OPEN Y Replace Base 913.67 RECO OPEN2 Y Replace Base 1598.94 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.6 P 431.64 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 326.09 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% © Government of Alberta

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ALBERTA HEALTH CARE INSURANCE PLAN Page 59 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.6 P (cont'd) ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% RECO OPEN Y Replace Base 1287.45 RECO OPEN2 Y Replace Base 2253.07 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.6 Q 431.64 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 145.88 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% RECO OPEN Y Replace Base 1287.45 RECO OPEN2 Y Replace Base 2253.07 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.6 R 431.64 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 317.51 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% RECO OPEN Y Replace Base 1287.45


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ALBERTA HEALTH CARE INSURANCE PLAN Page 60 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.6 R (cont'd) RECO OPEN2 Y Replace Base 2253.07 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.6 S 431.64 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 326.09 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% RECO OPEN Y Replace Base 1287.45 RECO OPEN2 Y Replace Base 2253.07 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.6 U 913.67 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 317.51 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.6 V 1287.45 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 326.09 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54


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ALBERTA HEALTH CARE INSURANCE PLAN Page 61 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.6 V (cont'd) ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.6 W 882.21 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 120.14 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.6 X 1558.10 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 840.97 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.6 Y 483.62 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25%


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ALBERTA HEALTH CARE INSURANCE PLAN Page 62 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.6 Y (cont'd) BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 205.95 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.6 Z 483.62 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 154.46 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.6 CA 156.77 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 107.37 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.6 DA 1558.10 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 463.39 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54


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ALBERTA HEALTH CARE INSURANCE PLAN Page 63 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.6 DA (cont'd) ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.6 EA 1692.75 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 480.55 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.7 Other facial bone repair and osteoplasty -------------------------------------------------------------------------------------------------- 88.71B 913.67 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 343.25 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.71C 335.72 BMI BMIANE Y Increase By 25% 14


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ALBERTA HEALTH CARE INSURANCE PLAN Page 64 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.71C (cont'd) BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 317.51 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% RECO OPEN Y Replace Base 913.67 RECO OPEN2 Y Replace Base 1598.94 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.71D 335.72 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 188.79 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% RECO OPEN Y Replace Base 913.67 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.76B 385.26 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 171.63 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 © Government of Alberta

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ALBERTA HEALTH CARE INSURANCE PLAN Page 65 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.76B (cont'd) ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.76DA 1783.36 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 652.18 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.77A 385.26 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 178.95 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 66 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.77A (cont'd) SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.77DA 1783.36 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 680.02 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.8 Invasive diagnostic procedures on facial bones -------------------------------------------------------------------------------------------------- 88.81A 119.90 BMI BMIANE Y Increase By 25% M+ BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 138.83 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.9 Other operations on facial bones and joints -------------------------------------------------------------------------------------------------- 88.92B 23.99 ROLE SA Y Replace Base 92.23 M SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 UGA UGA Y Replace Base 141.75 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 LVP LVP50 Y Reduce Base To 50% -------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------- 88.92C 117.58 BMI BMIANE Y Increase By 25% M BMI BMIANT Y Increase By 25%


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ALBERTA HEALTH CARE INSURANCE PLAN Page 67 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.92C (cont'd) ROLE ANE Y Replace Base 108.47 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 50% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 UGA UGA Y Replace Base 141.75 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 50% CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP50 Y Reduce Base To 50% -------------------------------------------------------------------------------------------------- 88.93D 1313.59 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 823.18 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.93E 2015.08 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 1149.89 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CMPD CMPD Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84


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ALBERTA HEALTH CARE INSURANCE PLAN Page 68 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.93E (cont'd) SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.93F 363.72 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 197.37 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.93G 846.56 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 343.25 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 88.95A 118.79 UGA UGA Y Replace Base 141.75 M CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 88.97A 483.62 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 208.25 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 © Government of Alberta

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ALBERTA HEALTH CARE INSURANCE PLAN Page 69 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 88.97A (cont'd) SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 89 INCISION, EXCISION, AND DIVISION OF OTHER BONES 89.0 Sequestrectomy -------------------------------------------------------------------------------------------------- 89.09C 218.38 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 171.63 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 89.09D 271.81 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 188.79 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75%


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ALBERTA HEALTH CARE INSURANCE PLAN Page 70 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 90 OTHER OPERATIONS ON BONES EXCEPT FACIAL BONES 90.6 Removal of internal fixation device ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT -------------------------------------------------------------------------------------------------- 90.6 DD 357.70 BMI BMIANE Y Increase By 25% 14 BMI BMISRG Y Increase By 25% BMI BMI2AN Y Increase By 25% ROLE ANE Y Replace Base 326.09 ROLE SA Y Replace Base 92.23 ROLE 2ANES Y Replace Base 21.70 2ANU 2ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 21.70 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 92 INCISION AND EXCISION OF JOINT STRUCTURES 92.4 Synovectomy -------------------------------------------------------------------------------------------------- 92.49A 335.72 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 163.04 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 93 REPAIR AND PLASTIC OPERATIONS ON JOINT STRUCTURES 93.9 Other operations on joints -------------------------------------------------------------------------------------------------- 93.91DA 287.74 BMI BMIANE Y Increase By 25% M+ BMI BMI2AN Y Increase By 25% ROLE ANE Y Replace Base 450.00 ROLE 2ANES Y Replace Base 21.70 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75%


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ALBERTA HEALTH CARE INSURANCE PLAN Page 71 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 93.91DA (cont'd) 2ANU 2ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 21.70 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 93.96A 392.65 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 197.37 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 95 OPERATIONS ON MUSCLES, TENDONS, FASCIA, AND BURSA, EXCEPT HAND 95.0 Incision of muscle, tendon, fascia and bursa -------------------------------------------------------------------------------------------------- 95.02B 392.65 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 107.27 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17


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ALBERTA HEALTH CARE INSURANCE PLAN Page 72 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 95.02B (cont'd) SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- XVII. OPERATIONS ON SKIN AND SUBCUTANEOUS TISSUE 98 OPERATIONS ON SKIN AND SUBCUTANEOUS TISSUE 98.1 Excision of skin and subcutaneous tissue -------------------------------------------------------------------------------------------------- 98.11DB 398.66 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 144.76 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 98.11DC 664.67 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 197.37 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 98.12DN 59.87 BMI BMIANE Y Increase By 25% M BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 120.14 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 © Government of Alberta

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ALBERTA HEALTH CARE INSURANCE PLAN Page 73 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 98.12DN (cont'd) CALL NBRSER 1 For Each Call Pay Base At 100% 2-3 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 98.12DP 0.00 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 120.14 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 98.13DB 230.10 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 107.27 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 98.3 Relaxation of scar or contracture of skin -------------------------------------------------------------------------------------------------- 98.3 A 125.90 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 108.47 ROLE ANEST Y Replace Base 18.10 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 98.3 B 785.08 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 291.76 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54


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ALBERTA HEALTH CARE INSURANCE PLAN Page 74 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 98.3 B (cont'd) ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 98.3 C 1192.94 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 399.15 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 98.3 D 907.44 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 343.25 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 98.3 E 1313.59 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25%


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ALBERTA HEALTH CARE INSURANCE PLAN Page 75 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 98.3 E (cont'd) ROLE ANE Y Replace Base 480.55 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 98.5 Flap or pedicle graft -------------------------------------------------------------------------------------------------- 98.5 DA 357.08 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 197.37 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 RECO CMPRSC Y Increase Base To 125% RECO FNCAR Y Increase Base To 150% RECO 2ZPL Y Increase Base To 125% RECO 3ZPL Y Increase Base To 150% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 98.51D 744.01 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 291.76 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANEU ANEU 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10


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ALBERTA HEALTH CARE INSURANCE PLAN Page 76 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 98.51D (cont'd) SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 CALL NBRSER 1 For Each Call Pay Base At 100% 2-2 For Each Call Pay Base At 75% SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 LVP LVP75 Y Reduce Base To 75% -------------------------------------------------------------------------------------------------- 98.6 Plastic operations on lip and external mouth -------------------------------------------------------------------------------------------------- 98.6 DA 71.36 BMI BMIANE Y Increase By 25% 4 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 163.04 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 98.6 DB 142.10 BMI BMIANE Y Increase By 25% 4 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 163.04 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 98.6 DC 117.00 BMI BMIANE Y Increase By 25% 4 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 163.04 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 UGA UGA Y Replace Base 141.75 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 98.6 DD 231.25 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 154.46 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC EV Y Increase By 47.59


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ALBERTA HEALTH CARE INSURANCE PLAN Page 77 Schedule of Dentistry Benefits Generated 2014/07/29 Part C - Price List As of 2014/10/01 ---------------------- MODIFIER --------------------- HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 98.6 DD (cont'd) SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 98.6 DE 288.75 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% BMI BMISRG Y Increase By 25% ROLE ANE Y Replace Base 171.63 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 98.6 DF 0.00 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 163.04 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- 98.6 DG 0.00 BMI BMIANE Y Increase By 25% 14 BMI BMIANT Y Increase By 25% ROLE ANE Y Replace Base 163.04 ROLE ANEST Y Replace Base 18.10 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59 -------------------------------------------------------------------------------------------------- XVIII. PROCEDURES NOT ELSEWHERE CLASSIFIED 99 PROCEDURES NOT ELSEWHERE CLASSIFIED 99.0 Ill-defined operations -------------------------------------------------------------------------------------------------- 99.09S 0.00 BMI BMIANT Y Increase By 25% 14 ROLE ANEST Y Replace Base 18.10 ROLE SA Y Replace Base 92.23 ROLE SOSS Y Replace Base 285.54 ANU ANU 1 For Each Call Pay Base At 100% 2-150 For Each Call Increase By 18.10 SAU SAU 1 For Each Call Pay Base At 100% 2-21 For Each Call Increase By 22.89 SOSU SOSU 1 For Each Call Pay Base At 100% 2-33 For Each Call Increase By 95.17 SURC DEV Y Increase By 89.10 SURC DNTAM Y Increase By 213.84 SURC DNTPM Y Increase By 213.84 SURC DWK Y Increase By 89.10 SURC EV Y Increase By 47.59 SURC NTAM Y Increase By 114.17 SURC NTPM Y Increase By 114.17 SURC WK Y Increase By 47.59


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dentistry price list - october 1, 2014 · 2019. 3. 18. · generated 2014/07/29 part c - price list...

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