Top Extras dental schedule as at 1 September 2014

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1 Top Extras dental schedule as at 1 September 2014 Item Description Benefit Service limit Category Waiting 011 Comprehensive oral examination $ per Preventive 2 months 012 Periodic oral examination $ per Preventive 2 months 013 Oral examination limited $ per Preventive 2 months 014 Consultation $ per Preventive 2 months 015 Consultation extended (30 minutes or more) $56.00 Preventive 2 months 016 Consultation by referral $59.00 General 2 months 017 Consultation by referral extended (30 minutes or more) $66.50 General 2 months 018 Written report $0.00 General 2 months 019 Letter of referral $0.00 General 2 months 022 Intraoral periapical or bitewing radiograph $26.00 General 2 months reduced benefit for each subsequent radiogaph in a visit $ Intraoral radiograph occlusal, maxillary, mandibular per $ per General 2 months exposure 031 Extraoral radiograph maxillary, mandibular per exposure $ per General 2 months 033 Lateral, antero posterior or postero anterior or submento vertex $ per General 2 months radiograph of the skull per exposure 035 Radiograph of temporomandibular joint per exposure $ per General 2 months 036 Cephalometric radiograph lateral, antero posterior, posteroanterior $ per General 2 months or submento vertex per exposure 037 Panoramic radiograph per exposure $ per General 2 months 038 Hand wrist radiograph for skeletal age assessment $ per visit General 2 months 039 Tomograghy of the skull or parts thereof $ per visit General 2 months 041 Bacteriological examination $0.00 General 2 months 042 Culture examination and identification $0.00 General 2 months 043 Antibiotic sensitivity test $72.00 General 2 months 044 Collection of specimen for pathology examination $0.00 General 2 months 047 Saliva screening test $0.00 General 2 months 048 Bacteriological screening test $0.00 General 2 months 051 Biopsy of tissue $91.00 General 2 months 052 Histopathological examination of tissue $0.00 General 2 months 053 Cytological examination $0.00 General 2 months 054 Mucosal screening $0.00 General 2 months 055 Blood sample $ General 2 months 056 Haematological examination $27.50 General 2 months 061 Pulp testing per visit $0.00 General 2 months 071 Diagnostic model per model $ per General 2 months 072 Photographic records intraoral $ per General 2 months 073 Photographic records extraoral $ per General 2 months 074 Diagnostic wax up $ per General 2 months 081 Cephalometric analysis excluding radiographs $ per General 2 months 082 Tooth jaw size prediction analysis $ per General 2 months 083 Tomographic analysis $ per visit General 2 months 085 Electromyographic recording $0.00 General 2 months 086 Electromyographic analysis $ per General 2 months 111 Removal of plaque and/or stain $ per visit, 2 per Preventive 2 months 113 Recontouring of pre existing restoration(s) $0.00 Preventive 2 months 114 Removal of calculus first visit $ per Preventive 2 months 115 Removal of calculus subsequent visit $ per Preventive 2 months 116 Enamel micro abrasion per tooth $36.50 Preventive 2 months 117 Bleaching, internal per tooth $ per tooth, 2 per General 2 months 118 Bleaching, external per tooth $ per General 2 months 119 Bleaching, home application per arch $ per General 2 months 121 Topical application of remineralising and/or cariostatic agents, one $ per visit, 2 per Preventive 2 months treatment 122 Topical remineralising and/or cariostatic agent, home application $ per General 2 months per arch 123 Concentrated remineralising and/or cariostatic agent, application $33.50 Preventive 2 months single tooth 131 Dietary advice $0.00 General 2 months 141 Oral hygiene instruction $0.00 General 2 months 151 Provision of a mouthguard indirect $76.50 General 2 months 153 Bimaxillary mouthguard indirect $ General 2 months

2 161 Fissure sealing per tooth $32.50 Preventive 2 months 165 Desensitising procedure per visit $21.00 General 2 months 171 Odontoplasty per tooth $0.00 General 2 months 213 Treatment of acute ontal infection per visit $ per visit General 2 months 221 Clinical ontal analysis and recording $ per General 2 months 222 Root planing and subgingival curettage per tooth $ Gingivectomy per tooth $ Periodontal flap surgery per tooth $ Gingival graft per tooth or implant $ Guided tissue regeneration per tooth or implant $ Guided tissue regeneration membrane removal $ Periodontal flap surgery for crown lengthening per tooth $ Root resection per root $ Osseous surgery per tooth $ Osseous graft per tooth or implant $ Osseous graft block $ Periodontal surgery involving one tooth or implant $ Course of non surgical ontal treatment $ per course of treatment 282 Continuation of ontal treatment or maintenance subsequent $ per visit to item Removal of a tooth or part(s) thereof $74.00 General 2 months 314 Sectional removal of a tooth $ General 2 months 322 Surgical removal of a tooth or tooth fragment not requiring $ removal of bone or tooth division 323 Surgical removal of a tooth or tooth fragment requiring removal of $ Major 12months bone 324 Surgical removal of a tooth or tooth fragment requiring both $ removal of bone and tooth division 331 Alveolectomy per segment $ Ostectomy per jaw $ Reduction of fibrous tuberosity $ Reduction of flabby ridge per segment $ Removal of hyperplastic tissue $ Repositioning of muscle attachment $ Vestibuloplasty $ Skin or mucosal graft $ Repair of skin and subcutaneous tissue or mucous membrane $ Fracture of maxilla or mandible not requiring splinting $ Fracture of maxilla or mandible with wiring of teeth or intra oral $ fixation 354 Fracture of maxilla or mandible with external fixation $ Fracture of the zygoma $ Fracture of the maxilla or mandible requiring open reduction $ Mandible relocation following dislocation $ per visit 363 Mandible relocation requiring open operation $ Osteotomy maxilla $ per visit 366 Osteotomy mandible $ per visit 371 Removal of tumour, cyst or scar cutaneous, subcutaneous or in $ mucous membrane 373 Removal of tumour, cyst or scar involving muscle, bone or other $ deep tissue 375 Surgery to salivary duct $ Surgery to salivary gland $ Removal or repair of soft tissue (not elsewhere defined) $ Surgical removal of foreign body $ Marsupialisation of cyst $ Surgical exposure of unerupted tooth $ per tooth, per visit 382 Surgical exposure and attachment of device for orthodontic $ per tooth, per visit traction 384 Repositioning of displaced tooth/teeth per tooth $ per tooth, per visit 385 Surgical repositioning of unerupted tooth $ per tooth, per visit 386 Splinting of displaced tooth/teeth per tooth $ per tooth, per visit 387 Replantation and splinting of a tooth $ per tooth, per visit 388 Transplantation of tooth or tooth bud $ per tooth, per visit 389 Surgery to isolate and preserve neurovascular tissue $ Frenectomy $140.00

3 392 Drainage of abscess $ Surgery involving the maxillary antrum $ Surgery for osteomyelitis $ per visit 395 Repair of nerve trunk $ Control of reactionary or secondary post operative haemorrhage $ Direct pulp capping $ Incomplete endodontic therapy (inoperable or fractured tooth) $ Pulpotomy $ per tooth, per visit 415 Complete chemo mechanical preparation of root canal one canal $ per tooth, per visit 416 Complete chemo mechanical preparation of root canal each $58.00 additional canal 417 Root canal obturation one canal $ per tooth, per visit 418 Root canal obturation each additional canal $ Extirpation of pulp or debridement of root canal(s) emergency or $ per tooth, per visit palliative 421 Resorbable root canal filling primary tooth $ per tooth, per visit 431 Periapical curettage per root $ reduced benefit for each subsequent root in same tooth n/a 432 Apicectomy per root $ reduced benefit for each subsequent root in same tooth n/a 433 Exploratory periradicular surgery $ Apical seal per canal $ reduced benefit for each subsequent canal in same tooth n/a 436 Sealing of perforation $ Surgical treatment and repair of external root resorption per $ per tooth, per visit tooth 438 Hemisection $ per tooth, per visit 445 Exploration and/or negotiation of calcified canal per canal, per $50.50 visit reduced benefit for each subsequent canal in same tooth n/a 451 Removal of root filling per canal $50.50 reduced benefit for each subsequent canal in same tooth n/a 452 Removal of a cemented root canal post or post crown $ Removal or bypassing fractured endodontic instrument $ Additional visit for irrigation and/or dressing of the root canal $ per tooth, per visit system per tooth 457 Obturation of resorption defect or perforation (non surgical) $ per tooth, per visit 458 Interim therapeutic root filling per tooth $ per tooth, per visit 511 Metallic restoration one surface direct $ per tooth, per visit General 2 months 512 Metallic restoration two surfaces direct $ per tooth, per visit General 2 months 513 Metallic restoration three surfaces direct $ per tooth, per visit General 2 months 514 Metallic restoration four surfaces direct $ per tooth, per visit General 2 months 515 Metallic restoration five surfaces direct $ per tooth, per visit General 2 months 521 Adhesive restoration one surface anterior tooth direct $ per tooth, per visit General 2 months 522 Adhesive restoration two surfaces anterior tooth direct $ per tooth, per visit General 2 months 523 Adhesive restoration three surfaces anterior tooth direct $ per tooth, per visit General 2 months 524 Adhesive restoration four surfaces anterior tooth direct $ per tooth, per visit General 2 months 525 Adhesive restoration five surfaces anterior tooth direct $ per tooth, per visit General 2 months 531 Adhesive restoration one surface posterior tooth direct $ per tooth, per visit General 2 months 532 Adhesive restoration two surfaces posterior tooth direct $ per tooth, per visit General 2 months 533 Adhesive restoration three surfaces posterior tooth direct $ per tooth, per visit General 2 months 534 Adhesive restoration four surfaces posterior tooth direct $ per tooth, per visit General 2 months 535 Adhesive restoration five surfaces posterior tooth direct $ per tooth, per visit General 2 months 541 Metallic restoration one surface indirect $ per tooth, per 542 Metallic restoration two surfaces indirect $ per tooth, per 543 Metallic restoration three surfaces indirect $ per tooth, per Major Major Major 12 months 12 months 12 months

4 544 Metallic restoration four surfaces indirect $ per tooth, per 545 Metallic restoration five surfaces indirect $ per tooth, per 551 Tooth coloured restoration one surface indirect $ per tooth, per 552 Tooth coloured restoration two surfaces indirect $ per tooth, per 553 Tooth coloured restoration three surfaces indirect $ per tooth, per 554 Tooth coloured restoration four surfaces indirect $ per tooth, per 555 Tooth coloured restoration five surfaces indirect $ per tooth, per 572 Provisional (intermediate/temporary) restoration $ per tooth, per visit General 2 months 574 Metal band $ per tooth, per General 2 months 575 Pin retention per pin $16.50 General 2 months 576 Metallic crown preformed $ General 2 months 577 Cusp capping per cusp $17.50 General 2 months 578 Restoration of an incisal corner per corner $36.50 General 2 months 579 Bonding of tooth fragment $67.50 General 2 months 582 Veneer direct $ General 2 months 583 Veneer indirect $ Removal of inlay/onlay $38.50 General 2 months 596 Recementing of inlay/onlay $56.50 General 2 months 597 Post direct $65.50 General 2 months 611 Full crown acrylic resin indirect $ per tooth, per 613 Full crown non metallic indirect $ per tooth, per 615 Full crown veneered indirect $ per tooth, per 618 Full crown metallic indirect $ per tooth, per 625 Post and core for crown indirect $ per tooth, per 627 Preliminary restoration for crown direct $ per tooth, per 629 Post and root cap indirect $ per tooth, per 631 Provisional crown $ per tooth, per visit 632 Provisional bridge per pontic $ Provisional implant abutment per abutment $ Provisional implant restoration per implant abutment $ per tooth, per visit 642 Bridge pontic direct per pontic $ per tooth, per 643 Bridge pontic indirect per pontic $ per tooth, per 644 Semi fixed attachment $ Precision or magnetic attachment $ Retainer for bonded fixture indirect per tooth $ Recementing crown or veneer $53.00 General 2 months 652 Recementing bridge or splint per abutment $56.50 General 2 months 653 Rebonding of bridge or splint where retreatment of bridge surface $67.50 General 2 months is required 655 Removal of crown $53.00 General 2 months 656 Removal of bridge or splint $56.50 General 2 months 658 Repair of crown, bridge or splint indirect $50.50 General 2 months 659 Repair of crown, bridge or splint direct $59.00 General 2 months 661 Fitting of implant abutment per abutment $ Removal of implant $ Fitting of bar for denture per abutment $ Prosthesis with resin base attached to implants removable per $ arch 666 Prosthesis with metal frame attached to implants per tooth $ Prosthesis with metal frame attached to implants removable per arch $850.00

5 668 Fixture or abutment screw removal and replacement $ Removal and reattachment of prosthesis fixed to implant(s) per $95.00 implant reduced benefit for each subsequent implant n/a 671 Full crown attached to osseointegrated implant non metallic $ indirect 672 Full crown attached to osseointegrated implant veneered $ indirect 673 Full crown attached to osseointegrated implant metallic indirect $ Diagnostic template $ Surgical implant guide $ Insertion of first stage of two stage endosseous implant per $ implant 688 Insertion of one stage endosseous implant per implant $ Provisional implant $ Provisional retention device $ Second stage surgery of two stage endosseous implant per $ implant 711 Complete maxillary denture $ every 3 financial 712 Complete mandibular denture $ every 3 financial 716 Metal palate or plate $ per visit 719 Complete maxillary and mandibular dentures $ every 3 financial 721 Partial maxillary denture resin base $ every 3 financial 722 Partial mandibular denture resin base $ every 3 financial 727 Partial maxillary denture cast metal framework $ every 3 financial 728 Partial mandibular denture cast metal framework $ every 3 financial 730 Veteran Affairs Item number only $ Retainer per tooth $ Occlusal rest per rest $ Tooth/teeth (partial denture) $ Overlays per tooth $ Precision or magnetic denture attachment $ Immediate tooth replacement per tooth $ Resilient lining $ Wrought bar $ Metal backing per backing $ Adjustment of a denture $ Relining complete denture processed $ Relining partial denture processed $ Remodelling complete denture $ Remodelling partial denture $ Relining complete denture direct $ Relining partial denture direct $ Cleaning and polishing of pre existing denture $ per 754 Denture base modification $ Reattaching pre existing tooth or clasp to denture $ Replacing/adding clasp to denture per clasp $ Repairing broken base of a complete denture $ Repairing broken base of a partial denture $ Replacing tooth on denture per tooth $ Reattaching existing tooth on denture per tooth $ Adding tooth to partial denture to replace an extracted or $66.50 decoronated tooth per tooth 769 Repair or addition to metal casting $ Tissue conditioning preparatory to impressions per application $ Splint resin indirect $ Splint metal indirect $ Obturator $ Characterisation of denture base $ Impression denture repair/modification $ per General 2 months

6 777 Identification $ Inlay for denture tooth $ Surgical guide for an immediate denture $ Passive removable appliance per arch $ per Orthodontics 12 months 821 Active removable appliance per arch $ per Orthodontics 12 months 823 Functional orthopaedic appliance $ per Orthodontics 12 months 825 Sequential Plastic Aligners per arch $ Orthodontics 12 months 829 Partial banding per arch $ Orthodontics 12 months 831 Full arch banding per arch $ Orthodontics 12 months 841 Fixed palatal or lingual arch appliance $ per Orthodontics 12 months 842 Partial banding for inter maxillary elastics (cross elastics) $ per Orthodontics 12 months 843 Maxillary expansion appliance $ per Orthodontics 12 months 845 Passive fixed appliance $ per Orthodontics 12 months 846 Minor tooth guidance fixed $ Orthodontics 12 months 851 Extraoral appliance $ per visit Orthodontics 12 months 862 Bonding of attachment for application of orthodontic force $ Orthodontics 12 months 871 Orthodontic adjustment $ per visit Orthodontics 12 months 875 Repair of removable appliance, resin base $ per Orthodontics 12 months 876 Repair of removable appliance clasp, spring or tooth $45.00 Orthodontics 12 months 877 Addition to removable appliance clasp, spring or tooth $48.50 Orthodontics 12 months 878 Relining removable appliance processed $ per Orthodontics 12 months 881 Complete course of orthodontic treatment $ Orthodontics 12 months 911 Palliative care $ per visit General 2 months 915 After hours callout $ per visit General 2 months 916 Travel to provide services $ per visit General 2 months 926 Individually made tray medicament(s) $87.50 General 2 months 927 Provision of medication/medicament $29.50 General 2 months 928 Intravenous cannulation and establishment of infusion $ per visit General 2 months 941 Local anaesthesia $25.00 General 2 months 942 Sedation intravenous per 30 minutes or part thereof $ per visit General 2 months 943 Sedation inhalation per 30 minutes or part thereof $ per visit General 2 months 944 Relaxation therapy $0.00 General 2 months 949 Treatment under general anaesthesia/sedation $ per visit General 2 months 961 Minor occlusal adjustment per visit $ per visit General 2 months 963 Clinical occlusal analysis including muscle and joint palpation $ per General 2 months 964 Registration and mounting of models for occlusal analysis $0.00 General 2 months 965 Occlusal splint $ per 966 Adjustment of pre existing occlusal splint per visit $ per General 2 months 967 Pantographic tracing $ per General 2 months 968 Occlusal adjustment following occlusal analysis per visit $ per visit General 2 months 971 Adjunctive physical therapy for temporomandibular joint and $0.00 General 2 months associated structures 972 Repair/addition occlusal splint $ per General 2 months 981 Splinting and stabilisation direct per tooth $67.50 General 2 months 982 Enamel stripping per visit $ per visit General 2 months 983 Single arch oral appliance for diagnosed snoring and obstructive $ every 3 financial snoring and sleep apnoea 984 Bi maxillary oral appliance for diagnosed snoring and obstructive $ every 3 financial snoring and sleep apnoea 986 Post operative care not otherwise included $0.00 General 2 months 990 Treatment not otherwise included (specify) $0.00 General 2 months Preventive Dental limit General Dental limit Major Dental limit Orthodontic limit Financial year maximum No annual limit No annual limit $850 per person $800 per person Important: Some services are not payable in combination with others. Some are limited by the number of times they attract a benefit per year. Others may not attract a benefit at all.

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