Schedule of Fees (effective 1 August 2013) Specialist Dental

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1 PAGE 1 of 6 Schedule of Fees (effective 1 August 2013) Specialist Dental The following fee structure applies for Dentists when treating Entitled Personnel. Diagnostic / Preventative Item No. Fee Periodic oral examination S012 $69.10 Oral examination - limited S013 $43.50 Consultation S014 $ Consultation - extended (30 minutes or more) S015 $ Consultation by referral including examination S016 $ Consultation by referral - extended (30 minutes) - including examination S017 $ Written report (not elsewhere included) S018 $66.50 Letter of referral S019 $35.70 Intraoral periapical or bitewing radiograph - per exposure S022 $54.50 Intraoral radiograph - occlusal, maxillary, mandibular - per exposure S025 $97.20 Extraoral radiograph - maxillary, mandibular - per exposure S031 $ Lateral, antero-posterior, postero-anterior or submento-vertex radiograph S033 $ Radiograph of temporomandibular joint - per exposure S035 $ Cephalometric radiograph - lateral, antero-posterior, postero-anterior or submento-vertex - per exposure S036 $ Panoramic radiograph - per exposure S037 $ Hand-wrist radiograph for skeletal age assessment S038 $ Tomography of the skull or parts thereof S039 $ Bacteriologic examination S041 $84.10 Culture examination and identification S042 $67.70 Antibiotic sensitivity test S043 $60.50 Collection of specimen for pathology examination S044 $76.10 Saliva screening test S047 $64.00 Bacteriological screening test S048 $65.30 Biopsy of tissue S051 $ Histopathological examination of tissue S052 $ Cytological investigation S053 $ Blood sample S055 $ Haematological examination S056 $15.50 Pulp testing - per visit S061 $36.70 Diagnostic model per model # S071 $95.40 Photographic records - intraoral S072 $42.80 Photographic records - extraoral S073 $41.80 Diagnostic wax-up S074 $ Cephalometric analysis - excluding radiographs S081 $83.10 Tooth-jaw size prediction analysis S082 $ Tomographic analysis S083 $ Electromyographic recording S085 $ Electromyographic analysis S086 $ Removal of plaque/and or stain S111 $79.00 Recontouring of pre-existing restoration(s) S113 $29.90 Removal of calculus first visit S114 $ Removal of calculus - subsequent visit S115 $85.70 Enamel micro-abrasion - per tooth S116 $71.50 Bleaching, internal - per tooth S117 $ Bleaching, external - per tooth S118 $76.40 Bleaching, home application - per arch S119 $ Topical application of remineralizing and/or cariostatic agents, one treatment S121 $50.70 Topical remineralizing and/or cariostatic agent,home application-per arch S122 $71.60 Concentrated remineralizing and/or cariostatic agent, application single tooth S123 $39.80 MHSWL

2 PAGE 2 of 6 Diagnostic / Preventative (continued) Item No. Fee Dietary advice S131 $53.50 Oral hygiene instruction S141 $72.60 Provision of a mouthguard - indirect S151 $ Bimaxillary mouthguard - indirect S153 $ Fissure sealing per tooth S161 $67.50 Desensitising procedure - per visit S165 $39.80 Periodontics Item No. Fee Odontoplasty - per tooth S171 $74.50 Treatment of acute periodontal infection - per visit S213 $ Clinical periodontal analysis and recording S221 $ Root planing and subgingival curettage per tooth S222 $56.00 Non-surgical periodontal treatment where not otherwise specified - per visit S225 $ Gingivectomy per tooth S231 $ Periodontal flap surgery per tooth S232 $ Gingival graft - per tooth or implant S235 $ Guided tissue regeneration - per tooth or implant S236 $ Guided tissue regeneration - membrane removal S237 $ Periodontal flap surgery for crown lengthening - per tooth S238 $ Root resection - per root S241 $ Osseous surgery per eight teeth or less S242 $ Osseous graft per tooth or implant S243 $ Osseous graft - block S244 $ Periodontal surgery involving one tooth or implant S245 $ Course of non-surgical periodontal treatment S281 $ Cont of periodontal treatment or maintenance subsequent to item S281 S282 $ Oral Surgery Item No. Fee Removal of a tooth or part(s) thereof S311 $ Sectional removal of a tooth S314 $ Surgical removal of a tooth or tooth fragment not requiring removal of bone or tooth division S322 $ Surgical removal of a tooth or tooth fragment requiring removal of bone S323 $ Surgical removal of a tooth or tooth fragment requiring both removal of bone and tooth divison S324 $ Alveolectomy - per segment S331 $ Ostectomy - per jaw S332 $ Reduction of fibrous tuberosity S337 $ Reduction of flabby ridge - per segment S338 $ Removal of hyperplastic tissue S341 $ Repositioning of muscle attachment S343 $ Vestibuloplasty S344 $ Skin or mucosal graft S345 $ Repair of skin and subcutaneous tissue or mucous membrane S351 $ Fracture of maxilla or mandible - not requiring splinting S352 $ Fracture of maxilla or mandible - with wiring of teeth or intra-oral fixation S353 $ Fracture of maxilla or mandible - with external fixation S354 $ Fracture of zygoma S355 $ Fracture of the maxilla or mandible requiring open reduction S359 $1, Mandible - relocation following dislocation S361 $ Mandible relocation - requiring open operation S363 $1, Osteotomy - maxilla S365 $1, Osteotomy - mandible S366 $1, Removal of tumour, cyst or scar - cutaneous, subcutaneous or in mucous membrane S371 $ Removal of tumour, cyst or scar involving muscle, bone or other deep tissue S373 $ Surgery to salivary duct S375 $ Surgery to salivary gland S376 $ Removal or repair of soft tissue (not elsewhere defined) S377 $ Surgical removal of foreign body S378 $ Marsupialisation of cyst S379 $390.00

3 PAGE 3 of 6 Oral Surgery (continued) Item No. Fee Surgical exposure of unerupted tooth S381 $ Surgical exposure and attachment of device for orthodontic traction S382 $ Repositioning of displaced tooth/teeth - per tooth S384 $ Surgical repositioning of unerupted tooth S385 $ Splinting of displaced tooth/teeth - per tooth S386 $ Replantation and splinting of a tooth S387 $ Transplantation of tooth or tooth bud S388 $ Surgery to isolate and preserve neurovascular tissue S389 $ Frenectomy S391 $ Drainage of abscess S392 $ Surgery involving the maxillary antrum S393 $ Surgery for osteomyelitis S394 $ Repair of nerve trunk S395 $1, Control of reactionary or secondary post-operative haemorrhage S399 $63.60 Endodontic / Restorative Item No. Fee Direct pulp capping S411 $48.20 Incomplete endodontic therapy (inoperable or fractured tooth) S412 $ Pulpotomy S414 $91.90 Complete chemo-mechanical preparation of root canal - one canal S415 $ Complete chemo-mechanical preparation of root canal - each additional canal S416 $ Root canal obturation - one canal S417 $ Root canal obturation - each additional canal S418 $ Extirpation of pulp or debridement of root canal(s) - emergency or palliative S419 $ Resorbable root canal filling - primary tooth S421 $ Periapical curettage - per root S431 $ Apicectomy - per root S432 $ Exploratory periradicular surgery S433 $ Apical seal - per canal S434 $ Sealing of perforation S436 $ Surgical treatment and repair of external root resorption - per tooth S437 $ Hemisection S438 $ Exploration and/or negotiation of a calcified canal - per canal, per visit S445 $ Removal of root filling - per canal S451 $ Removal of a cemented root canal post or post crown S452 $ Removal or bypassing fractured endodontic instrument S453 $ Additional visit for irrigation and/or dressing of the root canal system - per tooth S455 $ Obturation of resorption defect or perforation (non-surgical) S457 $ Interim therapeutic root filling - per tooth S458 $ Metallic restoration - one surface - direct S511 $ Metallic restoration - two surfaces - direct S512 $ Metallic restoration - three surfaces - direct S513 $ Metallic restoration - four surfaces - direct S514 $ Metallic restoration - five surfaces - direct S515 $ Adhesive restoration - one surface - anterior tooth - direct S521 $ Adhesive restoration - two surfaces - anterior tooth - direct S522 $ Adhesive restoration - three surfaces - anterior tooth - direct S523 $ Adhesive restoration - four surfaces - anterior tooth - direct S524 $ Adhesive restoration - five surfaces - anterior tooth - direct S525 $ Adhesive restoration - one surface - posterior tooth - direct S531 $ Adhesive restoration - two surfaces - posterior tooth - direct S532 $ Adhesive restoration - three surfaces - posterior tooth - direct S533 $ Adhesive restoration - four surfaces - posterior tooth - direct S534 $ Adhesive restoration - five surfaces - posterior tooth - direct S535 $ Metallic restoration - one surface - indirect S541 $ Metallic restoration - two surfaces - indirect S542 $787.80

4 PAGE 4 of 6 Endodontic / Restorative (continued) Item No. Fee Metallic restoration - three surfaces - indirect S543 $1, Metallic restoration - four surfaces - indirect S544 $1, Metallic restoration - five surfaces - indirect S545 $1, Tooth-coloured restoration - one surface - indirect S551 $ Tooth-coloured restoration - two surfaces - indirect S552 $1, Tooth-coloured restoration - three surfaces - indirect S553 $1, Non-metallic restoration - four surfaces - indirect S554 $1, Non-metallic restoration - five surfaces - indirect S555 $1, Provisional (intermediate/temporary) restoration S572 $64.70 Metal band S574 $54.50 Pin retention - per pin S575 $37.20 Metallic crown - direct S576 $ Cusp capping - per cusp S577 $40.20 Restoration of an incisal corner - per corner S578 $40.20 Bonding of tooth fragment S579 $ Veneer - direct S582 $ Veneer - indirect S583 $1, Removal of inlay/onlay S595 $ Recementing of inlay/onlay S596 $ Post - direct S597 $ Prosthodontics Item No. Fee Full crown - acrylic resin - indirect S611 $1, Full crown - non-metallic - indirect S613 $1, Full crown - veneered - indirect S615 $1, Full crown - metallic - indirect S618 $1, Post and core for crown - indirect S625 $ Preliminary restoration for crown direct S627 $ Post and root cap - indirect S629 $ Provisional crown S631 $ Provisional bridge - per pontic S632 $ Bridge pontic - direct - per pontic S642 $1, Bridge pontic - indirect - per pontic S643 $1, Semi-fixed attachment S644 $ Precision or magnetic attachment S645 $ Retainer for bonded fixture - indirect - per tooth S649 $ Recementing crown or veneer S651 $ Recementing bridge or splint - per abutment S652 $ Rebonding of bridge or splint where retreatment of bridge surface is required S653 $ Removal of crown S655 $78.80 Removal of bridge or splint S656 $ Repair of crown, bridge or splint - indirect S658 $ Repair of crown, bridge or splint - direct S659 $ Fitting of implant abutment - per abutment S661 $ Provisional implant crown abutment - per abutment S662 $ Removal of implant S663 $ Fitting of bar for denture - per abutment S664 $ Prosthesis with metal frame attached to implants - per tooth S666 $ Fixture or abutment screw removal and replacement S668 $ Removal and reattachment of prosthesis fixed to implant(s) - per implant S669 $ Full crown attached to osseointegrated implant - non-metallic - indirect S671 $1, Full crown attached to osseointegrated implant - veneered - indirect S672 $1, Full crown attached to osseointegrated implant - metallic - indirect S673 $1, Diagnostic template S678 $ Surgical implant guide S679 $ Insertion of first stage of two-stage endosseous implant - per implant S684 $1, Insertion of one-stage endosseous implant - per implant S688 $1, Provisional implant S689 $751.50

5 PAGE 5 of 6 Prosthodontics (continued) Item No. Fee Second stage surgery of two-stage endosseous implant - per implant S691 $ Complete maxillary denture S711 $1, Complete mandibular denture S712 $1, Metal palate or plate S716 $ Complete maxillary and mandibular dentures S719 $1, Partial maxillary denture - resin base S721 $ Partial mandibular denture - resin base S722 $ Partial maxillary denture - cast metal framework S727 $1, Partial mandibular denture - cast metal framework S728 $1, Retainer - per tooth S731 $52.80 Occlusal rest - per rest S732 $25.70 Tooth/teeth (partial denture) S733 $54.50 Overlays - per tooth S734 $90.90 Precision or magnetic denture attachment S735 $ Immediate tooth replacement - per tooth S736 $10.90 Resilient lining S737 $ Wrought bar S738 $ Metal backing - per backing S739 $95.30 Adjustment of a denture S741 $62.50 Relining - complete denture - processed S743 $ Relining - partial denture - processed S744 $ Remodelling - complete denture S745 $ Remodelling - partial denture S746 $ Relining - complete denture - direct S751 $ Relining - partial denture - direct S752 $ Cleaning and polishing of pre-existing denture S753 $67.50 Denture base modification S754 $ Reattaching pre-existing tooth or clasp to denture S761 $ Replacing/adding clasp to denture - per clasp S762 $ Repairing broken base of a complete denture S763 $ Repairing broken base of a partial denture S764 $ Replacing tooth on denture - per tooth S765 $ Adding tooth to partial denture to replace an extracted or decoronated tooth - per tooth S768 $ Repair or addition to metal casting S769 $ Tissue conditioning preparatory to impressions - per application S771 $82.90 Splint - resin - indirect S772 $ Splint - metal - indirect S773 $ Obturator S774 $1, Characterization of denture base S775 $ Impression - denture repair/modification S776 $55.10 Identification S777 $44.10 Inlay for denture tooth S778 $ Surgical guide for an immediate denture S779 $ Orthodontics Item No. Fee Passive removable appliance - per arch S811 $ Active removable appliance - per arch S821 $ Functional orthopaedic appliance S823 $ Sequential plastic aligners - per arch S825 $1, Partial banding - per arch S829 $ Full arch banding - per arch S831 $1, Fixed palatal or lingual arch appliance S841 $ Partial banding for inter-maxillary elastics (cross elastics) S842 $ Maxillary expansion appliance S843 $1, Passive fixed appliance S845 $ Minor tooth guidance - fixed S846 $486.90

6 PAGE 6 of 6 Orthodontics (continued) Item No. Fee Extraoral appliance S851 $ Bonding of attachment for application of orthodontic force S862 $ Orthodontic adjustment S871 $ Repair of removable appliance - resin base S875 $ Repair of removable appliance - clasp, spring or tooth S876 $ Addition to removable appliance - clasp, spring or tooth S877 $ Relining - removable appliance - processed S878 $ Complete course of orthodontic treatment S881 $1, General Services Item No. Fee Palliative care S911 $91.00 After-hours callout S915 $ Travel to provide services S916 $ Individually made tray - medicament(s) S926 $ Provision of medication/medicament S927 $29.00 Intravenous cannulation and establishment of infusion S928 $ Local anaesthesia S941 $57.00 Sedation - intravenous - per 30 minutes or part thereof S942 $ Sedation - inhalation - per 30 minutes or part therof S943 $93.20 Relaxation therapy S944 $ Treatment under general anaesthesia/sedation S949 $ Minor occlusal adjustment - per visit S961 $64.80 Clinical occlusal analysis including muscle and joint palpation S963 $ Registration and mounting of models for occlusal analysis S964 $92.00 Occlusal splint S965 $ Adjustment of pre-existing occlusal splint - per visit S966 $90.00 Pantographic tracing S967 $ Occlusal adjustment following occlusal analysis - per visit S968 $ Adjunctive physical therapy for temporomandibular joint and associated structures S971 $91.00 Repair/addition - occlusal splint S972 $ Splinting and stabilisation - direct - per tooth S981 $ Enamel stripping - per visit S982 $ Single arch oral appliance-diagnosed snoring, obstructive snoring, sleep apnoea S983 $1, Bimaxillary oral appliance-diagnosed snoring, obstructive snoring, sleep apnoea S984 $1, Post-operative care not otherwise included S986 $89.00 Treatment not otherwise included (specify) S990 $ GST 999 Actual Cost MHSWL

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