Top Extras dental schedule as at 1 September 2014

Top Extras dental schedule as at 1 September 2014 Item Description Benefit Service limit Category Waiting 011 Comprehensive oral examination $41.00 1 per Preventive 2 months 012 Periodic oral examination $37.00 2 per Preventive 2 months 013 Oral examination limited $31.50 2 per Preventive 2 months 014 Consultation $37.50 2 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 $18.00 025 Intraoral radiograph occlusal, maxillary, mandibular per $34.00 2 per General 2 months exposure 031 Extraoral radiograph maxillary, mandibular per exposure $56.50 2 per General 2 months 033 Lateral, antero posterior or postero anterior or submento vertex $56.50 2 per General 2 months radiograph of the skull per exposure 035 Radiograph of temporomandibular joint per exposure $56.50 2 per General 2 months 036 Cephalometric radiograph lateral, antero posterior, posteroanterior $56.50 2 per General 2 months or submento vertex per exposure 037 Panoramic radiograph per exposure $64.50 1 per General 2 months 038 Hand wrist radiograph for skeletal age assessment $100.50 1 per visit General 2 months 039 Tomograghy of the skull or parts thereof $112.00 1 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 $109.00 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 $34.00 2 per General 2 months 072 Photographic records intraoral $20.50 1 per General 2 months 073 Photographic records extraoral $20.50 1 per General 2 months 074 Diagnostic wax up $88.50 1 per General 2 months 081 Cephalometric analysis excluding radiographs $30.50 1 per General 2 months 082 Tooth jaw size prediction analysis $19.50 1 per General 2 months 083 Tomographic analysis $30.50 1 per visit General 2 months 085 Electromyographic recording $0.00 General 2 months 086 Electromyographic analysis $89.50 1 per General 2 months 111 Removal of plaque and/or stain $37.50 1 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 $69.50 2 per Preventive 2 months 115 Removal of calculus subsequent visit $67.50 2 per Preventive 2 months 116 Enamel micro abrasion per tooth $36.50 Preventive 2 months 117 Bleaching, internal per tooth $0.00 1 per tooth, 2 per General 2 months 118 Bleaching, external per tooth $0.00 6 per General 2 months 119 Bleaching, home application per arch $0.00 2 per General 2 months 121 Topical application of remineralising and/or cariostatic agents, one $21.00 1 per visit, 2 per Preventive 2 months treatment 122 Topical remineralising and/or cariostatic agent, home application $0.00 2 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 $129.50 General 2 months

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 $40.50 1 per visit General 2 months 221 Clinical ontal analysis and recording $25.50 1 per General 2 months 222 Root planing and subgingival curettage per tooth $22.00 231 Gingivectomy per tooth $76.50 232 Periodontal flap surgery per tooth $106.50 235 Gingival graft per tooth or implant $200.50 236 Guided tissue regeneration per tooth or implant $363.00 237 Guided tissue regeneration membrane removal $257.00 238 Periodontal flap surgery for crown lengthening per tooth $112.00 241 Root resection per root $123.00 242 Osseous surgery per tooth $106.50 243 Osseous graft per tooth or implant $226.00 244 Osseous graft block $251.00 245 Periodontal surgery involving one tooth or implant $47.50 281 Course of non surgical ontal treatment $501.50 per course of treatment 282 Continuation of ontal treatment or maintenance subsequent $110.00 1 per visit to item 281 311 Removal of a tooth or part(s) thereof $74.00 General 2 months 314 Sectional removal of a tooth $101.50 General 2 months 322 Surgical removal of a tooth or tooth fragment not requiring $134.00 removal of bone or tooth division 323 Surgical removal of a tooth or tooth fragment requiring removal of $145.50 Major 12months bone 324 Surgical removal of a tooth or tooth fragment requiring both $178.50 removal of bone and tooth division 331 Alveolectomy per segment $89.50 332 Ostectomy per jaw $62.00 337 Reduction of fibrous tuberosity $200.50 338 Reduction of flabby ridge per segment $234.50 341 Removal of hyperplastic tissue $219.00 343 Repositioning of muscle attachment $468.50 344 Vestibuloplasty $468.50 345 Skin or mucosal graft $468.50 351 Repair of skin and subcutaneous tissue or mucous membrane $151.00 352 Fracture of maxilla or mandible not requiring splinting $105.50 353 Fracture of maxilla or mandible with wiring of teeth or intra oral $557.50 fixation 354 Fracture of maxilla or mandible with external fixation $323.50 355 Fracture of the zygoma $436.50 359 Fracture of the maxilla or mandible requiring open reduction $724.50 361 Mandible relocation following dislocation $39.50 1 per visit 363 Mandible relocation requiring open operation $95.00 365 Osteotomy maxilla $557.50 1 per visit 366 Osteotomy mandible $557.50 1 per visit 371 Removal of tumour, cyst or scar cutaneous, subcutaneous or in $106.50 mucous membrane 373 Removal of tumour, cyst or scar involving muscle, bone or other $200.50 deep tissue 375 Surgery to salivary duct $311.00 376 Surgery to salivary gland $352.50 377 Removal or repair of soft tissue (not elsewhere defined) $102.50 378 Surgical removal of foreign body $221.00 379 Marsupialisation of cyst $219.00 381 Surgical exposure of unerupted tooth $167.50 1 per tooth, per visit 382 Surgical exposure and attachment of device for orthodontic $251.00 1 per tooth, per visit traction 384 Repositioning of displaced tooth/teeth per tooth $50.50 1 per tooth, per visit 385 Surgical repositioning of unerupted tooth $167.50 1 per tooth, per visit 386 Splinting of displaced tooth/teeth per tooth $106.50 1 per tooth, per visit 387 Replantation and splinting of a tooth $106.50 1 per tooth, per visit 388 Transplantation of tooth or tooth bud $212.00 1 per tooth, per visit 389 Surgery to isolate and preserve neurovascular tissue $156.50 391 Frenectomy $140.00

392 Drainage of abscess $110.00 393 Surgery involving the maxillary antrum $351.50 394 Surgery for osteomyelitis $284.50 1 per visit 395 Repair of nerve trunk $295.50 399 Control of reactionary or secondary post operative haemorrhage $56.50 411 Direct pulp capping $0.00 412 Incomplete endodontic therapy (inoperable or fractured tooth) $59.00 414 Pulpotomy $67.50 1 per tooth, per visit 415 Complete chemo mechanical preparation of root canal one canal $126.50 1 per tooth, per visit 416 Complete chemo mechanical preparation of root canal each $58.00 additional canal 417 Root canal obturation one canal $133.00 1 per tooth, per visit 418 Root canal obturation each additional canal $56.00 419 Extirpation of pulp or debridement of root canal(s) emergency or $72.00 1 per tooth, per visit palliative 421 Resorbable root canal filling primary tooth $100.50 1 per tooth, per visit 431 Periapical curettage per root $134.00 reduced benefit for each subsequent root in same tooth n/a 432 Apicectomy per root $167.50 reduced benefit for each subsequent root in same tooth n/a 433 Exploratory periradicular surgery $106.50 434 Apical seal per canal $301.00 reduced benefit for each subsequent canal in same tooth n/a 436 Sealing of perforation $118.00 437 Surgical treatment and repair of external root resorption per $134.00 1 per tooth, per visit tooth 438 Hemisection $134.00 1 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 $112.00 453 Removal or bypassing fractured endodontic instrument $112.00 455 Additional visit for irrigation and/or dressing of the root canal $58.00 1 per tooth, per visit system per tooth 457 Obturation of resorption defect or perforation (non surgical) $84.00 1 per tooth, per visit 458 Interim therapeutic root filling per tooth $58.00 1 per tooth, per visit 511 Metallic restoration one surface direct $59.00 1 per tooth, per visit General 2 months 512 Metallic restoration two surfaces direct $71.00 1 per tooth, per visit General 2 months 513 Metallic restoration three surfaces direct $85.00 1 per tooth, per visit General 2 months 514 Metallic restoration four surfaces direct $97.50 1 per tooth, per visit General 2 months 515 Metallic restoration five surfaces direct $106.50 1 per tooth, per visit General 2 months 521 Adhesive restoration one surface anterior tooth direct $64.50 1 per tooth, per visit General 2 months 522 Adhesive restoration two surfaces anterior tooth direct $77.50 1 per tooth, per visit General 2 months 523 Adhesive restoration three surfaces anterior tooth direct $88.50 1 per tooth, per visit General 2 months 524 Adhesive restoration four surfaces anterior tooth direct $103.50 1 per tooth, per visit General 2 months 525 Adhesive restoration five surfaces anterior tooth direct $122.50 1 per tooth, per visit General 2 months 531 Adhesive restoration one surface posterior tooth direct $69.50 1 per tooth, per visit General 2 months 532 Adhesive restoration two surfaces posterior tooth direct $90.00 1 per tooth, per visit General 2 months 533 Adhesive restoration three surfaces posterior tooth direct $120.00 1 per tooth, per visit General 2 months 534 Adhesive restoration four surfaces posterior tooth direct $131.50 1 per tooth, per visit General 2 months 535 Adhesive restoration five surfaces posterior tooth direct $143.00 1 per tooth, per visit General 2 months 541 Metallic restoration one surface indirect $178.50 1 per tooth, per 542 Metallic restoration two surfaces indirect $323.50 1 per tooth, per 543 Metallic restoration three surfaces indirect $379.00 1 per tooth, per Major Major Major 12 months 12 months 12 months

544 Metallic restoration four surfaces indirect $412.50 1 per tooth, per 545 Metallic restoration five surfaces indirect $457.50 1 per tooth, per 551 Tooth coloured restoration one surface indirect $323.50 1 per tooth, per 552 Tooth coloured restoration two surfaces indirect $379.00 1 per tooth, per 553 Tooth coloured restoration three surfaces indirect $445.50 1 per tooth, per 554 Tooth coloured restoration four surfaces indirect $490.50 1 per tooth, per 555 Tooth coloured restoration five surfaces indirect $524.00 1 per tooth, per 572 Provisional (intermediate/temporary) restoration $40.50 1 per tooth, per visit General 2 months 574 Metal band $58.00 1 per tooth, per General 2 months 575 Pin retention per pin $16.50 General 2 months 576 Metallic crown preformed $103.50 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 $134.00 General 2 months 583 Veneer indirect $434.50 595 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 $276.00 1 per tooth, per 613 Full crown non metallic indirect $639.50 1 per tooth, per 615 Full crown veneered indirect $660.00 1 per tooth, per 618 Full crown metallic indirect $574.00 1 per tooth, per 625 Post and core for crown indirect $167.50 1 per tooth, per 627 Preliminary restoration for crown direct $95.00 1 per tooth, per 629 Post and root cap indirect $123.00 1 per tooth, per 631 Provisional crown $100.50 1 per tooth, per visit 632 Provisional bridge per pontic $63.50 633 Provisional implant abutment per abutment $91.00 634 Provisional implant restoration per implant abutment $91.00 1 per tooth, per visit 642 Bridge pontic direct per pontic $501.50 1 per tooth, per 643 Bridge pontic indirect per pontic $501.50 1 per tooth, per 644 Semi fixed attachment $129.00 645 Precision or magnetic attachment $120.00 649 Retainer for bonded fixture indirect per tooth $112.00 651 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 $379.00 663 Removal of implant $134.00 664 Fitting of bar for denture per abutment $167.50 665 Prosthesis with resin base attached to implants removable per $606.00 arch 666 Prosthesis with metal frame attached to implants per tooth $850.00 667 Prosthesis with metal frame attached to implants removable per arch $850.00

668 Fixture or abutment screw removal and replacement $34.00 669 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 $850.00 indirect 672 Full crown attached to osseointegrated implant veneered $850.00 indirect 673 Full crown attached to osseointegrated implant metallic indirect $850.00 678 Diagnostic template $207.00 679 Surgical implant guide $212.00 684 Insertion of first stage of two stage endosseous implant per $850.00 implant 688 Insertion of one stage endosseous implant per implant $850.00 689 Provisional implant $140.00 690 Provisional retention device $121.50 691 Second stage surgery of two stage endosseous implant per $334.50 implant 711 Complete maxillary denture $445.50 1 every 3 financial 712 Complete mandibular denture $445.50 1 every 3 financial 716 Metal palate or plate $270.50 2 per visit 719 Complete maxillary and mandibular dentures $850.00 1 every 3 financial 721 Partial maxillary denture resin base $257.00 1 every 3 financial 722 Partial mandibular denture resin base $257.00 1 every 3 financial 727 Partial maxillary denture cast metal framework $485.00 1 every 3 financial 728 Partial mandibular denture cast metal framework $485.00 1 every 3 financial 730 Veteran Affairs Item number only $0.00 731 Retainer per tooth $20.50 732 Occlusal rest per rest $23.00 733 Tooth/teeth (partial denture) $19.50 734 Overlays per tooth $30.50 735 Precision or magnetic denture attachment $80.00 736 Immediate tooth replacement per tooth $26.50 737 Resilient lining $110.00 738 Wrought bar $48.50 739 Metal backing per backing $48.50 741 Adjustment of a denture $26.50 743 Relining complete denture processed $146.50 744 Relining partial denture processed $129.00 745 Remodelling complete denture $167.50 746 Remodelling partial denture $178.50 751 Relining complete denture direct $471.00 752 Relining partial denture direct $140.00 753 Cleaning and polishing of pre existing denture $0.00 2 per 754 Denture base modification $50.50 761 Reattaching pre existing tooth or clasp to denture $55.50 762 Replacing/adding clasp to denture per clasp $60.50 763 Repairing broken base of a complete denture $55.50 764 Repairing broken base of a partial denture $55.50 765 Replacing tooth on denture per tooth $60.50 766 Reattaching existing tooth on denture per tooth $55.50 768 Adding tooth to partial denture to replace an extracted or $66.50 decoronated tooth per tooth 769 Repair or addition to metal casting $82.00 771 Tissue conditioning preparatory to impressions per application $39.50 772 Splint resin indirect $207.00 773 Splint metal indirect $323.50 774 Obturator $557.50 775 Characterisation of denture base $0.00 776 Impression denture repair/modification $23.00 2 per General 2 months

777 Identification $0.00 778 Inlay for denture tooth $100.50 779 Surgical guide for an immediate denture $207.00 811 Passive removable appliance per arch $174.50 2 per Orthodontics 12 months 821 Active removable appliance per arch $295.50 2 per Orthodontics 12 months 823 Functional orthopaedic appliance $479.50 1 per Orthodontics 12 months 825 Sequential Plastic Aligners per arch $334.50 Orthodontics 12 months 829 Partial banding per arch $279.00 Orthodontics 12 months 831 Full arch banding per arch $350.00 Orthodontics 12 months 841 Fixed palatal or lingual arch appliance $173.50 2 per Orthodontics 12 months 842 Partial banding for inter maxillary elastics (cross elastics) $173.50 2 per Orthodontics 12 months 843 Maxillary expansion appliance $250.00 1 per Orthodontics 12 months 845 Passive fixed appliance $173.50 2 per Orthodontics 12 months 846 Minor tooth guidance fixed $140.00 Orthodontics 12 months 851 Extraoral appliance $173.50 1 per visit Orthodontics 12 months 862 Bonding of attachment for application of orthodontic force $134.00 Orthodontics 12 months 871 Orthodontic adjustment $60.00 1 per visit Orthodontics 12 months 875 Repair of removable appliance, resin base $45.00 2 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 $140.00 2 per Orthodontics 12 months 881 Complete course of orthodontic treatment $800.00 Orthodontics 12 months 911 Palliative care $33.50 1 per visit General 2 months 915 After hours callout $41.50 1 per visit General 2 months 916 Travel to provide services $45.00 1 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 $47.50 1 per visit General 2 months 941 Local anaesthesia $25.00 General 2 months 942 Sedation intravenous per 30 minutes or part thereof $91.00 2 per visit General 2 months 943 Sedation inhalation per 30 minutes or part thereof $30.50 2 per visit General 2 months 944 Relaxation therapy $0.00 General 2 months 949 Treatment under general anaesthesia/sedation $78.50 1 per visit General 2 months 961 Minor occlusal adjustment per visit $0.00 1 per visit General 2 months 963 Clinical occlusal analysis including muscle and joint palpation $63.00 1 per General 2 months 964 Registration and mounting of models for occlusal analysis $0.00 General 2 months 965 Occlusal splint $300.00 1 per 966 Adjustment of pre existing occlusal splint per visit $47.50 2 per General 2 months 967 Pantographic tracing $162.50 1 per General 2 months 968 Occlusal adjustment following occlusal analysis per visit $70.00 1 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 $95.00 1 per General 2 months 981 Splinting and stabilisation direct per tooth $67.50 General 2 months 982 Enamel stripping per visit $28.00 1 per visit General 2 months 983 Single arch oral appliance for diagnosed snoring and obstructive $450.00 1 every 3 financial snoring and sleep apnoea 984 Bi maxillary oral appliance for diagnosed snoring and obstructive $600.00 1 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.