Schedule of Fees (effective 1 August 2013) Specialist Dental

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 $100.30 Consultation - extended (30 minutes or more) S015 $164.10 Consultation by referral including examination S016 $157.80 Consultation by referral - extended (30 minutes) - including examination S017 $220.00 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 $110.80 Lateral, antero-posterior, postero-anterior or submento-vertex radiograph S033 $140.00 Radiograph of temporomandibular joint - per exposure S035 $159.80 Cephalometric radiograph - lateral, antero-posterior, postero-anterior or submento-vertex - per exposure S036 $234.70 Panoramic radiograph - per exposure S037 $148.90 Hand-wrist radiograph for skeletal age assessment S038 $139.30 Tomography of the skull or parts thereof S039 $234.80 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 $195.70 Histopathological examination of tissue S052 $906.60 Cytological investigation S053 $137.70 Blood sample S055 $145.00 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 $250.00 Cephalometric analysis - excluding radiographs S081 $83.10 Tooth-jaw size prediction analysis S082 $167.00 Tomographic analysis S083 $115.60 Electromyographic recording S085 $229.80 Electromyographic analysis S086 $189.20 Removal of plaque/and or stain S111 $79.00 Recontouring of pre-existing restoration(s) S113 $29.90 Removal of calculus first visit S114 $131.60 Removal of calculus - subsequent visit S115 $85.70 Enamel micro-abrasion - per tooth S116 $71.50 Bleaching, internal - per tooth S117 $416.30 Bleaching, external - per tooth S118 $76.40 Bleaching, home application - per arch S119 $161.10 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 MHSWL2100713

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 $198.80 Bimaxillary mouthguard - indirect S153 $305.80 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 $104.00 Clinical periodontal analysis and recording S221 $210.40 Root planing and subgingival curettage per tooth S222 $56.00 Non-surgical periodontal treatment where not otherwise specified - per visit S225 $210.40 Gingivectomy per tooth S231 $150.00 Periodontal flap surgery per tooth S232 $270.00 Gingival graft - per tooth or implant S235 $652.40 Guided tissue regeneration - per tooth or implant S236 $771.40 Guided tissue regeneration - membrane removal S237 $335.60 Periodontal flap surgery for crown lengthening - per tooth S238 $603.20 Root resection - per root S241 $372.80 Osseous surgery per eight teeth or less S242 $851.50 Osseous graft per tooth or implant S243 $931.70 Osseous graft - block S244 $551.20 Periodontal surgery involving one tooth or implant S245 $236.70 Course of non-surgical periodontal treatment S281 $485.00 Cont of periodontal treatment or maintenance subsequent to item S281 S282 $324.70 Oral Surgery Item No. Fee Removal of a tooth or part(s) thereof S311 $172.20 Sectional removal of a tooth S314 $235.70 Surgical removal of a tooth or tooth fragment not requiring removal of bone or tooth division S322 $299.10 Surgical removal of a tooth or tooth fragment requiring removal of bone S323 $371.30 Surgical removal of a tooth or tooth fragment requiring both removal of bone and tooth divison S324 $459.70 Alveolectomy - per segment S331 $176.70 Ostectomy - per jaw S332 $487.70 Reduction of fibrous tuberosity S337 $262.20 Reduction of flabby ridge - per segment S338 $150.00 Removal of hyperplastic tissue S341 $358.00 Repositioning of muscle attachment S343 $410.00 Vestibuloplasty S344 $837.20 Skin or mucosal graft S345 $837.20 Repair of skin and subcutaneous tissue or mucous membrane S351 $230.00 Fracture of maxilla or mandible - not requiring splinting S352 $275.50 Fracture of maxilla or mandible - with wiring of teeth or intra-oral fixation S353 $600.00 Fracture of maxilla or mandible - with external fixation S354 $600.00 Fracture of zygoma S355 $780.00 Fracture of the maxilla or mandible requiring open reduction S359 $1,224.00 Mandible - relocation following dislocation S361 $277.10 Mandible relocation - requiring open operation S363 $1,008.00 Osteotomy - maxilla S365 $1,400.00 Osteotomy - mandible S366 $1,400.00 Removal of tumour, cyst or scar - cutaneous, subcutaneous or in mucous membrane S371 $216.90 Removal of tumour, cyst or scar involving muscle, bone or other deep tissue S373 $729.80 Surgery to salivary duct S375 $651.80 Surgery to salivary gland S376 $229.50 Removal or repair of soft tissue (not elsewhere defined) S377 $284.70 Surgical removal of foreign body S378 $160.90 Marsupialisation of cyst S379 $390.00

PAGE 3 of 6 Oral Surgery (continued) Item No. Fee Surgical exposure of unerupted tooth S381 $367.10 Surgical exposure and attachment of device for orthodontic traction S382 $416.30 Repositioning of displaced tooth/teeth - per tooth S384 $268.60 Surgical repositioning of unerupted tooth S385 $416.30 Splinting of displaced tooth/teeth - per tooth S386 $280.00 Replantation and splinting of a tooth S387 $536.50 Transplantation of tooth or tooth bud S388 $604.40 Surgery to isolate and preserve neurovascular tissue S389 $198.60 Frenectomy S391 $248.20 Drainage of abscess S392 $130.30 Surgery involving the maxillary antrum S393 $836.60 Surgery for osteomyelitis S394 $537.80 Repair of nerve trunk S395 $1,025.00 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 $199.10 Pulpotomy S414 $91.90 Complete chemo-mechanical preparation of root canal - one canal S415 $413.30 Complete chemo-mechanical preparation of root canal - each additional canal S416 $211.20 Root canal obturation - one canal S417 $413.30 Root canal obturation - each additional canal S418 $211.20 Extirpation of pulp or debridement of root canal(s) - emergency or palliative S419 $172.60 Resorbable root canal filling - primary tooth S421 $223.00 Periapical curettage - per root S431 $410.00 Apicectomy - per root S432 $410.00 Exploratory periradicular surgery S433 $165.90 Apical seal - per canal S434 $546.80 Sealing of perforation S436 $380.00 Surgical treatment and repair of external root resorption - per tooth S437 $529.00 Hemisection S438 $390.60 Exploration and/or negotiation of a calcified canal - per canal, per visit S445 $146.90 Removal of root filling - per canal S451 $146.90 Removal of a cemented root canal post or post crown S452 $137.80 Removal or bypassing fractured endodontic instrument S453 $128.70 Additional visit for irrigation and/or dressing of the root canal system - per tooth S455 $146.90 Obturation of resorption defect or perforation (non-surgical) S457 $146.90 Interim therapeutic root filling - per tooth S458 $165.40 Metallic restoration - one surface - direct S511 $138.40 Metallic restoration - two surfaces - direct S512 $169.60 Metallic restoration - three surfaces - direct S513 $202.20 Metallic restoration - four surfaces - direct S514 $230.60 Metallic restoration - five surfaces - direct S515 $263.30 Adhesive restoration - one surface - anterior tooth - direct S521 $153.20 Adhesive restoration - two surfaces - anterior tooth - direct S522 $185.90 Adhesive restoration - three surfaces - anterior tooth - direct S523 $220.10 Adhesive restoration - four surfaces - anterior tooth - direct S524 $254.30 Adhesive restoration - five surfaces - anterior tooth - direct S525 $355.50 Adhesive restoration - one surface - posterior tooth - direct S531 $163.60 Adhesive restoration - two surfaces - posterior tooth - direct S532 $205.30 Adhesive restoration - three surfaces - posterior tooth - direct S533 $246.90 Adhesive restoration - four surfaces - posterior tooth - direct S534 $278.20 Adhesive restoration - five surfaces - posterior tooth - direct S535 $416.30 Metallic restoration - one surface - indirect S541 $596.10 Metallic restoration - two surfaces - indirect S542 $787.80

PAGE 4 of 6 Endodontic / Restorative (continued) Item No. Fee Metallic restoration - three surfaces - indirect S543 $1,029.50 Metallic restoration - four surfaces - indirect S544 $1,202.90 Metallic restoration - five surfaces - indirect S545 $1,489.20 Tooth-coloured restoration - one surface - indirect S551 $940.40 Tooth-coloured restoration - two surfaces - indirect S552 $1,053.00 Tooth-coloured restoration - three surfaces - indirect S553 $1,306.30 Non-metallic restoration - four surfaces - indirect S554 $1,404.80 Non-metallic restoration - five surfaces - indirect S555 $1,489.20 Provisional (intermediate/temporary) restoration S572 $64.70 Metal band S574 $54.50 Pin retention - per pin S575 $37.20 Metallic crown - direct S576 $380.90 Cusp capping - per cusp S577 $40.20 Restoration of an incisal corner - per corner S578 $40.20 Bonding of tooth fragment S579 $222.00 Veneer - direct S582 $437.70 Veneer - indirect S583 $1,624.70 Removal of inlay/onlay S595 $186.90 Recementing of inlay/onlay S596 $105.00 Post - direct S597 $234.00 Prosthodontics Item No. Fee Full crown - acrylic resin - indirect S611 $1,220.00 Full crown - non-metallic - indirect S613 $1,780.00 Full crown - veneered - indirect S615 $1,950.00 Full crown - metallic - indirect S618 $1,550.00 Post and core for crown - indirect S625 $422.10 Preliminary restoration for crown direct S627 $175.10 Post and root cap - indirect S629 $428.70 Provisional crown S631 $151.40 Provisional bridge - per pontic S632 $390.00 Bridge pontic - direct - per pontic S642 $1,280.00 Bridge pontic - indirect - per pontic S643 $1,177.70 Semi-fixed attachment S644 $421.60 Precision or magnetic attachment S645 $415.90 Retainer for bonded fixture - indirect - per tooth S649 $525.00 Recementing crown or veneer S651 $116.60 Recementing bridge or splint - per abutment S652 $133.00 Rebonding of bridge or splint where retreatment of bridge surface is required S653 $124.30 Removal of crown S655 $78.80 Removal of bridge or splint S656 $183.70 Repair of crown, bridge or splint - indirect S658 $464.30 Repair of crown, bridge or splint - direct S659 $440.00 Fitting of implant abutment - per abutment S661 $720.00 Provisional implant crown abutment - per abutment S662 $538.40 Removal of implant S663 $567.20 Fitting of bar for denture - per abutment S664 $854.50 Prosthesis with metal frame attached to implants - per tooth S666 $693.60 Fixture or abutment screw removal and replacement S668 $604.80 Removal and reattachment of prosthesis fixed to implant(s) - per implant S669 $223.30 Full crown attached to osseointegrated implant - non-metallic - indirect S671 $1,760.00 Full crown attached to osseointegrated implant - veneered - indirect S672 $1,950.00 Full crown attached to osseointegrated implant - metallic - indirect S673 $1,550.00 Diagnostic template S678 $465.70 Surgical implant guide S679 $382.40 Insertion of first stage of two-stage endosseous implant - per implant S684 $1,488.60 Insertion of one-stage endosseous implant - per implant S688 $1,627.20 Provisional implant S689 $751.50

PAGE 5 of 6 Prosthodontics (continued) Item No. Fee Second stage surgery of two-stage endosseous implant - per implant S691 $551.10 Complete maxillary denture S711 $1,056.90 Complete mandibular denture S712 $1,056.90 Metal palate or plate S716 $377.90 Complete maxillary and mandibular dentures S719 $1,807.30 Partial maxillary denture - resin base S721 $508.50 Partial mandibular denture - resin base S722 $508.50 Partial maxillary denture - cast metal framework S727 $1,518.20 Partial mandibular denture - cast metal framework S728 $1,518.20 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 $305.00 Immediate tooth replacement - per tooth S736 $10.90 Resilient lining S737 $226.30 Wrought bar S738 $210.90 Metal backing - per backing S739 $95.30 Adjustment of a denture S741 $62.50 Relining - complete denture - processed S743 $578.00 Relining - partial denture - processed S744 $449.50 Remodelling - complete denture S745 $739.20 Remodelling - partial denture S746 $607.10 Relining - complete denture - direct S751 $269.00 Relining - partial denture - direct S752 $210.70 Cleaning and polishing of pre-existing denture S753 $67.50 Denture base modification S754 $175.70 Reattaching pre-existing tooth or clasp to denture S761 $172.50 Replacing/adding clasp to denture - per clasp S762 $180.30 Repairing broken base of a complete denture S763 $155.70 Repairing broken base of a partial denture S764 $172.50 Replacing tooth on denture - per tooth S765 $180.30 Adding tooth to partial denture to replace an extracted or decoronated tooth - per tooth S768 $182.50 Repair or addition to metal casting S769 $218.30 Tissue conditioning preparatory to impressions - per application S771 $82.90 Splint - resin - indirect S772 $448.30 Splint - metal - indirect S773 $448.30 Obturator S774 $1,140.70 Characterization of denture base S775 $255.80 Impression - denture repair/modification S776 $55.10 Identification S777 $44.10 Inlay for denture tooth S778 $244.30 Surgical guide for an immediate denture S779 $439.90 Orthodontics Item No. Fee Passive removable appliance - per arch S811 $427.80 Active removable appliance - per arch S821 $777.20 Functional orthopaedic appliance S823 $610.90 Sequential plastic aligners - per arch S825 $1,339.00 Partial banding - per arch S829 $735.60 Full arch banding - per arch S831 $1,893.60 Fixed palatal or lingual arch appliance S841 $506.20 Partial banding for inter-maxillary elastics (cross elastics) S842 $460.80 Maxillary expansion appliance S843 $1,107.30 Passive fixed appliance S845 $415.90 Minor tooth guidance - fixed S846 $486.90

PAGE 6 of 6 Orthodontics (continued) Item No. Fee Extraoral appliance S851 $591.40 Bonding of attachment for application of orthodontic force S862 $158.90 Orthodontic adjustment S871 $179.90 Repair of removable appliance - resin base S875 $197.80 Repair of removable appliance - clasp, spring or tooth S876 $154.40 Addition to removable appliance - clasp, spring or tooth S877 $135.90 Relining - removable appliance - processed S878 $210.80 Complete course of orthodontic treatment S881 $1,040.30 General Services Item No. Fee Palliative care S911 $91.00 After-hours callout S915 $169.30 Travel to provide services S916 $112.90 Individually made tray - medicament(s) S926 $160.00 Provision of medication/medicament S927 $29.00 Intravenous cannulation and establishment of infusion S928 $143.40 Local anaesthesia S941 $57.00 Sedation - intravenous - per 30 minutes or part thereof S942 $256.00 Sedation - inhalation - per 30 minutes or part therof S943 $93.20 Relaxation therapy S944 $189.60 Treatment under general anaesthesia/sedation S949 $146.50 Minor occlusal adjustment - per visit S961 $64.80 Clinical occlusal analysis including muscle and joint palpation S963 $125.00 Registration and mounting of models for occlusal analysis S964 $92.00 Occlusal splint S965 $880.00 Adjustment of pre-existing occlusal splint - per visit S966 $90.00 Pantographic tracing S967 $174.10 Occlusal adjustment following occlusal analysis - per visit S968 $135.00 Adjunctive physical therapy for temporomandibular joint and associated structures S971 $91.00 Repair/addition - occlusal splint S972 $284.00 Splinting and stabilisation - direct - per tooth S981 $125.00 Enamel stripping - per visit S982 $100.00 Single arch oral appliance-diagnosed snoring, obstructive snoring, sleep apnoea S983 $1,345.10 Bimaxillary oral appliance-diagnosed snoring, obstructive snoring, sleep apnoea S984 $1,609.70 Post-operative care not otherwise included S986 $89.00 Treatment not otherwise included (specify) S990 $104.70 GST 999 Actual Cost MHSWL2100713