Please note the Discovery Health Rates are applicable for services rendered with effect 01 January 2013

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1 Please note the Discovery Health s are applicable for services rendered with effect 01 January 2013 Payment of these claims are subject to the Discovery Health scheme benefit rules. R0.00: Discovery Health does not pay for this procedure code. Practice Type Code Description 8099 Dental laboratory service 8101 Oral examination Comprehensive oral examination Limited oral examination Special report Intraoral radiograph - periapical Intraoral radiographs - complete series Infection control/barrier techniques Sterilized instrumentation Dental testimony 8112 Intraoral radiograph - bitewing Intraoral radiograph - occlusal Extraoral radiograph - hand-wrist Extraoral radiograph - panoramic Extraoral radiograph - cephalometric Diagnostic models Extraoral radiograph - skull/facial bone Diagnostic models mounted Treatment plan completed 8121 (digital/conventional) Microbiological studies Caries susceptibility tests (By Arrangement) Pulp tests scheduled hours Emergency dental treatment Pulp removal (pulpectomy) Recement inlay, onlay, crown or veneer Remove inlay, onlay or crown Access through a prosthetic crown or inlay to facilitate root canal treatment Emergency crown (chair-side) cast) Appointment not kept /30min House/extended care facility/hospital call thereof Inhalation sedation - each addnl 15 minutes Intravenous sedation Local anaesthetic - per visit Resin bonding for restorations sedation Nutritional counselling Tobacco counselling Oral hygiene instruction visit Polishing - complete dentition Re-burnishing and polishing of restorations - complete dentition Enamel microabrasion Prophylaxis - complete dentition Removal of gross calculus Topical application of fluoride - child Topical application of fluoride - adult Dental sealant Sedative filling Application of desensitising resin, per tooth per visit Behavior management

2 Code Description 8169 Occlusal guard Mouth guard Cost of orthotic appliance 8173 Space maintainer - fixed, per abutment Space maintainer - removable Periodontal screening compromised patient) Oral hygiene instruction - each additional visit (periodontally compromised patient) Polishing - complete dentition (periodontally compromised patient) Prophylaxis - complete dentition (periodontally compromised patient) Therapeutic drug injection Re-examination - existing condition Consultation - second opinion or advice Suture - minor (first per quadrant) tooth roots per tooth Surgical removal of residual roots, second and subsequent teeth's roots Cost of suture material 8231 mandibular Complete denture - maxillary or mandibular Partial denture - resin base - one tooth Partial denture - resin base - two teeth Partial denture - resin base - three teeth Partial denture - resin base - four teeth Partial denture - resin base - five teeth Partial denture - resin base - six teeth Partial denture - resin base - seven teeth Partial denture - resin base - eight teeth teeth Immediate denture - maxillary Immediate denture - mandibular Clasp or rest - cast gold Clasp or rest - wrought gold Clasp or rest - stainless steel Bar - lingual or palatal (laboratory) Remodel complete or partial denture side) self-cure reline) (laboratory) Repair denture or other intra-oral appliance Add clasp to existing partial denture Add tooth to existing partial denture Impression to repair or modify a denture or other intra-oral appliance Adjust complete or partial denture Inlay in denture Partial denture - cast metal framework only Pulp cap - direct Pulp cap - indirect Rubber dam per arch Cost of MTA Pulp amputation (pulpotomy) External bleaching - per arch Home bleaching - instructions and applicator Supply of bleaching materials Home bleaching - subsequent visit Internal bleaching - per tooth Internal bleaching - each additional visit

3 Code Description 8328 Root canal obturation - anteriors and premolars - each additional canal Root canal therapy - anteriors and premolars - each additional canal Removal of root canal obstruction tooth tooth canal Root canal obturation - anteriors and canal additional canal first canal Root canal therapy - posteriors - first canal additional canal Amalgam - one surface Amalgam - two surfaces Amalgam - three surfaces Amalgam - four or more surfaces Prefabricated post retention, per post (in addition to restoration) restoration) addition to restoration) Carve restoration to accommodate existing removable prosthesis Resin crown - anterior primary tooth (direct) Resin - one surface, anterior Resin - two surfaces, anterior Resin - three surfaces, anterior Resin - four or more surfaces, anterior Veneer - resin (chair-side) Prefabricated metal crown Inlay - metal - one surface Inlay/onlay - metal - two surfaces Inlay/onlay - metal - three surfaces Inlay/onlay - metal - four or more surfaces number of pins) Resin - one surface, posterior Resin - two surfaces, posterior Resin - three surfaces, posterior Resin - four or more surfaces, posterior Inlay - porcelain - one surface Inlay/onlay - porcelain - two surfaces Inlay/onlay - porcelain - three surfaces surfaces Prefabricated resin crown Core build-up with prefabricated posts Cost of prefabricated posts 8381 Inlay - resin - one surface Inlay/onlay - resin - two surfaces Inlay/onlay - resin - three surfaces Inlay/onlay - resin - four or more surfaces Cast core with single post Cast post (each additional) Cast core with pins (any number of pins) Core build-up with or without pins Crown - full cast metal Crown - 3/4 cast metal Crown - 3/4 porcelain/ceramic Crown - resin laboratory Crown - resin with metal Crown - porcelain/ceramic Provisional crown Crown - porcelain with metal Repair crown (permanent or provisional)

4 Code Description 8414 Additional fee for provision of crown within an existing clasp or rest Pontic - porcelain/ceramic Pontic - cast metal Pontic - resin with metal Pontic - porcelain fused to metal Provisional pontic Inlay/onlay retainer - metal - two surfaces Inlay/onlay retainer - metal - three surfaces surfaces surfaces surfaces surfaces Crown retainer - full cast metal Crown retainer - 3/4 cast metal Crown retainer - porcelain/ceramic Crown retainer - 3/4 porcelain/ceramic Crown retainer - porcelain with metal Crown retainer - resin with metal Provisional crown retainer General anaesthetic 8501 Consultation - Prosthodontis Occlusion analysis mounted Pantographic recording Detailed consultation - Prosthodontist Prosthodontist Electrognathographic recording computer analysis Recement bridge Remove bridge stabilisation) Repair bridge overdenture overdenture porcelain/ceramic porcelain with metal metal Crown retainer - implant/abutment supported - porcelain/ceramic Crown retainer - implant/abutment supported - porcelain with metal cast metal Occlusal adjustment - major Veneer - porcelain (laboratory) Occlusal adjustment - minor Veneer - resin (laboratory) Cost of ceramic block 8561 Gold foil class I or IV Gold foil class V Gold foil class III restoration Prefabricated abutment Custom abutment Cast core with single post Cast core with double post Cast core with triple post Connector bar - implant supported Connector bar Stress breaker Coping metal implant Crown - implant/abutment supported Repair of implant supported prosthesis Repair of implant abutment

5 Code Description 8597 Locks and milled rests Precision attachment (removable denture) Cost of implant components 8611 Pontic - sanitary Pontic - posterior Pontic - anterior/premolar Retainer cast metal (Maryland type retainer) Root canal therapy - first canal Root canal therapy - each additional canal Apexification/recalcification per visit from root canal Complete dentures - maxillary and mandibular (with complications) Complete dentures - maxillary and mandibular (with major complications) Complete denture - maxillary or mandibular (with complications) Complete denture - maxillary or mandibular (with major complications) Overdenture - complete Overdenture - partial complete overdenture overdenture Replacement of precision attachment Interim complete denture Interim partial denture Additional fee to implant supported fixeddetachable denture - per implant conditioning) (remounting) Metal base to complete denture Remount crown or bridge for prosthetics Soft base to denture (heat cured) Partial denture - cast metal framework with resin denture base denture) Additive partial denture Consultation - periodontist Consultation - Periodontist (detailed) Re-examination - Periodontist Periodontal screening - Periodontist per sextant Provisional splinting - extracoronal (wire plus resin) - per sextant Provisional splinting - intracoronal - per tooth Incision & drainage of abscess - intra-oral quadrant quadrant teeth per quadrant Gingivectomy or gingivoplasty - one to three teeth per quadrant Flap procedure, root planing and one to three surgical services - per quadrant Flap procedure, root planing and one to three surgical services - per sextant Flap procedure, root planing and four or more surgical services - per quadrant Flap procedure, root planing and four or more surgical services - per sextant procedure) Pedicle flapped graft (isolated procedure) Masticatory mucosal autograft - one to four teeth (isolated procedure)

6 Code Description Masticatory mucosal autograft - four or more 8762 teeth (isolated procedure) Wedge resection (isolated procedure) Hemisection of a tooth, resection of a root or 8765 tunnel preparation (isolated procedure) Bone regeneration/repair procedure - as part of a flap operation single site Unlisted periodontal procedure regeneration) Cost of bone regenerative/repair material 8772 (isolated procedure) Cost of intrapocket chemotherapeutic agent 8781 Consultation - Oral medicine (simple) Consultation - Oral medicine (complex) Consultation - Oral medicine (subsequent) Unlisted oral medicine procedure Consultation - Orthodontist Consultation - Orthodontis (subsequent, retention and post treatment) Tracing and analysis of extra-oral film Orthodontist Diagnostic setup (orthodontics) ALL Ortho Tx - fixed lingual appliance - one arch modeate severe Repair orthodontic appliance - removable Replace orthodontic appliance - removable Repair orthodontic appliance - fixed Retainer (orthodontic) Treatment of MPDS - first visit Treatment of MPDS - subsequent visit Occlusal orthotic appliance hospital) Consultation - cleft palate (subsequent) Consultation - cleft palate (maximum) Ortho Tx - functional appliance Ortho Tx - partial fixed appliance - minor Ortho Tx - removable appliance appliance Ortho Tx - partial fixed appliance - one arch arches Ortho Tx - fixed appliance - one arch modeate Ortho Tx - fixed appliance - one arch, severe Class 1 mild arches, Class 1 mild Class 1 moderate arches, Class 1 moderate Class 1 severe arches, Class 1 severe Ortho Tx - fixed appliance - both arches, Class 1 severe w/ complications arches, Class 1 severe w/ complications Class 2/3 mild arches, Class 2/3 mild Class 2/3 moderate arches, Class 2/3 moderate Class 2/3 severe

7 Code Description 8886 arches, Class 2/3 severe Ortho Tx - fixed appliance - both arches, Class 2/3 severe w/ complications arches, Class 2/3 severe w/ complications Monthly instalment ortho tx 8891 Orthodontic transfer 8892 Orthodontic re-treatment 8901 Consultation - MFOS Consultation - MFOS (detailed) MFOS (subsequent) - MFOS After regularly hours consultation - MFOS House/Hosp/Nursing home consultation (maximum per week) - MFOS antrum Oral antral fistula closure Caldwell-Luc procedure Biopsy of oral tissue - soft Biopsy of bone - needle Biopsy extra-oral bone/soft tissue Treatment of post-extraction haemorrhage dyscracias) Treatment of septic socket Surgical removal of tooth tooth tooth Surgical removal of impacted tooth - third and subsequent teeth per tooth extractions) Emergency tracheotomy Pharyngostomy Tooth transplantation Harvest iliac crest graft Harvest rib graft Harvest cranium graft Peripheral neurectomy Repair of oronasal fistula (local flaps) approach approach Excision of tumour of the soft tissue Surgical excision of tumours of the jaw Hemiresection of jaw excluding condyl major Harvesting of autogenous grafts (intra-oral) Surgical exposure of impacted or unerupted teeth to aid eruption Corticotomy - first tooth Corticotomy - each additional tooth Frenulectomy/frenulotomy Reduction of mylohyoid ridges - per side Removal torus mandibularis Removal of torus palatinus per side Gingivectomy - per jaw Sulcoplasty / Vestibuloplasty side Lateralization of inferior dental nerve graft) alloplastic material) tooth sites

8 Code Description Alveolar ridge augmentation - three across or more tooth sites Sinus lift procedure (pyogenic) (pyogenic) filling) retrograde filling) sequestrectomy or ramus Suture - reconstruction, minor (excludes closure of surgical incisions) Suture - reconstruction, major (excludes closure of surgical incisions) Dento-alveolar fracture - per sextant Mandible fracture - closed reduction wiring Mandible fracture - splints Mandible fracture - open reduction Reduction of masseter muscle and bone - extra-oral approach 9033 intra-oral approach 9035 Maxilla fracture - Le Fort I or Guerin face disjunction Zygomatic arch fracture - closed reduction Zygomatic arch fracture - open reduction Zygomatic arch fracture - open reduction (requiring osteosynthesis and/or grafting) Placement of Zygomaticus fixture, per fixture Osteotomy - open with stabilisation per site segmental Osteotomy - total subapical Genioplasty Midfacial exposure Coronoidectomy (intra-oral approach) Osteotomy - segmented, posterior Osteotomy - segmented, anterior one piece Reconstruct maxilla - Le Fort I osteotomy w/ repositioning and graft Palatal osteotomy multiple segments Reconstruct maxilla - Le Fort 2 osteotomy (facial and post-traumatic deformities) Reconstruct maxilla - Le Fort 3 osteotomy (severe congenital deformities) mandibular Glossectomy - partial Geniohyoidotomy Close secondary oro-nasal fistula w/ bone grafting (complete procedure) Tmj arthroscopy diagnostic Condylectomy, coronoidectomy or both TMJ artrocentesis TMJ intra-articular injection Trigger point injection Condylectomy (Ward/Kostecka) TMJ srthroplasty Reduction of TMJ disloc w/o anaesthetic Reduction of TMJ disloc w/ anaesthetic immobobilisation reduction Joint reconstruction

9 Code Description 9093 Removal of salivary stone (Sialolithotomy) Excision of sublinglual salivary gland approach report) 9101 denture base Obturator prosthesis, surgical - split base denture denture box glove flange flange augmentation Glossal resection prosthesis - simple Glossal resection prosthesis - complex Radiation carrier - simple Radiation carrier - complex Radiation shield - simple Radiation shield - complex Radiation cone locator Chemotherapeutic agent carrier Feeding aid prosthesis, neonatal minor moderate severe modification alteration alteration pharyngeal alteration modification Speech aid/obturator prosthesis - surgical Speech aid appliance - palatal lift Speech aid appliance - palatal stimulating Speech aid appliance - bulb Speech aid appliance - modification Unspecified speech aid appliance 9135 Auricular prosthesis - simple Auricular prosthesis - complex Nasal prosthesis - simple Nasal prosthesis - complex Ocular prosthesis - interim Ocular prosthesis - modified stock appliance Ocular prosthesis - custom appliance Orbital prosthesis - simple Orbital prosthesis - complex Facial prosthesis, combination - small 9145 Facial prosthesis, combination - medium 9146 Facial prosthesis, combination - large 9147 Facial prosthesis, combination - complex 9148 Unspecified body prosthesis - simple Unspecified body prosthesis - complex Facial prosthesis, surgical - simple Facial prosthesis, surgical - complex Extraoral appliance - additional prosthesis 9153 Extraoral appliance - replacement prosthesis 9155 Cranial prosthesis Cranial implant prosthesis, custom made simple complex Ocular implant prosthesis, custom made Body implant prosthesis - custom made Surgical splint - simple Surgical splint - complex

10 Code Description 9163 Surgical template - simple Surgical template - complex Surgical conformer - simple Surgical conformer - complex Trismus appliance (simple) Trismus appliance (complex) Orthoses appliance Facial palsy appliance Commissure splint Oral retractor, dynamic - per arm Hand splint 9174 Unspecified burn appliance 9175 /hour Surgical placement of sub-periosteal implant - preparatory stage Surgical placement of sub-periosteal implant - placement stage plate first per jaw second per jaw Surgical placement of endosteal implant - third and subsequent per jaw Cost of endosteal implant body 9188 Cost of prefabricated abutment 9189 Cost of other implant compnts 9190 jaw per jaw Surgical placement of abutment - third and subsequent per jaw Surgical removal of implant Consultation - oral pathologist Oral pathologist Consultation - oral pathologist (subsequent) After hours visit - Oral pathologist Repair cleft hard palate - unilateral procedure) procedures) reconstruction reconstruction Repair submucosal cleft and/or bifid uvula - w/ muscle reconstruction uncomplicated Velopharyngeal reconstruction - complicated Repair oronasal fistula (one procedure) Repair oronasal fistula (two procedures) Secondary periosteal flaps Lipadhesion reconstruction reconstruction reconstruction reconstruction Repair anterior nasal floor partial Revision of secondary cleft lip deformity - total w/ muscle reconstruction Abbe-flap - two stages Reconstruct columella partial complete deviation supraorbital rim 9276 obturation and/or cranialisation of frontal sinus 9278 (canthopexy), per side

11 Code Description 9280 fractures 9282 fracture 9284 Musculofascial flap 9286 Musculocranial flap 9288 Buccal fat pad (major repair) 9290 Maxillectomy - Alveolus only, Level I 9292 floor, Level II Maxillectomy - Alveolus, sinus, nasal floor 9294 and zygoma excluding orbital rim Level III Maxillectomy - Alveolus, sinus, nasal floor 9296 and zygoma including orbital rim Level IV zygoma, orbital rim and pterygoid plates 9298 Level V 9300 coronoid process

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