General 2 months - reduced benefit for each subsequent radiogaph in a visit n/a 025 Intraoral radiograph - occlusal, maxillary, mandibular - per

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Kelley Douglas
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1 Premier Extras dental schedule As at 1 April Comprehensive oral examination $ per financial year Preventive 2 months 012 Periodic oral examination $ per financial year Preventive 2 months 013 Oral examination - limited $ per financial year Preventive 2 months 014 Consultation $ per financial year Preventive 2 months 015 Consultation - extended (30 minutes or more) $64.00 Preventive 2 months 016 Consultation by referral $66.80 General 2 months 017 Consultation by referral - extended (30 minutes or more) $72.00 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 $30.00 General 2 months - reduced benefit for each subsequent radiogaph in a visit n/a 025 Intraoral radiograph - occlusal, maxillary, mandibular - per $ per financial year General 2 months exposure 026 Cone Beam Volumetric Tomography Scan Acquisition per $ per appointment, 2 per financial year General 2 months appointment 031 Extraoral radiograph - maxillary, mandibular - per exposure $ per financial year General 2 months 033 Lateral, antero-posterior or postero-anterior or submento-vertex $ per financial year General 2 months radiograph of the skull - per exposure 035 Radiograph of temporomandibular joint - per exposure $ per financial year General 2 months 036 Cephalometric radiograph - lateral, antero-posterior, posteroanterior $ per financial year General 2 months or submento-vertex - per exposure 037 Panoramic radiograph - per exposure $ per financial year General 2 months 038 Hand-wrist radiograph for skeletal age assessment $ per appointment General 2 months 039 Tomograghy of the skull or parts thereof $ per appointment 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 $0.00 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 $97.60 General 2 months 052 Histopathological examination of tissue $0.00 General 2 months 053 Cytological examination $0.00 General 2 months 054 Mucosal screening $ per financial year General 2 months 055 Blood sample $0.00 General 2 months 056 Haematological examination $0.00 General 2 months 059 Comprehensive head and neck cancer examination and risk $0.00 General 2 months assessment 061 Pulp testing - per visit $0.00 General 2 months 071 Diagnostic model - per model $ per financial year General 2 months 072 Photographic records - intraoral $ per financial year General 2 months 073 Photographic records - extraoral $ per financial year General 2 months 074 Diagnostic wax-up $ per financial year General 2 months 075 Diagnostic modelling $ per financial year General 2 months 081 Cephalometric analysis - excluding radiographs $ per financial year General 2 months 082 Tooth-jaw size prediction analysis $ per financial year General 2 months 083 Tomographic analysis $ per appointment General 2 months 085 Electromyographic recording $0.00 General 2 months 086 Electromyographic analysis $ per financial year General 2 months 087 Cone Beam Volumetric Tomography analysis and/or interpretation small field of view (less than one complete dental arch) $ per appointment General 2 months 088 Cone Beam Volumetric Tomography analysis and/or interpretation maxillary or mandibular dentition (single arch) 089 Cone Beam Volumetric Tomography analysis and/or interpretation maxillary and mandibular dentition (both arches) $ per appointment General 2 months $ per appointment General 2 months 090 Cone Beam Volumetric Tomography analysis and/or interpretation $ per appointment General 2 months temporomandibular joints only 091 Cone Beam Volumetric Tomography analysis and/or interpretation $ per appointment General 2 months orofacial structures 111 Removal of plaque and/or stain $ per appointment, 2 per financial year Preventive 2 months 113 Recontouring of pre-existing restoration(s) $18.00 Preventive 2 months 114 Removal of calculus - first visit $ per financial year Preventive 2 months 115 Removal of calculus - subsequent visit $ per financial year Preventive 2 months 116 Enamel micro-abrasion - per tooth $32.60 Preventive 2 months 117 Bleaching, internal - per tooth $ per tooth, 2 per financial year General 2 months 118 Bleaching, external - per tooth $ per financial year General 2 months 119 Bleaching, home application -per arch $ per financial year General 2 months

2 121 Topical application of remineralising and/or cariostatic agents, one $ per appointment, 2 per financial year Preventive 2 months treatment 122 Topical remineralising and/or cariostatic agent, home application - $ per financial year General 2 months per arch 123 Concentrated remineralising and/or cariostatic agent, application - $22.00 Preventive 2 months single tooth 131 Dietary advice $0.00 General 2 months 141 Oral hygiene instruction $0.00 General 2 months 142 Tobacco counselling $0.00 General 2 months 151 Provision of a mouthguard - indirect $ General 2 months 153 Bimaxillary mouthguard - indirect $ General 2 months 161 Fissure sealing - per tooth $33.00 Preventive 2 months 165 Desensitising procedure-per visit $20.80 General 2 months 171 Odontoplasty - per tooth $0.00 General 2 months 213 Treatment of acute ontal infection - per visit $ per appointment General 2 months 221 Clinical ontal analysis and recording $ per financial year General 2 months 222 Periodontal Debridement - per tooth $ Non-surgical treatment of peri-implant disease per implant $ Gingivectomy - per tooth $ Periodontal flap surgery - per tooth $ Surgical treatment of peri-implant disease - per implant $ Application of biologically active material $ 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 $ Maxillary sinus augmentation - Trans-alveolar technique per $ sinus 247 Maxillary sinus augmentation - Lateral wall approach per sinus $ Active non-surgical ontal therapy - per quadrant $ per appointment, 4 per financial year 251 Supportive ontal therapy - per appointment $ per appointment 311 Removal of a tooth or part(s) thereof $ 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 appointment 363 Mandible - relocation requiring open operation $ Osteotomy - maxilla $1, per appointment 366 Osteotomy - mandible $1, per appointment 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 $146.20

3 379 Marsupialisation of cyst $ Surgical exposure of unerupted tooth $ per tooth, per appointment 382 Surgical exposure and attachment of device for orthodontic $ per tooth, per appointment traction 384 Repositioning of displaced tooth/teeth - per tooth $ per tooth, per appointment 385 Surgical repositioning of unerupted tooth $ per tooth, per appointment 386 Splinting of displaced tooth/teeth - per tooth $ per tooth, per appointment 387 Replantation and splinting of a tooth $ per tooth, per appointment 388 Transplantation of tooth or tooth bud $ per tooth, per appointment 389 Surgery to isolate and preserve neurovascular tissue $ Frenectomy $ Drainage of abscess $ Surgery involving the maxillary antrum $ Surgery for osteomyelitis $ per appointment 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 appointment 415 Complete chemo-mechanical preparation of root canal - one canal $ per tooth, per appointment 416 Complete chemo-mechanical preparation of root canal - each $54.40 additional canal 417 Root canal obturation - one canal $ per tooth, per appointment 418 Root canal obturation - each additional canal $ Extirpation of pulp or debridement of root canal(s) - emergency or $ per tooth, per appointment palliative 421 Resorbable root canal filling - primary tooth $ per tooth, per appointment 431 Periapical curettage - per root $ reduced benefit for each subsequent root in same tooth $ Apicectomy - per root $ Major 12 months - reduced benefit for each subsequent root in same tooth $ Exploratory periradicular surgery $ Apical seal - per canal $ reduced benefit for each subsequent canal in same tooth $ Sealing of perforation $ Surgical treatment and repair of external root resorption - per $ per tooth, per appointment tooth 438 Hemisection $ per tooth, per appointment 445 Exploration and/or negotiation of calcified canal - per canal, per $56.40 visit - reduced benefit for each subsequent canal in same tooth $ Removal of root filling - per canal $ reduced benefit for each subsequent canal in same tooth $ 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 appointment system - per tooth 457 Obturation of resorption defect or perforation (non-surgical) $ per tooth, per appointment 458 Interim therapeutic root filling - per tooth $ per tooth, per appointment 511 Metallic restoration - one surface - direct $ per tooth, per appointment General 2 months 512 Metallic restoration - two surfaces - direct $ per tooth, per appointment General 2 months 513 Metallic restoration - three surfaces - direct $ per tooth, per appointment General 2 months 514 Metallic restoration - four surfaces - direct $ per tooth, per appointment General 2 months 515 Metallic restoration - five surfaces - direct $ per tooth, per appointment General 2 months 521 Adhesive restoration - one surface - anterior tooth - direct $ per tooth, per appointment General 2 months 522 Adhesive restoration - two surfaces - anterior tooth - direct $ per tooth, per appointment General 2 months 523 Adhesive restoration - three surfaces - anterior tooth - direct $ per tooth, per appointment General 2 months 524 Adhesive restoration - four surfaces - anterior tooth - direct $ per tooth, per appointment General 2 months 525 Adhesive restoration - five surfaces - anterior tooth - direct $ per tooth, per appointment General 2 months 526 Adhesive restoration Veneer direct $ per tooth, per financial year General 2 months 531 Adhesive restoration - one surface - posterior tooth - direct $ per tooth, per appointment General 2 months 532 Adhesive restoration - two surfaces - posterior tooth - direct $ per tooth, per appointment General 2 months 533 Adhesive restoration - three surfaces - posterior tooth - direct $ per tooth, per appointment General 2 months 534 Adhesive restoration - four surfaces - posterior tooth - direct $ per tooth, per appointment General 2 months 535 Adhesive restoration - five surfaces - posterior tooth - direct $ per tooth, per appointment General 2 months 536 Adhesive restoration Veneer posterior tooth direct $ per tooth, per financial year General 2 months 541 Metallic restoration - one surface - indirect $ per tooth, per financial year 542 Metallic restoration - two surfaces - indirect $ per tooth, per financial year 543 Metallic restoration - three surfaces - indirect $ per tooth, per financial year

4 544 Metallic restoration - four surfaces - indirect $ per tooth, per financial year 545 Metallic restoration - five surfaces - indirect $ per tooth, per financial year 551 Tooth-coloured restoration - one surface - indirect $ per tooth, per financial year 552 Tooth-coloured restoration - two surfaces - indirect $ per tooth, per financial year 553 Tooth-coloured restoration - three surfaces - indirect $ per tooth, per financial year 554 Tooth-coloured restoration - four surfaces - indirect $ per tooth, per financial year 555 Tooth-coloured restoration - five surfaces - indirect $ per tooth, per financial year 556 Tooth coloured restoration Veneer indirect $ per tooth, per financial year 571 Adaptation of new restoration to existing removable prosthesis $ per tooth, per appointment General 2 months per tooth 572 Provisional (intermediate/temporary) restoration $ per tooth, per appointment General 2 months 574 Metal band $ per tooth, per financial year General 2 months 575 Pin retention - per pin $19.60 General 2 months 577 Cusp capping - per cusp $23.80 General 2 months 578 Restoration of an incisal corner - per corner $23.80 General 2 months 579 Bonding of tooth fragment $97.60 General 2 months 586 Crown Metallic with tooth preparation preformed $ per tooth, per visit General 2 months 587 Crown Metallic minimal tooth preparation preformed $ per tooth, per visit General 2 months 588 Crown Non-metallic - preformed $ per tooth, per visit General 2 months 595 Removal of inlay/onlay $68.00 General 2 months 596 Recementing of inlay/onlay $72.00 General 2 months 597 Post - direct $99.60 General 2 months 611 Full crown - acrylic resin - indirect $ per tooth, per financial year 613 Full crown - non-metallic - indirect $1, per tooth, per financial year 615 Full crown - veneered - indirect $1, per tooth, per financial year 618 Full crown - metallic - indirect $1, per tooth, per financial year 625 Post and core for crown - indirect $ per tooth, per financial year 627 Preliminary restoration for crown - direct $ per tooth, per financial year 629 Post and root cap - indirect $ per tooth, per financial year 631 Provisional crown $ per tooth, per appointment 632 Provisional bridge - per pontic $ Provisional implant abutment - per abutment $ Provisional implant restoration - per implant abutment $ per tooth, per appointment 642 Bridge pontic - direct - per pontic $ per tooth, per financial year 643 Bridge pontic - indirect - per pontic $ per tooth, per financial year 644 Semi-fixed attachment $ Precision or magnetic attachment $ Retainer for bonded fixture - indirect - per tooth $ Recementing crown or veneer $77.20 General 2 months 652 Recementing bridge or splint - per abutment $77.20 General 2 months 653 Rebonding of bridge or splint where retreatment of bridge surface $87.40 General 2 months is required 655 Removal of crown $56.60 General 2 months 656 Removal of bridge or splint $72.00 General 2 months 658 Repair of crown, bridge or splint - indirect $ General 2 months 659 Repair of crown, bridge or splint - direct $97.60 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 $1, arch 666 Prosthesis with metal frame attached to implants - per tooth $1, Prosthesis with metal frame attached to implants - removable per $1, arch 668 Fixture or abutment screw removal and replacement $ Removal and reattachment of prosthesis fixed to implant(s) - per $ implant - reduced benefit for each subsequent implant $ Full crown attached to osseointegrated implant - non-metallic - $1, indirect 672 Full crown attached to osseointegrated implant - veneered - $1, indirect 673 Full crown attached to osseointegrated implant - metallic - indirect $1, Diagnostic template $ Surgical implant guide $ Insertion of first stage of two stage endosseous implant - per $1, implant 688 Insertion of one stage endosseous implant - per implant $1, Provisional implant $ Provisional retention device $ Second stage surgery of two stage endosseous implant - per implant $345.60

5 711 Complete maxillary denture $ Complete mandibular denture $ every financial year 713 Provisional complete maxillary denture $ every financial year 714 Provisional complete mandibular denture $ every financial year 715 Provisional complete maxillary and mandibular dentures $ every financial year 716 Metal palate or plate $ per appointment 719 Complete maxillary and mandibular dentures $1, every 3 financial years 721 Partial maxillary denture - resin base $ every financial year 722 Partial mandibular denture - resin base $ every financial year 723 Provisional partial maxillary denture $ every financial year 724 Provisional partial mandibular denture $ every financial year 727 Partial maxillary denture - cast metal framework $ every financial year 728 Partial mandibular denture - cast metal framework $ every financial year 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 financial year 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 $95.20 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 financial year General 2 months 777 Identification $ Inlay for denture tooth $ Surgical guide for an immediate denture $ Passive removable appliance - per arch $ per financial year Orthodontics 12 months 821 Active removable appliance - per arch $ per financial year Orthodontics 12 months 823 Functional orthopaedic appliance $ per financial year Orthodontics 12 months 824 Functional orthopaedic appliance prefabricated $ per financial year 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 833 Removal of banding per arch $ per financial year Orthodontics 12 months 841 Fixed palatal or lingual arch appliance $ per financial year Orthodontics 12 months 842 Partial banding for inter-maxillary elastics (cross elastics) $ per financial year Orthodontics 12 months 843 Maxillary expansion appliance $ per financial year Orthodontics 12 months 845 Passive fixed appliance $ per financial year Orthodontics 12 months 846 Minor tooth guidance - fixed $ Orthodontics 12 months 851 Extraoral appliance $ per appointment Orthodontics 12 months 862 Bonding of attachment for application of orthodontic force $ Orthodontics 12 months 871 Orthodontic adjustment $ per appointment Orthodontics 12 months 872 Re-attachment of passive appliance fixed $ per appointment Orthodontics 12 months 873 Repair of passive appliance fixed $ per appointment Orthodontics 12 months 874 Removal of passive appliance fixed $ per appointment Orthodontics 12 months 875 Repair of removable appliance, resin base $ per financial year Orthodontics 12 months 876 Repair of removable appliance - clasp, spring or tooth $56.40 Orthodontics 12 months 877 Addition to removable appliance - clasp, spring or tooth $56.40 Orthodontics 12 months

6 878 Relining -removable appliance - processed $ per financial year Orthodontics 12 months 881 Complete course of orthodontic treatment $1, Orthodontics 12 months 911 Palliative care $ per appointment General 2 months 915 After hours callout $ per appointment General 2 months 916 Travel to provide services $ per appointment General 2 months 926 Individually made tray - medicament(s) $0.00 General 2 months 927 Provision of medication/medicament $0.00 General 2 months 928 Intravenous cannulation and establishment of infusion $ per appointment General 2 months 941 Local anaesthesia $0.00 General 2 months 942 Sedation - intravenous - per 30 minutes or part thereof $ per appointment General 2 months 943 Sedation - inhalation - per 30 minutes or part thereof $ per appointment General 2 months 944 Relaxation therapy $0.00 General 2 months 945 Low level laser therapy per appointment $0.00 General 2 months 948 Dental acupuncture per appointment $0.00 General 2 months 949 Treatment under general anaesthesia/sedation $ per appointment General 2 months 961 Minor occlusal adjustment - per visit $ per appointment General 2 months 963 Clinical occlusal analysis including muscle and joint palpation $ per financial year General 2 months 964 Registration and mounting of models for occlusal analysis $0.00 General 2 months 965 Occlusal splint $ per financial year 966 Adjustment of pre-existing occlusal splint - per visit $ per financial year General 2 months 967 Pantographic tracing $ per financial year General 2 months 968 Occlusal adjustment following occlusal analysis - per visit $ per appointment General 2 months 971 Adjunctive physical therapy for temporomandibular joint and $0.00 General 2 months associated structures 972 Repair/addition - occlusal splint $ per financial year General 2 months 981 Splinting and stabilisation - direct - per tooth $66.80 General 2 months 982 Enamel stripping - per visit $ per appointment General 2 months 983 Single arch oral appliance for diagnosed snoring and obstructive $ every 3 financial years snoring and sleep apnoea 984 Bi-maxillary oral appliance for diagnosed snoring and obstructive $ every 3 financial years snoring and sleep apnoea 985 Repair/addition snoring or sleep apnoea device $ every financial year General 2 months 986 Post-operative care not otherwise included $0.00 General 2 months 987 Re-contour tissue per appointment $ per appointment General 2 months 990 Treatment not otherwise included (specify) $0.00 General 2 months Financial year maximum Preventive General Dental Major Dental No annual limit No annual limit $1100 per person Orthodontic limit $1000 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.

Top Extras dental schedule As at 1 April 2018

Top Extras dental schedule As at 1 April 2018 Item Description Benefit Service limit Category Waiting 011 Comprehensive oral examination $39.60 1 per Preventive 012 Periodic oral examination $36.40 2 per