TREATMENT PRICE NEW VAT EFFECTIVE START DATE DISCIPLINE DESCRIPTION CATEGORY TREATMENT CODE TREATMENT DESCRIPTION

Transcription

1 General Dental Practice DENTAL 9272 Paranasal augmentation for nasal base deviation 1300,73 04/01/ :00:00 General Dental Practice DENTAL 9270 Reconstruct nose due to cleft deformity - complete 2612,39 04/01/ :00:00 General Dental Practice DENTAL 9268 Reconstruct nose due to cleft deformity - partial 1652,87 04/01/ :00:00 General Dental Practice DENTAL 9266 Reconstruct columella 1300,73 04/01/ :00:00 General Dental Practice DENTAL 9264 Abbe-flap - two stages 2200,56 04/01/ :00:00 General Dental Practice DENTAL 9262 Revision of secondary cleft lip deformity - total w/ muscle reconstruction 1943,30 04/01/ :00:00 General Dental Practice DENTAL 9260 Revision of secondary cleft lip deformity - partial 860,10 04/01/ :00:00 General Dental Practice DENTAL 9258 Repair anterior nasal floor 860,10 04/01/ :00:00 General Dental Practice DENTAL 9256 Repair cleft lip - bilateral w/ muscle reconstruction 3406,37 04/01/ :00:00 General Dental Practice DENTAL 9254 Repair cleft lip - bilateral w/o muscle reconstruction 2204,94 04/01/ :00:00 General Dental Practice DENTAL 9252 Repair cleft lip - unilateral w/ muscle reconstruction 2140,73 04/01/ :00:00 General Dental Practice DENTAL 9250 Repair cleft lip - unilateral w/o muscle reconstruction 1578,92 04/01/ :00:00 General Dental Practice DENTAL 9248 Lipadhesion 896,36 04/01/ :00:00 General Dental Practice DENTAL 9246 Secondary periosteal flaps 2398,01 04/01/ :00:00

2 General Dental Practice DENTAL 9240 Repair oronasal fistula (two procedures) 4798,47 04/01/ :00:00 General Dental Practice DENTAL 9238 Repair oronasal fistula (one procedure) 2750,53 04/01/ :00:00 General Dental Practice DENTAL 9234 Velopharyngeal reconstruction - complicated 4808,59 04/01/ :00:00 General Dental Practice DENTAL 9232 Velopharyngeal reconstruction - uncomplicated 4497,07 04/01/ :00:00 General Dental Practice DENTAL 9230 Repair submucosal cleft and/or bifid uvula - w/ muscle reconstruction 4370,09 04/01/ :00:00 General Dental Practice DENTAL 9228 Repair cleft soft palate - w/ muscle reconstruction 5869,45 04/01/ :00:00 General Dental Practice DENTAL 9226 Repair cleft soft palate - w/o muscle reconstruction 4042,15 04/01/ :00:00 General Dental Practice DENTAL 9224 Repair cleft hard palate - bilateral (two procedures) 9124,59 04/01/ :00:00 General Dental Practice DENTAL 9222 Repair cleft hard palate - bilateral (one procedure) 6123,42 04/01/ :00:00 General Dental Practice DENTAL 9220 Repair cleft hard palate - unilateral 4823,95 04/01/ :00:00 General Dental Practice DENTAL 9198 Surgical removal of implant 581,89 04/01/ :00:00 General Dental Practice DENTAL 9192 Surgical placement of abutment - third and subsequent per jaw 235,14 04/01/ :00:00 General Dental Practice DENTAL 9191 Surgical placement of abutment - second per jaw 350,96 04/01/ :00:00 General Dental Practice DENTAL 9190 Surgical placement of abutment - first per jaw 466,96 04/01/ :00:00 General Dental Practice DENTAL 9185 General Dental Practice DENTAL 9184 General Dental Practice DENTAL 9183 General Dental Practice DENTAL 9182 Surgical placement of endosteal implant - third and subsequent per jaw 630,90 04/01/ :00:00 Surgical placement of endosteal implant - second per jaw 942,41 04/01/ :00:00 Surgical placement of endosteal implant - first per jaw 1258,67 04/01/ :00:00 Surgical placement of endosteal implant plate 894,30 04/01/ :00:00

3 General Dental Practice DENTAL 9181 Surgical placement of sub-periosteal implant - placement stage 1786,49 04/01/ :00:00 General Dental Practice DENTAL 9180 Surgical placement of sub-periosteal implant - preparatory stage 1786,49 04/01/ :00:00 General Dental Practice DENTAL 9175 Theatre attendance (MaxFac prosthod) /hour 407,28 04/01/ :00:00 General Dental Practice DENTAL 9172 Oral retractor, dynamic - per arm 301,25 04/01/ :00:00 General Dental Practice DENTAL 9171 Commissure splint 301,25 04/01/ :00:00 General Dental Practice DENTAL 9170 Facial palsy appliance 731,93 04/01/ :00:00 General Dental Practice DENTAL 9169 Orthoses appliance 2433,43 04/01/ :00:00 General Dental Practice DENTAL 9168 Trismus appliance (complex) 1104,13 04/01/ :00:00 General Dental Practice DENTAL 9167 Trismus appliance (simple) 123,68 04/01/ :00:00 General Dental Practice DENTAL 9166 Surgical conformer - complex 1104,13 04/01/ :00:00 General Dental Practice DENTAL 9165 Surgical conformer - simple 301,25 04/01/ :00:00 General Dental Practice DENTAL 9164 Surgical template - complex 1104,13 04/01/ :00:00 General Dental Practice DENTAL 9163 Surgical template - simple 301,25 04/01/ :00:00 General Dental Practice DENTAL 9162 Surgical splint - complex 1104,13 04/01/ :00:00 General Dental Practice DENTAL 9161 Surgical splint - simple 301,25 04/01/ :00:00 General Dental Practice DENTAL 9160 Body implant prosthesis - custom made 2963,50 04/01/ :00:00 General Dental Practice DENTAL 9159 Ocular implant prosthesis, custom made 665,80 04/01/ :00:00 General Dental Practice DENTAL 9158 Facial implant prosthesis, custom made - complex 1332,80 04/01/ :00:00 General Dental Practice DENTAL 9157 Facial implant prosthesis, custom made - simple 665,80 04/01/ :00:00 General Dental Practice DENTAL 9156 Cranial implant prosthesis, custom made 1332,80 04/01/ :00:00 General Dental Practice DENTAL 9155 Cranial prosthesis 1104,13 04/01/ :00:00 General Dental Practice DENTAL 9151 Facial prosthesis, surgical - complex 2739,20 04/01/ :00:00 General Dental Practice DENTAL 9150 Facial prosthesis, surgical - simple 2131,99 04/01/ :00:00 General Dental Practice DENTAL 9149 Unspecified body prosthesis - complex 3976,05 04/01/ :00:00 General Dental Practice DENTAL 9148 Unspecified body prosthesis - simple 2739,20 04/01/ :00:00 General Dental Practice DENTAL 9143 Orbital prosthesis - complex 3976,05 04/01/ :00:00

4 General Dental Practice DENTAL 9142 Orbital prosthesis - simple 2739,20 04/01/ :00:00 General Dental Practice DENTAL 9141 Ocular prosthesis - custom appliance 3976,05 04/01/ :00:00 General Dental Practice DENTAL 9140 Ocular prosthesis - modified stock appliance 2739,20 04/01/ :00:00 General Dental Practice DENTAL 9139 Ocular prosthesis - interim 1104,13 04/01/ :00:00 General Dental Practice DENTAL 9138 Nasal prosthesis - complex 3976,05 04/01/ :00:00 General Dental Practice DENTAL 9137 Nasal prosthesis - simple 3047,41 04/01/ :00:00 General Dental Practice DENTAL 9136 Auricular prosthesis - complex 3976,05 04/01/ :00:00 General Dental Practice DENTAL 9135 Auricular prosthesis - simple 3047,41 04/01/ :00:00 General Dental Practice DENTAL 9133 Speech aid appliance - modification 123,68 04/01/ :00:00 General Dental Practice DENTAL 9132 Speech aid appliance - bulb 2433,43 04/01/ :00:00 General Dental Practice DENTAL 9131 Speech aid appliance - palatal stimulating 1104,13 04/01/ :00:00 General Dental Practice DENTAL 9130 Speech aid appliance - palatal lift 491,18 04/01/ :00:00 General Dental Practice DENTAL 9129 Speech aid/obturator prosthesis - surgical 977,15 04/01/ :00:00 General Dental Practice DENTAL 9128 Speech aid/obturator prosthesis - modification 123,68 04/01/ :00:00 General Dental Practice DENTAL 9127 Speech aid/obturator prosthesis - pharyngeal alteration 2433,43 04/01/ :00:00 General Dental Practice DENTAL 9126 Speech aid/obturator prosthesis - velar alteration 1104,13 04/01/ :00:00 General Dental Practice DENTAL 9125 Speech aid/obturator prosthesis - palatal alteration 492,42 04/01/ :00:00 General Dental Practice DENTAL 9123 Orthopaedic appliance, active presurgical - modification 123,68 04/01/ :00:00 General Dental Practice DENTAL 9122 Orthopaedic appliance, active presurgical - severe 2433,43 04/01/ :00:00 General Dental Practice DENTAL 9121 Orthopaedic appliance, active presurgical - moderate 1446,35 04/01/ :00:00 General Dental Practice DENTAL 9120 Orthopaedic appliance, active presurgical - minor 977,15 04/01/ :00:00 General Dental Practice DENTAL 9119 Feeding aid prosthesis, neonatal 977,15 04/01/ :00:00 General Dental Practice DENTAL 9118 Chemotherapeutic agent carrier 1104,13 04/01/ :00:00 General Dental Practice DENTAL 9117 Radiation cone locator 1104,13 04/01/ :00:00

5 General Dental Practice DENTAL 9116 Radiation shield - complex 3047,41 04/01/ :00:00 General Dental Practice DENTAL 9115 Radiation shield - simple 1104,13 04/01/ :00:00 General Dental Practice DENTAL 9114 Radiation carrier - complex 3047,41 04/01/ :00:00 General Dental Practice DENTAL 9113 Radiation carrier - simple 1104,13 04/01/ :00:00 General Dental Practice DENTAL 9112 Glossal resection prosthesis - complex 1534,77 04/01/ :00:00 General Dental Practice DENTAL 9111 Glossal resection prosthesis - simple 1024,58 04/01/ :00:00 General Dental Practice DENTAL 9110 Mandibular resection prosthesis, palatal augmentation 491,18 04/01/ :00:00 General Dental Practice DENTAL 9109 Mandibular resection prosthesis w/o guide flange 2433,43 04/01/ :00:00 General Dental Practice DENTAL 9108 Mandibular resection prosthesis w/ guide flange 2619,02 04/01/ :00:00 General Dental Practice DENTAL 9107 Obturator prosthesis, definitive - silicone glove 2131,99 04/01/ :00:00 General Dental Practice DENTAL 9106 Obturator prosthesis, definitive - open/hollow box 1104,13 04/01/ :00:00 General Dental Practice DENTAL 9105 Obturator prosthesis, interim - on new denture 3409,67 04/01/ :00:00 General Dental Practice DENTAL 9104 Obturator prosthesis, interim - on existing denture 1104,13 04/01/ :00:00 General Dental Practice DENTAL 9103 Obturator prosthesis, surgical - split base 731,93 04/01/ :00:00 General Dental Practice DENTAL 9102 Obturator prosthesis, surgical - continuous base 491,18 04/01/ :00:00 General Dental Practice DENTAL 9101 Obturator prosthesis, surgical - modified denture 181,24 04/01/ :00:00 General Dental Practice DENTAL 9096 Excision of salivary gland - extra oral approach 2160,79 04/01/ :00:00 General Dental Practice DENTAL 9095 Excision of sublinglual salivary gland 1458,57 04/01/ :00:00 General Dental Practice DENTAL 9093 Removal of salivary stone (Sialolithotomy) 591,84 04/01/ :00:00 General Dental Practice DENTAL 9092 Joint reconstruction 8745,92 04/01/ :00:00 General Dental Practice DENTAL 9091 Reduction of TMJ dislocation - open reduction 3275,90 04/01/ :00:00

6 General Dental Practice DENTAL 9089 Reduction of TMJ disloc w/ anaesthetic and immobobilisation 1310,64 04/01/ :00:00 General Dental Practice DENTAL 9087 Reduction of TMJ disloc w/ anaesthetic 527,64 04/01/ :00:00 General Dental Practice DENTAL 9085 Reduction of TMJ disloc w/o anaesthetic 260,60 04/01/ :00:00 General Dental Practice DENTAL 9083 TMJ srthroplasty 3275,90 04/01/ :00:00 General Dental Practice DENTAL 9081 Condylectomy (Ward/Kostecka) 1310,64 04/01/ :00:00 General Dental Practice DENTAL 9079 Trigger point injection 153,31 04/01/ :00:00 General Dental Practice DENTAL 9077 TMJ intra-articular injection 196,41 04/01/ :00:00 General Dental Practice DENTAL 9076 TMJ artrocentesis 720,04 04/01/ :00:00 General Dental Practice DENTAL 9075 Condylectomy, coronoidectomy or both 3275,90 04/01/ :00:00 General Dental Practice DENTAL 9074 Tmj arthroscopy diagnostic 1304,01 04/01/ :00:00 General Dental Practice DENTAL 9072 Close secondary oro-nasal fistula w/ bone grafting (complete procedure) 8636,55 04/01/ :00:00 General Dental Practice DENTAL 9071 Geniohyoidotomy 1180,35 04/01/ :00:00 General Dental Practice DENTAL 9069 Glossectomy - partial 1967,34 04/01/ :00:00 General Dental Practice DENTAL 9066 Surgical expansion - maxilliary or mandibular 2626,50 04/01/ :00:00 General Dental Practice DENTAL 9065 Reconstruct maxilla - Le Fort 3 osteotomy (severe congenital deformities) 16530,89 04/01/ :00:00 General Dental Practice DENTAL 9063 Reconstruct maxilla - Le Fort 2 osteotomy (facial and post-traumatic deformities) 11030,20 04/01/ :00:00 General Dental Practice DENTAL 9062 Reconstruct maxilla - Le Fort I osteotomy, multiple segments 11024,77 04/01/ :00:00 General Dental Practice DENTAL 9061 Palatal osteotomy 3020,91 04/01/ :00:00 General Dental Practice DENTAL 9060 Reconstruct maxilla - Le Fort I osteotomy w/ repositioning and graft 9695,31 04/01/ :00:00 General Dental Practice DENTAL 9059 Reconstruct maxilla - Le Fort I osteotomy, one piece 8636,55 04/01/ :00:00 General Dental Practice DENTAL 9057 Osteotomy - segmented, anterior 4590,03 04/01/ :00:00 General Dental Practice DENTAL 9055 Osteotomy - segmented, posterior 4590,03 04/01/ :00:00

7 General Dental Practice DENTAL 9053 Coronoidectomy (intra-oral approach) 1638,56 04/01/ :00:00 General Dental Practice DENTAL 9052 Midfacial exposure 4158,14 04/01/ :00:00 General Dental Practice DENTAL 9051 Genioplasty 2626,50 04/01/ :00:00 General Dental Practice DENTAL 9050 Osteotomy - total subapical 8395,83 04/01/ :00:00 General Dental Practice DENTAL 9049 Osteotomy - mandible body, anterior segmental 4590,03 04/01/ :00:00 General Dental Practice DENTAL 9048 Surgical removal of internal fixation devices, per site 504,62 04/01/ :00:00 General Dental Practice DENTAL 9047 Osteotomy - open with stabilisation 5507,35 04/01/ :00:00 General Dental Practice DENTAL 9046 Placement of Zygomaticus fixture, per fixture 2599,31 04/01/ :00:00 General Dental Practice DENTAL 9045 Zygomatic arch fracture - open reduction (requiring osteosynthesis and/or grafting) 3935,05 04/01/ :00:00 General Dental Practice DENTAL 9043 Zygomatic arch fracture - open reduction 2626,50 04/01/ :00:00 General Dental Practice DENTAL 9041 Zygomatic arch fracture - closed reduction 1310,64 04/01/ :00:00 General Dental Practice DENTAL 9039 Maxilla fracture - Le Fort III or craniofacial disjunction 4332,75 04/01/ :00:00 General Dental Practice DENTAL 9037 Maxilla fracture - Le Fort II or middle third face 3020,91 04/01/ :00:00 General Dental Practice DENTAL 9035 Maxilla fracture - Le Fort I or Guerin 1843,86 04/01/ :00:00 General Dental Practice DENTAL 9031 Mandible fracture - open reduction 3020,91 04/01/ :00:00 General Dental Practice DENTAL 9029 Mandible fracture - splints 2038,01 04/01/ :00:00 Mandible fracture - compound, with eyelet General Dental Practice DENTAL 9027 wiring 1840,72 04/01/ :00:00 General Dental Practice DENTAL 9025 Mandible fracture - closed reduction 1310,64 04/01/ :00:00 General Dental Practice DENTAL 9024 Dento-alveolar fracture - per sextant 591,84 04/01/ :00:00 General Dental Practice DENTAL 9023 General Dental Practice DENTAL 9021 Suture - reconstruction, major (excludes closure of surgical incisions) 1245,59 04/01/ :00:00 Suture - reconstruction, minor (excludes closure of surgical incisions) 669,10 04/01/ :00:00

8 General Dental Practice DENTAL 9019 Sequestrectomy - intra oral per sextant and or ramus 527,64 04/01/ :00:00 General Dental Practice DENTAL 9017 Decortication, saucerisation and sequestrectomy 2430,12 04/01/ :00:00 General Dental Practice DENTAL 9016 Apicectomy - posteriors (including retrograde filling) 1180,35 04/01/ :00:00 General Dental Practice DENTAL 9015 Apicectomy - anteriors (including retrograde filling) 669,10 04/01/ :00:00 General Dental Practice DENTAL 9013 Incision & drainage of abscess - extra-oral (pyogenic) 459,12 04/01/ :00:00 General Dental Practice DENTAL 9011 Incision & drainage of abscess - intra-oral (pyogenic) 335,77 04/01/ :00:00 General Dental Practice DENTAL 9010 Sinus lift procedure 1793,12 04/01/ :00:00 General Dental Practice DENTAL 9009 Alveolar ridge augmentation - three across 3 or more tooth sites 1193,44 04/01/ :00:00 General Dental Practice DENTAL 9008 Alveolar ridge augmentation - one to two tooth sites 536,85 04/01/ :00:00 General Dental Practice DENTAL 9007 Alveolar ridge augmentation - total (by alloplastic material) 1736,76 04/01/ :00:00 General Dental Practice DENTAL 9005 Alveolar ridge augmentation - total (by bone graft) 2759,25 04/01/ :00:00 General Dental Practice DENTAL 9004 Lateralization of inferior dental nerve 2642,05 04/01/ :00:00 General Dental Practice DENTAL 9003 Reposition mental foramen and nerve - per side 1639,62 04/01/ :00:00 General Dental Practice DENTAL 8997 Sulcoplasty / Vestibuloplasty 2706,23 04/01/ :00:00 General Dental Practice DENTAL 8995 Gingivectomy - per jaw 1050,06 04/01/ :00:00 General Dental Practice DENTAL 8993 Surgical reduction of osseous tuberosity - per side 527,64 04/01/ :00:00 General Dental Practice DENTAL 8991 Removal of torus palatinus 1180,35 04/01/ :00:00 General Dental Practice DENTAL 8989 Removal torus mandibularis 1180,35 04/01/ :00:00 General Dental Practice DENTAL 8987 Reduction of mylohyoid ridges - per side 1180,35 04/01/ :00:00 General Dental Practice DENTAL 8985 Frenulectomy/frenulotomy 720,04 04/01/ :00:00 General Dental Practice DENTAL 8984 Corticotomy - each additional tooth 397,52 04/01/ :00:00 General Dental Practice DENTAL 8983 Corticotomy - first tooth 783,88 04/01/ :00:00

9 General Dental Practice DENTAL 8981 General Dental Practice DENTAL 8979 General Dental Practice DENTAL 8977 Surgical exposure of impacted or unerupted teeth to aid eruption 1083,18 04/01/ :00:00 Harvesting of autogenous grafts (intraoral) 227,29 04/01/ :00:00 Surgical repair of maxilla or mandible - major 2757,15 04/01/ :00:00 General Dental Practice DENTAL 8975 Hemiresection of jaw excluding condyl 2759,25 04/01/ :00:00 General Dental Practice DENTAL 8973 Surgical excision of tumours of the jaw 2626,50 04/01/ :00:00 General Dental Practice DENTAL 8971 Excision of tumour of the soft tissue 527,64 04/01/ :00:00 General Dental Practice DENTAL 8969 Surgical removal of jaw cyst - extra-oral approach 2626,50 04/01/ :00:00 General Dental Practice DENTAL 8967 Surgical removal of jaw cyst - intra-oral approach 1639,62 04/01/ :00:00 General Dental Practice DENTAL 8966 Repair of oronasal fistula (local flaps) 1641,89 04/01/ :00:00 General Dental Practice DENTAL 8965 Peripheral neurectomy 1180,35 04/01/ :00:00 General Dental Practice DENTAL 8964 Harvest cranium graft 390,88 04/01/ :00:00 General Dental Practice DENTAL 8963 Harvest rib graft 499,23 04/01/ :00:00 General Dental Practice DENTAL 8962 Harvest iliac crest graft 435,21 04/01/ :00:00 General Dental Practice DENTAL 8961 Tooth transplantation 1180,35 04/01/ :00:00 General Dental Practice DENTAL 8959 Pharyngostomy 604,90 04/01/ :00:00 General Dental Practice DENTAL 8958 Emergency tracheotomy 604,90 04/01/ :00:00 General Dental Practice DENTAL 8957 Alveolotomy or alveolectomy (including extractions) 720,04 04/01/ :00:00 General Dental Practice DENTAL 8945 Surgical removal of impacted tooth - third and subsequent teeth 296,34 04/01/ :00:00 General Dental Practice DENTAL 8943 Surgical removal of impacted tooth - second tooth 521,53 04/01/ :00:00 General Dental Practice DENTAL 8941 Surgical removal of impacted tooth - first tooth 972,26 04/01/ :00:00 General Dental Practice DENTAL 8937 Surgical removal of tooth 586,43 04/01/ :00:00 General Dental Practice DENTAL 8935 Treatment of septic socket 99,43 04/01/ :00:00

10 General Dental Practice DENTAL 8933 Treatment of haemorrhage (blood dyscracias) 1374,65 04/01/ :00:00 General Dental Practice DENTAL 8931 Treatment of post-extraction haemorrhage 99,43 04/01/ :00:00 General Dental Practice DENTAL 8921 Biopsy extra-oral bone/soft tissue 863,41 04/01/ :00:00 General Dental Practice DENTAL 8919 Biopsy of bone - needle 527,64 04/01/ :00:00 General Dental Practice DENTAL 8917 Biopsy of oral tissue - soft 342,76 04/01/ :00:00 General Dental Practice DENTAL 8911 Caldwell-Luc procedure 537,94 04/01/ :00:00 General Dental Practice DENTAL 8909 Oral antral fistula closure 1374,65 04/01/ :00:00 General Dental Practice DENTAL 8908 Surgical removal of roots from maxillary antrum 1793,12 04/01/ :00:00 General Dental Practice DENTAL 8888 General Dental Practice DENTAL 8887 General Dental Practice DENTAL 8886 General Dental Practice DENTAL 8885 General Dental Practice DENTAL 8884 General Dental Practice DENTAL 8883 General Dental Practice DENTAL 8882 General Dental Practice DENTAL 8881 General Dental Practice DENTAL 8880 General Dental Practice DENTAL 8879 Ortho Tx - fixed lingual appliance - both arches, Class 2/3 severe w/ complications 31731,43 04/01/ :00:00 Ortho Tx - fixed appliance - both arches, Class 2/3 severe w/ complications 19470,13 04/01/ :00:00 Ortho Tx - fixed lingual appliance - both arches, Class 2/3 severe 28517,27 04/01/ :00:00 Ortho Tx - fixed appliance - both arches, Class 2/3 severe 17280,76 04/01/ :00:00 Ortho Tx - fixed lingual appliance - both arches, Class 2/3 moderate 25604,71 04/01/ :00:00 Ortho Tx - fixed appliance - both arches, Class 2/3 moderate 15393,80 04/01/ :00:00 Ortho Tx - fixed lingual appliance - both arches, Class 2/3 mild 22888,38 04/01/ :00:00 Ortho Tx - fixed appliance - both arches, Class 2/3 mild 13697,69 04/01/ :00:00 Ortho Tx - fixed lingual appliance - both arches, Class 1 severe w/ complications 27647,23 04/01/ :00:00 Ortho Tx - fixed appliance - both arches, Class 1 severe w/ complications 15393,80 04/01/ :00:00

11 General Dental Practice DENTAL 8878 Ortho Tx - fixed lingual appliance - both arches, Class 1 severe 24916,76 04/01/ :00:00 General Dental Practice DENTAL 8877 Ortho Tx - fixed appliance - both arches, Class 1 severe 13697,69 04/01/ :00:00 General Dental Practice DENTAL 8876 Ortho Tx - fixed lingual appliance - both arches, Class 1 moderate 21955,53 04/01/ :00:00 General Dental Practice DENTAL 8875 Ortho Tx - fixed appliance - both arches, Class 1 moderate 11750,21 04/01/ :00:00 General Dental Practice DENTAL 8874 Ortho Tx - fixed lingual appliance - both arches, Class 1 mild 18752,56 04/01/ :00:00 General Dental Practice DENTAL 8873 Ortho Tx - fixed appliance - both arches, Class 1 mild 9571,64 04/01/ :00:00 General Dental Practice DENTAL 8869 Ortho Tx - fixed appliance - one arch, severe 7545,69 04/01/ :00:00 General Dental Practice DENTAL 8868 Ortho Tx - fixed appliance - one arch, modeate 6451,33 04/01/ :00:00 General Dental Practice DENTAL 8867 Ortho Tx - fixed appliance - one arch 5230,35 04/01/ :00:00 General Dental Practice DENTAL 8866 Ortho Tx - partial fixed appliance - both arches 6692,04 04/01/ :00:00 General Dental Practice DENTAL 8865 Ortho Tx - partial fixed appliance - one arch 4865,80 04/01/ :00:00 General Dental Practice DENTAL 8863 Ortho Tx - each additional removable appliance 765,22 04/01/ :00:00 General Dental Practice DENTAL 8862 Ortho Tx - removable appliance 1522,57 04/01/ :00:00 General Dental Practice DENTAL 8861 Ortho Tx - partial fixed appliance - minor 1824,16 04/01/ :00:00 General Dental Practice DENTAL 8858 Ortho Tx - functional appliance 2742,67 04/01/ :00:00 General Dental Practice DENTAL 8857 Consultation - cleft palate (maximum) 860,10 04/01/ :00:00 General Dental Practice DENTAL 8856 Consultation - cleft palate (subsequent) 123,68 04/01/ :00:00 General Dental Practice DENTAL 8855 Consultation - cleft palate therapy (house or hospital) 251,90 04/01/ :00:00 General Dental Practice DENTAL 8852 Occlusal orthotic appliance 521,53 04/01/ :00:00 General Dental Practice DENTAL 8851 Treatment of MPDS - subsequent visit 109,39 04/01/ :00:00 General Dental Practice DENTAL 8850 Treatment of MPDS - first visit 207,58 04/01/ :00:00

12 General Dental Practice DENTAL 8849 Retainer (orthodontic) 430,67 04/01/ :00:00 General Dental Practice DENTAL 8848 Repair orthodontic appliance - fixed 184,54 04/01/ :00:00 General Dental Practice DENTAL 8847 Replace orthodontic appliance - removable 430,67 04/01/ :00:00 General Dental Practice DENTAL 8846 Repair orthodontic appliance - removable 124,55 04/01/ :00:00 General Dental Practice DENTAL 8843 Ortho Tx - fixed lingual appliance - one arch, severe 13162,19 04/01/ :00:00 General Dental Practice DENTAL 8842 Ortho Tx - fixed lingual appliance - one arch, modeate 11552,42 04/01/ :00:00 General Dental Practice DENTAL 8841 Ortho Tx - fixed lingual appliance - one arch 9830,14 04/01/ :00:00 General Dental Practice DENTAL 8840 Treatment planning for orthognathic surgery - ALL 635,78 04/01/ :00:00 General Dental Practice DENTAL 8839 Diagnostic setup (orthodontics) 184,54 04/01/ :00:00 General Dental Practice DENTAL 8811 Tracing and analysis of extra-oral film 41,53 04/01/ :00:00 General Dental Practice DENTAL 8787 Unlisted oral medicine procedure 154,56 04/01/ :00:00 General Dental Practice DENTAL 8772 Submucosal connective tissue autograft (isolated procedure) 739,75 04/01/ :00:00 General Dental Practice DENTAL 8769 Membrane removal (used for guided tissue regeneration) 430,67 04/01/ :00:00 General Dental Practice DENTAL 8768 Unlisted periodontal procedure 430,67 04/01/ :00:00 General Dental Practice DENTAL 8767 Bone regeneration/repair procedure - at a single site 913,16 04/01/ :00:00 General Dental Practice DENTAL 8766 Bone regeneration/repair procedure - as part of a flap operation 352,18 04/01/ :00:00 General Dental Practice DENTAL 8765 Hemisection of a tooth, resection of a root or tunnel preparation (isolated procedure) 591,84 04/01/ :00:00 General Dental Practice DENTAL 8763 Wedge resection (isolated procedure) 398,77 04/01/ :00:00 General Dental Practice DENTAL 8762 Masticatory mucosal autograft - four or more teeth (isolated procedure) 1018,31 04/01/ :00:00 General Dental Practice DENTAL 8761 Masticatory mucosal autograft - one to four teeth (isolated procedure) 677,68 04/01/ :00:00

13 General Dental Practice DENTAL 8759 Pedicle flapped graft (isolated procedure) 623,77 04/01/ :00:00 General Dental Practice DENTAL 8756 Clinical crown lengthening (isolated procedure) 829,97 04/01/ :00:00 General Dental Practice DENTAL 8755 Flap procedure, root planing and four or more surgical services - per sextant 1368,78 04/01/ :00:00 General Dental Practice DENTAL 8753 General Dental Practice DENTAL 8751 General Dental Practice DENTAL 8749 General Dental Practice DENTAL 8743 General Dental Practice DENTAL 8741 General Dental Practice DENTAL 8739 General Dental Practice DENTAL 8737 Flap procedure, root planing and four or more surgical services - per quadrant 1689,02 04/01/ :00:00 Flap procedure, root planing and one to three surgical services - per sextant 1128,61 04/01/ :00:00 Flap procedure, root planing and one to three surgical services - per quadrant 1362,63 04/01/ :00:00 Gingivectomy or gingivoplasty - one to three teeth per quadrant 566,36 04/01/ :00:00 Gingivectomy/gingivoplasty - four or more teeth per quadrant 708,86 04/01/ :00:00 Root planing - one to three teeth per quadrant 432,22 04/01/ :00:00 Root planing - four or more teeth per quadrant 543,33 04/01/ :00:00 General Dental Practice DENTAL 8731 Incision & drainage of abscess - intra-oral 216,48 04/01/ :00:00 General Dental Practice DENTAL 8727 Provisional splinting - intracoronal - per tooth 114,74 04/01/ :00:00 General Dental Practice DENTAL 8725 Provisional splinting - extracoronal (wire plus resin) - per sextant 365,40 04/01/ :00:00 General Dental Practice DENTAL 8723 Provisional splinting - extracoronal (wire) - per sextant 251,90 04/01/ :00:00 General Dental Practice DENTAL 8674 Additive partial denture 1104,13 04/01/ :00:00 General Dental Practice DENTAL 8672 Altered cast technique (in addition to partial denture) 94,02 04/01/ :00:00 General Dental Practice DENTAL 8667 Soft base to denture (heat cured) 733,11 04/01/ :00:00

14 General Dental Practice DENTAL 8664 Remount crown or bridge for prosthetics 351,29 04/01/ :00:00 General Dental Practice DENTAL 8663 Metal base to complete denture 733,11 04/01/ :00:00 General Dental Practice DENTAL 8662 Adjust complete or partial dentures (remounting) 351,29 04/01/ :00:00 General Dental Practice DENTAL 8660 Additional fee to implant supported fixeddetachable denture - per implant 377,65 04/01/ :00:00 General Dental Practice DENTAL 8659 Interim partial denture 1079,69 04/01/ :00:00 General Dental Practice DENTAL 8658 Interim complete denture 1349,71 04/01/ :00:00 General Dental Practice DENTAL 8657 Replacement of precision attachment 172,18 04/01/ :00:00 General Dental Practice DENTAL 8655 Implant supported fixed-detachable partial overdenture 2189,55 04/01/ :00:00 General Dental Practice DENTAL 8654 Implant supported fixed-detachable complete overdenture 2737,12 04/01/ :00:00 General Dental Practice DENTAL 8653 Overdenture - partial 1946,60 04/01/ :00:00 General Dental Practice DENTAL 8652 Overdenture - complete 2433,43 04/01/ :00:00 General Dental Practice DENTAL 8635 Apexification/recalcification per visit 180,53 04/01/ :00:00 General Dental Practice DENTAL 8617 Retainer cast metal (Maryland type retainer) 602,84 04/01/ :00:00 General Dental Practice DENTAL 8599 Precision attachment (removable denture) 301,25 04/01/ :00:00 General Dental Practice DENTAL 8597 Locks and milled rests 123,68 04/01/ :00:00 General Dental Practice DENTAL 8595 Repair of implant abutment 123,68 04/01/ :00:00 General Dental Practice DENTAL 8594 Repair of implant supported prosthesis 123,68 04/01/ :00:00 General Dental Practice DENTAL 8590 Implant maintenance procedures - per implant 111,45 04/01/ :00:00 General Dental Practice DENTAL 8587 Coping metal 202,15 04/01/ :00:00 General Dental Practice DENTAL 8586 Stress breaker 907,72 04/01/ :00:00 General Dental Practice DENTAL 8585 Connector bar 2433,43 04/01/ :00:00 General Dental Practice DENTAL 8584 Connector bar - implant supported 2433,43 04/01/ :00:00 General Dental Practice DENTAL 8579 Custom abutment 1148,24 04/01/ :00:00 General Dental Practice DENTAL 8578 Prefabricated abutment 251,90 04/01/ :00:00 General Dental Practice DENTAL 8565 Gold foil class III 1156,99 04/01/ :00:00 General Dental Practice DENTAL 8563 Gold foil class V 919,74 04/01/ :00:00

15 General Dental Practice DENTAL 8561 Gold foil class I or IV 786,14 04/01/ :00:00 General Dental Practice DENTAL 8554 Veneer - resin (laboratory) 1040,98 04/01/ :00:00 General Dental Practice DENTAL 8553 Occlusal adjustment - minor 299,66 04/01/ :00:00 General Dental Practice DENTAL 8552 Veneer - porcelain (laboratory) 1040,98 04/01/ :00:00 General Dental Practice DENTAL 8551 Occlusal adjustment - major 795,26 04/01/ :00:00 General Dental Practice DENTAL 8548 Crown retainer - implant/abutment supported - cast metal 2012,18 04/01/ :00:00 General Dental Practice DENTAL 8547 Crown retainer - implant/abutment supported - porcelain with metal 2012,18 04/01/ :00:00 General Dental Practice DENTAL 8546 Crown retainer - implant/abutment supported - porcelain/ceramic 2012,18 04/01/ :00:00 General Dental Practice DENTAL 8538 Crown - implant/abutment supported - cast metal 2012,18 04/01/ :00:00 General Dental Practice DENTAL 8537 Crown - implant/abutment supported - porcelain with metal 2012,18 04/01/ :00:00 General Dental Practice DENTAL 8536 Crown - implant/abutment supported - porcelain/ceramic 2012,18 04/01/ :00:00 General Dental Practice DENTAL 8534 Implant supported removable partial overdenture 1946,60 04/01/ :00:00 General Dental Practice DENTAL 8533 Implant supported removable complete overdenture 2433,43 04/01/ :00:00 General Dental Practice DENTAL 8518 Repair bridge 301,25 04/01/ :00:00 General Dental Practice DENTAL 8517 Reimplantation of avulsed tooth (include stabilisation) 313,62 04/01/ :00:00 General Dental Practice DENTAL 8516 Remove bridge 269,99 04/01/ :00:00 General Dental Practice DENTAL 8514 Recement bridge 135,69 04/01/ :00:00 General Dental Practice DENTAL 8509 Electrognathographic recording with computer analysis 777,26 04/01/ :00:00 General Dental Practice DENTAL 8508 Electrognathographic recording 468,16 04/01/ :00:00 General Dental Practice DENTAL 8505 Pantographic recording 437,31 04/01/ :00:00 General Dental Practice DENTAL 8503 Occlusion analysis mounted 301,25 04/01/ :00:00 General Dental Practice DENTAL 8447 Provisional crown retainer 301,25 04/01/ :00:00 General Dental Practice DENTAL 8446 Crown retainer - resin with metal 1550,11 04/01/ :00:00 General Dental Practice DENTAL 8445 Crown retainer - porcelain with metal 1550,11 04/01/ :00:00

16 General Dental Practice DENTAL 8444 Crown retainer - 3/4 porcelain/ceramic 1550,11 04/01/ :00:00 General Dental Practice DENTAL 8443 Crown retainer - porcelain/ceramic 1550,11 04/01/ :00:00 General Dental Practice DENTAL 8442 Crown retainer - 3/4 cast metal 1550,11 04/01/ :00:00 General Dental Practice DENTAL 8441 Crown retainer - full cast metal 1550,11 04/01/ :00:00 General Dental Practice DENTAL 8438 Inlay/onlay retainer - porcelain - four or more surfaces 1464,11 04/01/ :00:00 General Dental Practice DENTAL 8437 Inlay/onlay retainer - porcelain - three surfaces 1208,96 04/01/ :00:00 General Dental Practice DENTAL 8436 Inlay/onlay retainer - porcelain - two surfaces 733,64 04/01/ :00:00 General Dental Practice DENTAL 8434 Inlay/onlay retainer - metal - four or more surfaces 1215,58 04/01/ :00:00 General Dental Practice DENTAL 8433 Inlay/onlay retainer - metal - three surfaces 1005,22 04/01/ :00:00 General Dental Practice DENTAL 8432 Inlay/onlay retainer - metal - two surfaces 602,84 04/01/ :00:00 General Dental Practice DENTAL 8419 Provisional pontic 301,25 04/01/ :00:00 General Dental Practice DENTAL 8418 Pontic - porcelain fused to metal 1265,29 04/01/ :00:00 General Dental Practice DENTAL 8417 Pontic - resin with metal 1265,29 04/01/ :00:00 General Dental Practice DENTAL 8416 Pontic - cast metal 1005,22 04/01/ :00:00 General Dental Practice DENTAL 8415 Pontic - porcelain/ceramic 1265,29 04/01/ :00:00 General Dental Practice DENTAL 8414 Additional fee for provision of crown within an existing clasp or rest 89,48 04/01/ :00:00 General Dental Practice DENTAL 8413 Repair crown (permanent or provisional) 301,25 04/01/ :00:00 General Dental Practice DENTAL 8411 Crown - porcelain with metal 1550,11 04/01/ :00:00 General Dental Practice DENTAL 8410 Provisional crown 301,25 04/01/ :00:00 General Dental Practice DENTAL 8409 Crown - porcelain/ceramic 1550,11 04/01/ :00:00 General Dental Practice DENTAL 8407 Crown - resin with metal 1550,11 04/01/ :00:00 General Dental Practice DENTAL 8405 Crown - resin laboratory 1463,98 04/01/ :00:00 General Dental Practice DENTAL 8404 Crown - 3/4 porcelain/ceramic 1463,98 04/01/ :00:00 General Dental Practice DENTAL 8403 Crown - 3/4 cast metal 1550,11 04/01/ :00:00 General Dental Practice DENTAL 8401 Crown - full cast metal 1550,11 04/01/ :00:00 General Dental Practice DENTAL 8398 Core build-up with or without pins 602,84 04/01/ :00:00

17 General Dental Practice DENTAL 8397 Cast core with pins (any number of pins) 496,96 04/01/ :00:00 General Dental Practice DENTAL 8392 Cast post (each additional) 185,42 04/01/ :00:00 General Dental Practice DENTAL 8391 Cast core with single post 311,53 04/01/ :00:00 General Dental Practice DENTAL 8384 Inlay/onlay - resin - four or more surfaces 1464,11 04/01/ :00:00 General Dental Practice DENTAL 8383 Inlay/onlay - resin - three surfaces 1208,96 04/01/ :00:00 General Dental Practice DENTAL 8382 Inlay/onlay - resin - two surfaces 733,64 04/01/ :00:00 General Dental Practice DENTAL 8381 Inlay - resin - one surface 496,96 04/01/ :00:00 General Dental Practice DENTAL 8376 Core build-up with prefabricated posts 738,52 04/01/ :00:00 General Dental Practice DENTAL 8375 Prefabricated resin crown 276,65 04/01/ :00:00 General Dental Practice DENTAL 8374 Inlay/onlay - porcelain - four or more surfaces 1464,11 04/01/ :00:00 General Dental Practice DENTAL 8373 Inlay/onlay - porcelain - three surfaces 1208,96 04/01/ :00:00 General Dental Practice DENTAL 8372 Inlay/onlay - porcelain - two surfaces 733,64 04/01/ :00:00 General Dental Practice DENTAL 8371 Inlay - porcelain - one surface 496,96 04/01/ :00:00 General Dental Practice DENTAL 8370 Resin - four or more surfaces, posterior 516,66 04/01/ :00:00 General Dental Practice DENTAL 8369 Resin - three surfaces, posterior 480,36 04/01/ :00:00 General Dental Practice DENTAL 8368 Resin - two surfaces, posterior 397,52 04/01/ :00:00 General Dental Practice DENTAL 8367 Resin - one surface, posterior 321,32 04/01/ :00:00 General Dental Practice DENTAL 8366 Pin retention as part of cast restoration (any number of pins) 200,42 04/01/ :00:00 General Dental Practice DENTAL 8364 Inlay/onlay - metal - four or more surfaces 1215,58 04/01/ :00:00 General Dental Practice DENTAL 8363 Inlay/onlay - metal - three surfaces 1005,22 04/01/ :00:00 General Dental Practice DENTAL 8362 Inlay/onlay - metal - two surfaces 602,84 04/01/ :00:00 General Dental Practice DENTAL 8361 Inlay - metal - one surface 412,34 04/01/ :00:00 General Dental Practice DENTAL 8357 Prefabricated metal crown 276,65 04/01/ :00:00 General Dental Practice DENTAL 8355 Veneer - resin (chair-side) 470,44 04/01/ :00:00 General Dental Practice DENTAL 8354 Resin - four or more surfaces, anterior 496,96 04/01/ :00:00 General Dental Practice DENTAL 8353 Resin - three surfaces, anterior 445,48 04/01/ :00:00 General Dental Practice DENTAL 8352 Resin - two surfaces, anterior 372,74 04/01/ :00:00

18 General Dental Practice DENTAL 8351 Resin - one surface, anterior 296,34 04/01/ :00:00 General Dental Practice DENTAL 8350 Resin crown - anterior primary tooth (direct) 589,04 04/01/ :00:00 General Dental Practice DENTAL 8349 Carve restoration to accommodate existing removable prosthesis 54,58 04/01/ :00:00 General Dental Practice DENTAL 8348 Pin retention - each additional pin (in addition to restoration) 124,18 04/01/ :00:00 General Dental Practice DENTAL 8347 Pin retention - first pin (in addition to restoration) 134,12 04/01/ :00:00 General Dental Practice DENTAL 8345 Prefabricated post retention, per post (in addition to restoration) 266,68 04/01/ :00:00 General Dental Practice DENTAL 8344 Amalgam - four or more surfaces 452,15 04/01/ :00:00 General Dental Practice DENTAL 8343 Amalgam - three surfaces 405,74 04/01/ :00:00 General Dental Practice DENTAL 8342 Amalgam - two surfaces 332,79 04/01/ :00:00 General Dental Practice DENTAL 8341 Amalgam - one surface 269,99 04/01/ :00:00 General Dental Practice DENTAL 8340 Root canal therapy - posteriors - each additional canal 314,68 04/01/ :00:00 General Dental Practice DENTAL 8339 Root canal therapy - posteriors - first canal 1294,94 04/01/ :00:00 General Dental Practice DENTAL 8338 Root canal therapy - anteriors and premolars - first canal 942,41 04/01/ :00:00 General Dental Practice DENTAL 8337 Root canal obturation - posteriors - each additional canal 251,90 04/01/ :00:00 General Dental Practice DENTAL 8336 Root canal obturation - posteriors - first canal 847,90 04/01/ :00:00 General Dental Practice DENTAL 8335 Root canal obturation - anteriors and premolars - first canal 616,09 04/01/ :00:00 General Dental Practice DENTAL 8334 Re-preparation of previously obturated root canal 200,42 04/01/ :00:00 General Dental Practice DENTAL 8333 Root canal preparatory visit - multi canal tooth 190,30 04/01/ :00:00 General Dental Practice DENTAL 8332 Root canal preparatory visit - single canal tooth 135,69 04/01/ :00:00 General Dental Practice DENTAL 8330 Removal of root canal obstruction 177,24 04/01/ :00:00

19 General Dental Practice DENTAL 8329 General Dental Practice DENTAL 8328 Root canal therapy - anteriors and premolars - each additional canal 314,68 04/01/ :00:00 Root canal obturation - anteriors and premolars - each additional canal 251,90 04/01/ :00:00 General Dental Practice DENTAL 8327 Internal bleaching - each additional visit 154,01 04/01/ :00:00 General Dental Practice DENTAL 8325 Internal bleaching - per tooth 321,32 04/01/ :00:00 General Dental Practice DENTAL 8307 Pulp amputation (pulpotomy) 177,24 04/01/ :00:00 General Dental Practice DENTAL 8304 Rubber dam per arch 106,05 04/01/ :00:00 General Dental Practice DENTAL 8303 Pulp cap - indirect 180,53 04/01/ :00:00 General Dental Practice DENTAL 8301 Pulp cap - direct 180,53 04/01/ :00:00 General Dental Practice DENTAL 8281 Partial denture - cast metal framework only 1464,11 04/01/ :00:00 General Dental Practice DENTAL 8275 Adjust complete or partial denture 99,43 04/01/ :00:00 General Dental Practice DENTAL 8273 Impression to repair or modify a denture or other intra-oral appliance 99,43 04/01/ :00:00 General Dental Practice DENTAL 8271 Add tooth to existing partial denture 124,18 04/01/ :00:00 General Dental Practice DENTAL 8270 Add clasp to existing partial denture 124,18 04/01/ :00:00 General Dental Practice DENTAL 8269 Repair denture or other intra-oral appliance 172,18 04/01/ :00:00 General Dental Practice DENTAL 8267 Reline complete or partial denture (laboratory) 747,05 04/01/ :00:00 General Dental Practice DENTAL 8265 Tissues conditioning per arch (including soft self-cure reline) 212,11 04/01/ :00:00 General Dental Practice DENTAL 8263 Reline complete or partial denture (chairside) 324,61 04/01/ :00:00 General Dental Practice DENTAL 8261 Remodel complete or partial denture 821,56 04/01/ :00:00 General Dental Practice DENTAL 8259 Rebase complete or partial denture (laboratory) 511,78 04/01/ :00:00 General Dental Practice DENTAL 8257 Bar - lingual or palatal 154,01 04/01/ :00:00 General Dental Practice DENTAL 8255 Clasp or rest - stainless steel 130,82 04/01/ :00:00 General Dental Practice DENTAL 8253 Clasp or rest - wrought gold 124,18 04/01/ :00:00 General Dental Practice DENTAL 8251 Clasp or rest - cast gold 124,18 04/01/ :00:00 General Dental Practice DENTAL 8245 Immediate denture - mandibular 1349,71 04/01/ :00:00 General Dental Practice DENTAL 8244 Immediate denture - maxillary 1349,71 04/01/ :00:00

20 General Dental Practice DENTAL 8241 Partial denture - resin base - nine or more teeth 1245,59 04/01/ :00:00 General Dental Practice DENTAL 8240 Partial denture - resin base - eight teeth 1245,59 04/01/ :00:00 General Dental Practice DENTAL 8239 Partial denture - resin base - seven teeth 1245,59 04/01/ :00:00 General Dental Practice DENTAL 8238 Partial denture - resin base - six teeth 1245,59 04/01/ :00:00 General Dental Practice DENTAL 8237 Partial denture - resin base - five teeth 939,12 04/01/ :00:00 General Dental Practice DENTAL 8236 Partial denture - resin base - four teeth 939,12 04/01/ :00:00 General Dental Practice DENTAL 8235 Partial denture - resin base - three teeth 939,12 04/01/ :00:00 General Dental Practice DENTAL 8234 Partial denture - resin base - two teeth 627,58 04/01/ :00:00 General Dental Practice DENTAL 8233 Partial denture - resin base - one tooth 627,58 04/01/ :00:00 General Dental Practice DENTAL 8232 Complete denture - maxillary or mandibular 1349,71 04/01/ :00:00 General Dental Practice DENTAL 8231 Complete dentures - maxillary and mandibular 2189,40 04/01/ :00:00 General Dental Practice DENTAL 8214 Surgical removal of residual roots, second and subsequent teeth s roots 452,15 04/01/ :00:00 General Dental Practice DENTAL 8213 Surgical removal of residual roots, first tooth - per tooth 586,43 04/01/ :00:00 General Dental Practice DENTAL 8202 Extraction - each additional tooth or exposed tooth roots 54,58 04/01/ :00:00 General Dental Practice DENTAL 8201 Extraction - tooth or exposed tooth roots (first per quadrant) 135,69 04/01/ :00:00 General Dental Practice DENTAL 8192 Suture - minor 669,10 04/01/ :00:00 General Dental Practice DENTAL 8190 Consultation - second opinion or advice 221,01 04/01/ :00:00 General Dental Practice DENTAL 8189 Re-examination - existing condition 107,10 04/01/ :00:00 General Dental Practice DENTAL 8183 Therapeutic drug injection 59,66 04/01/ :00:00 General Dental Practice DENTAL 8180 Prophylaxis - complete dentition (periodontally compromised patient) 289,71 04/01/ :00:00

21 General Dental Practice DENTAL 8179 Polishing - complete dentition (periodontally compromised patient) 155,75 04/01/ :00:00 General Dental Practice DENTAL 8178 Oral hygiene instruction - each additional visit (periodontally compromised patient) 110,94 04/01/ :00:00 General Dental Practice DENTAL 8177 Oral hygiene instruction (periodontally compromised patient) 205,47 04/01/ :00:00 General Dental Practice DENTAL 8176 Periodontal screening 186,13 04/01/ :00:00 General Dental Practice DENTAL 8175 Space maintainer - removable 324,61 04/01/ :00:00 General Dental Practice DENTAL 8173 Space maintainer - fixed, per abutment 251,90 04/01/ :00:00 General Dental Practice DENTAL 8171 Mouth guard 157,86 04/01/ :00:00 General Dental Practice DENTAL 8169 Occlusal guard 521,53 04/01/ :00:00 General Dental Practice DENTAL 8167 Application of desensitising medicament, per visit 104,31 04/01/ :00:00 General Dental Practice DENTAL 8166 Application of desensitising resin, per tooth 89,48 04/01/ :00:00 General Dental Practice DENTAL 8165 Sedative filling 135,69 04/01/ :00:00 General Dental Practice DENTAL 8163 Dental sealant 89,48 04/01/ :00:00 General Dental Practice DENTAL 8162 Topical application of fluoride - adult 135,69 04/01/ :00:00 General Dental Practice DENTAL 8161 Topical application of fluoride - child 135,69 04/01/ :00:00 General Dental Practice DENTAL 8159 Prophylaxis - complete dentition 266,68 04/01/ :00:00 General Dental Practice DENTAL 8158 Enamel microabrasion 124,18 04/01/ :00:00 General Dental Practice DENTAL 8157 Re-burnishing and polishing of restorations - complete dentition 135,69 04/01/ :00:00 General Dental Practice DENTAL 8155 Polishing - complete dentition 135,69 04/01/ :00:00 Oral hygiene instruction - each additional General Dental Practice DENTAL 8153 visit 99,43 04/01/ :00:00 General Dental Practice DENTAL 8151 Oral hygiene instruction 135,69 04/01/ :00:00 General Dental Practice DENTAL 8147 Monitoring equipment for intravenous sedation 212,11 04/01/ :00:00 General Dental Practice DENTAL 8145 Local anaesthetic - per visit 86,16 04/01/ :00:00 General Dental Practice DENTAL 8144 Intravenous sedation 59,66 04/01/ :00:00 General Dental Practice DENTAL 8143 Inhalation sedation - each addnl 15 minutes 51,28 04/01/ :00:00

22 General Dental Practice DENTAL 8141 Inhalation sedation - first 15 minutes or part thereof 99,43 04/01/ :00:00 General Dental Practice DENTAL 8140 House/extended care facility/hospital call 220,31 04/01/ :00:00 General Dental Practice DENTAL 8138 Remove retention post (prefabricated or cast) 177,24 04/01/ :00:00 General Dental Practice DENTAL 8137 Emergency crown (chair-side) 465,36 04/01/ :00:00 General Dental Practice DENTAL 8136 Access through a prosthetic crown or inlay to facilitate root canal treatment 120,89 04/01/ :00:00 General Dental Practice DENTAL 8135 Remove inlay, onlay or crown 269,99 04/01/ :00:00 General Dental Practice DENTAL 8133 Recement inlay, onlay, crown or veneer 135,69 04/01/ :00:00 General Dental Practice DENTAL 8132 Pulp removal (pulpectomy) 221,88 04/01/ :00:00 General Dental Practice DENTAL 8131 Emergency dental treatment 135,69 04/01/ :00:00 General Dental Practice DENTAL 8129 Office/hospital visit after regularly scheduled hours 332,79 04/01/ :00:00 General Dental Practice DENTAL 8124 Pulp tests 26,34 04/01/ :00:00 General Dental Practice DENTAL 8123 Caries susceptibility tests (By Arrangement) 99,96 04/01/ :00:00 General Dental Practice DENTAL 8121 Oral and/or facial image (digital/conventional) 96,12 04/01/ :00:00 General Dental Practice DENTAL 8119 Diagnostic models mounted 241,77 04/01/ :00:00 General Dental Practice DENTAL 8118 Extraoral radiograph - skull/facial bone 357,58 04/01/ :00:00 General Dental Practice DENTAL 8117 Diagnostic models 96,12 04/01/ :00:00 General Dental Practice DENTAL 8116 Extraoral radiograph - cephalometric 357,58 04/01/ :00:00 General Dental Practice DENTAL 8115 Extraoral radiograph - panoramic 357,58 04/01/ :00:00 General Dental Practice DENTAL 8114 Extraoral radiograph - hand-wrist 357,58 04/01/ :00:00 General Dental Practice DENTAL 8113 Intraoral radiograph - occlusal 154,01 04/01/ :00:00 General Dental Practice DENTAL 8112 Intraoral radiograph - bitewing 89,48 04/01/ :00:00 General Dental Practice DENTAL 8110 Sterilized instrumentation 51,28 04/01/ :00:00 General Dental Practice DENTAL 8109 Infection control/barrier techniques 19,90 04/01/ :00:00 General Dental Practice DENTAL 8108 Intraoral radiographs - complete series 692,48 04/01/ :00:00 General Dental Practice DENTAL 8107 Intraoral radiograph - periapical 89,48 04/01/ :00:00