Schedule of Fees (Effective 1 April 2017) Dental (VIC)

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Clementine Lyons
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1 PAGE 1 of 6 Schedule of Fees (Effective 1 April 2017) Dental (VIC) The following fee structure applies for Dentists when treating Entitled Personnel. Item No. Diagnostic / Preventative Fee D011 Comprehensive oral examination $53.00 D012 Periodic oral examination $48.00 D013 Oral examination limited $43.00 D014 Consultation $60.00 D015 Consultation extended (30 minutes or more) $73.00 D016 Consultation by referral including examination $49.00 D017 Consultation by referral extended (30 minutes) including examination $65.00 D018 Written report (not elsewhere included) $29.00 D019 Letter of referral $23.00 D022 Intraoral periapical or bitewing radiograph per exposure $39.00 D025 Intraoral radiograph occlusal, maxillary, mandibular per exposure $37.00 D031 Extraoral radiograph maxillary, mandibular per exposure $48.00 D033 Lateral, antero-posterior, postero-anterior or submento-vertex radiograph $53.00 D035 Radiograph of temporomandibular joint per exposure $67.00 D036 Cephalometric radiograph lateral, antero-posterior, postero-anterior or submento-vertex per exposure $71.00 D037 Panoramic radiograph per exposure $84.00 D038 Hand-wrist radiograph for skeletal age assessment $53.00 D039 Tomography of the skull or parts thereof $87.00 D041 Bacteriologic examination $32.00 D042 Culture examination and identification $38.00 D043 Antibiotic sensitivity test $21.00 D044 Collection of specimen for pathology examination $21.00 D047 Saliva screening test $22.00 D048 Bacteriological screening test $39.00 D051 Biopsy of tissue $88.00 D052 Histopathological examination of tissue $48.00 D053 Cytological investigation $47.00 D055 Blood sample $47.00 D056 Haematological examination $47.00 D061 Pulp testing per visit $27.00 D071 Diagnostic model per model # $54.00 D072 Photographic records intraoral $27.00 D073 Photographic records extraoral $26.00 D074 Diagnostic wax-up $58.00 D081 Cephalometric analysis excluding radiographs $49.00 D082 Tooth-jaw size prediction analysis $34.00 D083 Tomographic analysis $95.00 D085 Electromyographic recording $38.00 D086 Electromyographic analysis $38.00 D111 Removal of plaque/and or stain $49.00 D113 Recontouring of pre-existing restoration(s) $29.00 D114 Removal of calculus first visit $94.00 D115 Removal of calculus subsequent visit $96.00 D116 Enamel micro-abrasion per tooth $49.00 D117 Bleaching, internal per tooth $ D118 Bleaching, external per tooth $65.00 D119 Bleaching, home application per arch $96.00 D121 Topical application of remineralizing and/or cariostatic agents, one treatment $29.00 D122 Topical remineralizing and/or cariostatic agent,home application-per arch $75.00 This table is part of the Schedule of Fees. The fees for other services are set out in the full Schedule of Fees, which is located at

2 PAGE 2 of 6 Item No. Diagnostic / Preventative (continued) Fee D123 Concentrated remineralizing and/or cariostatic agent, application single tooth $29.00 D131 Dietary advice $25.00 D141 Oral hygiene instruction $27.00 D151 Provision of a mouthguard indirect $ D153 Bimaxillary mouthguard indirect $ D161 Fissure sealing per tooth $49.00 D165 Desensitising procedure per visit $35.00 Item No. Periodontics Fee D171 Odontoplasty per tooth $35.00 D213 Treatment of acute periodontal infection per visit $74.00 D221 Clinical periodontal analysis and recording $44.00 D222 Root planing and subgingival curettage per tooth $39.00 D231 Gingivectomy per tooth $54.00 D232 Periodontal flap surgery per tooth $ D235 Gingival graft per tooth or implant $ D236 Guided tissue regeneration per tooth or implant $ D237 Guided tissue regeneration membrane removal $ D238 Periodontal flap surgery for crown lengthening per tooth $87.00 D241 Root resection per root $ D242 Osseous surgery per eight teeth or less $ D243 Osseous graft per tooth or implant $ D244 Osseous graft block $ D245 Periodontal surgery involving one tooth or implant $71.00 D281 Course of non-surgical periodontal treatment $ D282 Cont of periodontal treatment or maintenance subsequent to item S281 $ Item No. Oral Surgery Fee D311 Removal of a tooth or part(s) thereof $ D314 Sectional removal of a tooth $ D322 Surgical removal of a tooth or tooth fragment not requiring removal of bone or tooth division $ D323 Surgical removal of a tooth or tooth fragment requiring removal of bone $ D324 Surgical removal of a tooth or tooth fragment requiring both removal of bone and tooth divison $ D331 Alveolectomy per segment $ D332 Ostectomy per jaw $90.00 D337 Reduction of fibrous tuberosity $93.00 D338 Reduction of flabby ridge per segment $91.00 D341 Removal of hyperplastic tissue $ D343 Repositioning of muscle attachment $77.00 D344 Vestibuloplasty $80.00 D345 Skin or mucosal graft $81.00 D351 Repair of skin and subcutaneous tissue or mucous membrane $ D352 Fracture of maxilla or mandible not requiring splinting $ D353 Fracture of maxilla or mandible with wiring of teeth or intra-oral fixation $ D354 Fracture of maxilla or mandible with external fixation $ D355 Fracture of zygoma $ D359 Fracture of the maxilla or mandible requiring open reduction $ D361 Mandible relocation following dislocation $70.00 D363 Mandible relocation requiring open operation $ D365 Osteotomy maxilla $ D366 Osteotomy mandible $ D371 Removal of tumour, cyst or scar cutaneous, subcutaneous or in mucous membrane $ D373 Removal of tumour, cyst or scar involving muscle, bone or other deep tissue $ D375 Surgery to salivary duct $ D376 Surgery to salivary gland $ D377 Removal or repair of soft tissue (not elsewhere defined) $77.00 D378 Surgical removal of foreign body $77.00 D379 Marsupialisation of cyst $105.00

3 PAGE 3 of 6 Item No. Oral Surgery (continued) Fee D381 Surgical exposure of unerupted tooth $ D382 Surgical exposure and attachment of device for orthodontic traction $ D384 Repositioning of displaced tooth/teeth per tooth $ D385 Surgical repositioning of unerupted tooth $96.00 D386 Splinting of displaced tooth/teeth per tooth $98.00 D387 Replantation and splinting of a tooth $87.00 D388 Transplantation of tooth or tooth bud $ D389 Surgery to isolate and preserve neurovascular tissue $66.00 D391 Frenectomy $ D392 Drainage of abscess $50.00 D393 Surgery involving the maxillary antrum $ D394 Surgery for osteomyelitis $ D395 Repair of nerve trunk $ D399 Control of reactionary or secondary post-operative haemorrhage $23.00 Item No. Endodontic / Restorative Fee D411 Direct pulp capping $37.00 D412 Incomplete endodontic therapy (inoperable or fractured tooth) $98.00 D414 Pulpotomy $77.00 D415 Complete chemo-mechanical preparation of root canal one canal $ D416 Complete chemo-mechanical preparation of root canal each additional canal $ D417 Root canal obturation one canal $ D418 Root canal obturation each additional canal $ D419 Extirpation of pulp or debridement of root canal(s) emergency or palliative $ D421 Resorbable root canal filling primary tooth $ D431 Periapical curettage per root $ D432 Apicectomy per root $ D433 Exploratory periradicular surgery $ D434 Apical seal per canal $ D436 Sealing of perforation $80.00 D437 Surgical treatment and repair of external root resorption per tooth $ D438 Hemisection $ D445 Exploration and/or negotiation of a calcified canal per canal, per visit $93.00 D451 Removal of root filling per canal $ D452 Removal of a cemented root canal post or post crown $99.00 D453 Removal or bypassing fractured endodontic instrument $82.00 D455 Additional visit for irrigation and/or dressing of the root canal system per tooth $ D457 Obturation of resorption defect or perforation (non-surgical) $74.00 D458 Interim therapeutic root filling per tooth $95.00 D511 Metallic restoration one surface direct $ D512 Metallic restoration two surfaces direct $ D513 Metallic restoration three surfaces direct $ D514 Metallic restoration four surfaces direct $ D515 Metallic restoration five surfaces direct $ D521 Adhesive restoration one surface anterior tooth direct $ D522 Adhesive restoration two surfaces anterior tooth direct $ D523 Adhesive restoration three surfaces anterior tooth direct $ D524 Adhesive restoration four surfaces anterior tooth direct $ D525 Adhesive restoration five surfaces anterior tooth direct $ D531 Adhesive restoration one surface posterior tooth direct $ D532 Adhesive restoration two surfaces posterior tooth direct $ D533 Adhesive restoration three surfaces posterior tooth direct $ D534 Adhesive restoration four surfaces posterior tooth direct $ D535 Adhesive restoration five surfaces posterior tooth direct $ D541 Metallic restoration one surface indirect $ D542 Metallic restoration two surfaces indirect $ D543 Metallic restoration three surfaces indirect $ D544 Metallic restoration four surfaces indirect $507.00

4 PAGE 4 of 6 Item No. Endodontic / Restorative (continued) Fee D545 Metallic restoration five surfaces indirect $ D551 Tooth-coloured restoration one surface indirect $ D552 Tooth-coloured restoration two surfaces indirect $ D553 Tooth-coloured restoration three surfaces indirect $ D554 Non-metallic restoration four surfaces indirect $ D555 Non-metallic restoration five surfaces indirect $ D572 Provisional (intermediate/temporary) restoration $75.00 D574 Metal band $77.00 D575 Pin retention per pin $29.00 D576 Metallic crown direct $ D577 Cusp capping per cusp $30.00 D578 Restoration of an incisal corner per corner $30.00 D579 Bonding of tooth fragment $ D582 Veneer direct $ D583 Veneer indirect $1, D595 Removal of inlay/onlay $72.00 D596 Recementing of inlay/onlay $69.00 D597 Post direct $ Item No. Prosthodontics Fee D611 Full crown acrylic resin indirect $ D613 Full crown non-metallic indirect $1, D615 Full crown veneered indirect $1, D618 Full crown metallic indirect $1, D625 Post and core for crown indirect $ D627 Preliminary restoration for crown direct $ D629 Post and root cap indirect $ D631 Provisional crown $ D632 Provisional bridge per pontic $ D642 Bridge pontic direct per pontic $ D643 Bridge pontic indirect per pontic $ D644 Semi-fixed attachment $ D645 Precision or magnetic attachment $ D649 Retainer for bonded fixture indirect per tooth $ D651 Recementing crown or veneer $ D652 Recementing bridge or splint per abutment $ D653 Rebonding of bridge or splint where retreatment of bridge surface is required $ D655 Removal of crown $ D656 Removal of bridge or splint $69.00 D658 Repair of crown, bridge or splint indirect $ D659 Repair of crown, bridge or splint direct $ D661 Fitting of implant abutment per abutment $ D663 Removal of implant $ D664 Fitting of bar for denture per abutment $ D666 Prosthesis with metal frame attached to implants per tooth $ D668 Fixture or abutment screw removal and replacement $ D669 Removal and reattachment of prosthesis fixed to implant(s) per implant $ D671 Full crown attached to osseointegrated implant non-metallic indirect $1, D672 Full crown attached to osseointegrated implant veneered indirect $1, D673 Full crown attached to osseointegrated implant metallic indirect $1, D678 Diagnostic template $ D679 Surgical implant guide $ D684 Insertion of first stage of two-stage endosseous implant per implant $1, D688 Insertion of one-stage endosseous implant per implant $ D689 Provisional implant $ D691 Second stage surgery of two-stage endosseous implant per implant $ D711 Complete maxillary denture $ D712 Complete mandibular denture $985.00

5 PAGE 5 of 6 Item No. Prosthodontics (continued) Fee D716 Metal palate or plate $ D719 Complete maxillary and mandibular dentures $1, D721 Partial maxillary denture resin base $ D722 Partial mandibular denture resin base $ D727 Partial maxillary denture cast metal framework $1, D728 Partial mandibular denture cast metal framework $1, D731 Retainer per tooth $42.00 D732 Occlusal rest per rest $37.00 D733 Tooth/teeth (partial denture) $39.00 D734 Overlays per tooth $56.00 D735 Precision or magnetic denture attachment $ D736 Immediate tooth replacement per tooth $41.00 D737 Resilient lining $ D738 Wrought bar $56.00 D739 Metal backing per backing $53.00 D741 Adjustment of a denture $47.00 D743 Relining complete denture processed $ D744 Relining partial denture processed $ D745 Remodelling complete denture $ D746 Remodelling partial denture $ D751 Relining complete denture direct $ D752 Relining partial denture direct $ D753 Cleaning and polishing of pre-existing denture $42.00 D754 Denture base modification $ D761 Reattaching pre-existing tooth or clasp to denture $ D762 Replacing/adding clasp to denture per clasp $ D763 Repairing broken base of a complete denture $ D764 Repairing broken base of a partial denture $ D765 Replacing tooth on denture per tooth $ D768 Adding tooth to partial denture to replace an extracted or decoronated tooth per tooth $ D769 Repair or addition to metal casting $ D771 Tissue conditioning preparatory to impressions per application $66.00 D772 Splint resin indirect $ D773 Splint metal indirect $ D774 Obturator $ D775 Characterization of denture base $ D776 Impression denture repair/modification $44.00 D777 Identification $50.00 D778 Inlay for denture tooth $ D779 Surgical guide for an immediate denture $ Item No. Orthodontics Fee D811 Passive removable appliance per arch $ D821 Active removable appliance per arch $ D823 Functional orthopaedic appliance $ D825 Sequential plastic aligners per arch $ D829 Partial banding per arch $ D831 Full arch banding per arch $1, D841 Fixed palatal or lingual arch appliance $ D842 Partial banding for inter-maxillary elastics (cross elastics) $1, D843 Maxillary expansion appliance $ D845 Passive fixed appliance $ D846 Minor tooth guidance fixed $ D851 Extraoral appliance $ D862 Bonding of attachment for application of orthodontic force $95.00 D871 Orthodontic adjustment $125.00

6 PAGE 6 of 6 Item No. Orthodontics (continued) Fee D875 Repair of removable appliance resin base $ D876 Repair of removable appliance clasp, spring or tooth $83.00 D877 Addition to removable appliance clasp, spring or tooth $75.00 D878 Relining removable appliance processed $ D881 Complete course of orthodontic treatment $ Item No. General Services Fee D911 Palliative care $59.00 D915 After-hours callout $ D916 Travel to provide services $83.00 D926 Individually made tray medicament(s) $ D927 Provision of medication/medicament $48.00 D928 Intravenous cannulation and establishment of infusion $37.00 D941 Local anaesthesia $42.00 D942 Sedation intravenous per 30 minutes or part thereof $ D943 Sedation inhalation per 30 minutes or part therof $68.00 D944 Relaxation therapy $ D949 Treatment under general anaesthesia/sedation $ D961 Minor occlusal adjustment per visit $42.00 D963 Clinical occlusal analysis including muscle and joint palpation $56.00 D964 Registration and mounting of models for occlusal analysis $ D965 Occlusal splint $ D966 Adjustment of pre-existing occlusal splint per visit $74.00 D967 Pantographic tracing $91.00 D968 Occlusal adjustment following occlusal analysis per visit $92.00 D971 Adjunctive physical therapy for temporomandibular joint and associated structures $99.00 D972 Repair/addition occlusal splint $87.00 D981 Splinting and stabilisation direct per tooth $94.00 D982 Enamel stripping per visit $33.00 D983 Single arch oral appliance-diagnosed snoring, obstructive snoring, sleep apnoea $ D984 Bimaxillary oral appliance-diagnosed snoring, obstructive snoring, sleep apnoea $1, D986 Post-operative care not otherwise included $40.00 D990 Treatment not otherwise included (specify) $35.00 D999 GST Actual Cost This table is part of the Schedule of Fees. The fees for other services are set out in the full Schedule of Fees, which is located at Submit your invoice via: Mail: Garrison Health Services C/- Medibank Health Solutions PO Box 9999 MELBOURNE VIC 3001 Fax: garrison.offbase@medibank.com.au Payment terms will be 14 days upon receipt of a valid invoice (with GST recorded separately). For further assistance: Phone: Visit: medibankhealth.com.au/garrisonhealthservices _0816

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