MEDSHIELD DENTAL TARIFFS - NON-NETWORK PROVIDERS

Transcription

1 Denis shall be entitled to update the tariff schedule from time to time. The tariffs listed do not consider scheme exclusions and scope of practice and is by no means a commitment of funding. Benefit entitlement is governed by the relevant scheme option and rules as well as risk management interventions and protocols. If the clinical code requires managed care intervention, all associated lab codes will be included in the authorisation process. * - Pre-authorisation is for the dental code to attract benefit Tariff amount not applicable MEDSHIELD DENTAL TARIFFS - NON-NETWORK PROVIDERS Trf Therapist 8025 HANDLING FEE - DIRECT MATERIALS (26% OF MATERIAL COST TO A MAXIMUM OF R26.00) R R ORAL EXAMINATION R R R COMPREHENSIVE ORAL EXAMINATION R R R LIMITED ORAL EXAMINATION R R R SPECIAL REPORT R INTRAORAL RADIOGRAPH - PERIAPICAL R R R R INTRAORAL RADIOGRAPHS - COMPLETE SERIES R R R R INFECTION CONTROL/BARRIER TECHNIQUES R R R R STERILIZED INSTRUMENTATION R R R R INTRAORAL RADIOGRAPH - BITEWING R R R INTRAORAL RADIOGRAPH - OCCLUSAL R R R EXTRAORAL RADIOGRAPH - HAND-WRIST R R EXTRAORAL RADIOGRAPH - PANORAMIC R R R EXTRAORAL RADIOGRAPH - CEPHALOMETRIC R R DIAGNOSTIC MODELS R R R R EXTRAORAL RADIOGRAPH - SKULL/FACIAL BONE R R DIAGNOSTIC MODELS MOUNTED R R TREATMENT PLAN COMPLETED ORAL AND/OR FACIAL IMAGE (DIGITAL/CONVENTIONAL) R R R R CARIES SUSCEPTIBILITY TESTS (BY ARRANGEMENT) PULP TESTS R OFFICE/HOSPITAL VISIT AFTER REGULARLY SCHEDULED HOURS R R R EMERGENCY DENTAL TREATMENT R R R R PULP REMOVAL (PULPECTOMY) R R RECEMENT INLAY, ONLAY, CROWN OR VENEER R R REMOVE INLAY, ONLAY OR CROWN R R ACCESS THROUGH A PROSTHETIC CROWN OR INLAY TO FACILITATE ROOT CANAL TREATMENT R R EMERGENCY CROWN (CHAIR-SIDE) R R REMOVE RETENTION POST (PREFABRICATED OR CAST) R R APPOINTMENT NOT KEPT /30MIN HOUSE/EXTENDED CARE FACILITY/HOSPITAL CALL * R R R INHALATION SEDATION - FIRST 15 MINUTES OR PART THEREOF R R INHALATION SEDATION - EACH ADDNL 15 MINUTES R R INTRAVENOUS SEDATION * R R LOCAL ANAESTHETIC - PER VISIT R R R R RESIN BONDING FOR RESTORATIONS MONITORING EQUIPMENT FOR INTRAVENOUS SEDATION R R ORAL HYGIENE INSTRUCTION R R R ORAL HYGIENE INSTRUCTION - EACH ADDITIONAL VISIT R R R 65.40

2 Therapist 8154 ORAL EXAMINATION - ORAL HYGIENIST POLISHING - COMPLETE DENTITION R R R R RE-BURNISHING AND POLISHING OF RESTORATIONS - COMPLETE DENTITION R ENAMEL MICROABRASION R PROPHYLAXIS - COMPLETE DENTITION R R R R REMOVAL OF GROSS CALCULUS TOPICAL APPLICATION OF FLUORIDE - CHILD R R R R TOPICAL APPLICATION OF FLUORIDE - ADULT R R R DENTAL SEALANT R R R R LIMITED ORAL EXAMINATION - ORAL HYGIENIST SEDATIVE FILLING R R R R APPLICATION OF DESENSITISING RESIN, PER TOOTH R R R R APPLICATION OF DESENSITISING MEDICAMENT, PER VISIT R R R R OCCLUSAL GUARD R R MOUTH PROTECTOR R R R COST OF ORTHOTIC APPLIANCE * * SPACE MAINTAINER - FIXED, PER ABUTMENT R R SPACE MAINTAINER - REMOVABLE R R PERIODONTAL SCREENING R R R ORAL HYGIENE INSTRUCTION (PERIODONTALLY COMPROMISED PATIENT) R ORAL HYGIENE INSTRUCTION - EACH ADDITIONAL VISIT (PERIODONTALLY COMPROMISED PATIENT) R POLISHING - COMPLETE DENTITION (PERIODONTALLY COMPROMISED PATIENT) R R R PROPHYLAXIS - COMPLETE DENTITION (PERIODONTALLY COMPROMISED PATIENT) * R R R THERAPEUTIC DRUG INJECTION R RE-EXAMINATION - EXISTING CONDITION R R R CONSULTATION - SECOND OPINION OR ADVICE R R SUTURE - MINOR R R EXTRACTION - TOOTH OR EXPOSED TOOTH ROOTS (FIRST PER QUADRANT) R R R EXTRACTION - EACH ADDITIONAL TOOTH OR EXPOSED TOOTH ROOTS R R R SURGICAL REMOVAL OF RESIDUAL ROOTS, FIRST TOOTH PER QUADRANT R R SURGICAL REMOVAL OF RESIDUAL ROOTS, SECOND AND SUBSEQUENT TEETH''S ROOTS R R COST OF SUTURE MATERIAL R R R ART RESTORATIONS COMPLETE DENTURES - MAXILLARY AND MANDIBULAR R R COMPLETE DENTURE - MAXILLARY OR MANDIBULAR R R PARTIAL DENTURE - RESIN BASE - ONE TOOTH R R PARTIAL DENTURE - RESIN BASE - TWO TEETH R R PARTIAL DENTURE - RESIN BASE - THREE TEETH R R PARTIAL DENTURE - RESIN BASE - FOUR TEETH R R PARTIAL DENTURE - RESIN BASE - FIVE TEETH R R PARTIAL DENTURE - RESIN BASE - SIX TEETH R R PARTIAL DENTURE - RESIN BASE - SEVEN TEETH R R PARTIAL DENTURE - RESIN BASE - EIGHT TEETH R R PARTIAL DENTURE - RESIN BASE - NINE OR MORE TEETH R R IMMEDIATE DENTURE - MAXILLARY R R

3 Therapist 8245 IMMEDIATE DENTURE - MANDIBULAR R R CLASP OR REST - CAST GOLD R CLASP OR REST - WROUGHT GOLD R CLASP OR REST - STAINLESS STEEL R BAR - LINGUAL OR PALATAL R (LABORATORY) R R REMODEL COMPLETE OR PARTIAL DENTURE R R RELINE COMPLETE OR PARTIAL DENTURE (CHAIR-SIDE) R R TISSUES CONDITIONING PER ARCH (INCLUDING SOFT SELF-CURE RELINE) R R R (LABORATORY) R R REPAIR DENTURE OR OTHER INTRA-ORAL APPLIANCE R ADD CLASP TO EXISTING PARTIAL DENTURE R ADD TOOTH TO EXISTING PARTIAL DENTURE R IMPRESSION TO REPAIR OR MODIFY A DENTURE OR OTHER INTRA-ORAL APPLIANCE R R ADJUST COMPLETE OR PARTIAL DENTURE R R INLAY IN DENTURE R PARTIAL DENTURE - CAST METAL FRAMEWORK ONLY R R PULP CAP - DIRECT R PULP CAP - INDIRECT R R RUBBER DAM PER ARCH R R COST OF MTA PULP AMPUTATION (PULPOTOMY) R R SUPPLY OF BLEACHING MATERIALS INTERNAL BLEACHING - PER TOOTH R INTERNAL BLEACHING - EACH ADDITIONAL VISIT R ROOT CANAL OBTURATION - ANTERIORS AND PREMOLARS - EACH ADDITIONAL CANAL R R ROOT CANAL THERAPY - ANTERIORS AND PREMOLARS - EACH ADDITIONAL CANAL R R REMOVAL OF ROOT CANAL OBSTRUCTION R R ROOT CANAL PREPARATORY VISIT - SINGLE CANAL TOOTH R R TOOTH R R RE-TREATMENT OF PREVIOUSLY COMPLETED ROOT CANAL THERAPY, PER CANAL R R ROOT CANAL OBTURATION - ANTERIORS AND PREMOLARS - FIRST CANAL R R ROOT CANAL OBTURATION - POSTERIORS - FIRST CANAL R R ROOT CANAL OBTURATION - POSTERIORS - EACH ADDITIONAL CANAL R R ROOT CANAL THERAPY - ANTERIORS AND PREMOLARS - FIRST CANAL R R ROOT CANAL THERAPY - POSTERIORS - FIRST CANAL R R ROOT CANAL THERAPY - POSTERIORS - EACH ADDITIONAL CANAL R R AMALGAM - ONE SURFACE R R R AMALGAM - TWO SURFACES R R R AMALGAM - THREE SURFACES R R R AMALGAM - FOUR OR MORE SURFACES R R R PREFABRICATED POST RETENTION, PER POST (IN ADDITION TO RESTORATION) R R PIN RETENTION - FIRST PIN (IN ADDITION TO RESTORATION) R R

4 Therapist 8348 PIN RETENTION - EACH ADDITIONAL PIN (IN ADDITION TO RESTORATION) R R CARVE RESTORATION TO ACCOMMODATE EXISTING REMOVABLE PROSTHESIS R RESIN CROWN - ANTERIOR PRIMARY TOOTH (DIRECT) R R R RESIN - ONE SURFACE, ANTERIOR R R R RESIN - TWO SURFACES, ANTERIOR R R R RESIN - THREE SURFACES, ANTERIOR R R R RESIN - FOUR OR MORE SURFACES, ANTERIOR R R R VENEER - RESIN (CHAIR-SIDE) R R PREFABRICATED METAL CROWN R R INLAY - METAL - ONE SURFACE R INLAY/ONLAY - METAL - TWO SURFACES R INLAY/ONLAY - METAL - THREE SURFACES R INLAY/ONLAY - METAL - FOUR OR MORE SURFACES R PIN RETENTION AS PART OF CAST RESTORATION (ANY NUMBER OF PINS) R RESIN - ONE SURFACE, POSTERIOR R R R RESIN - TWO SURFACES, POSTERIOR R R R RESIN - THREE SURFACES, POSTERIOR R R R RESIN - FOUR OR MORE SURFACES, POSTERIOR R R R INLAY - PORCELAIN - ONE SURFACE R INLAY/ONLAY - PORCELAIN - TWO SURFACES R INLAY/ONLAY - PORCELAIN - THREE SURFACES R INLAY/ONLAY - PORCELAIN - FOUR OR MORE SURFACES R PREFABRICATED RESIN CROWN R R CORE BUILD-UP WITH PREFABRICATED POSTS R R COST OF PREFABRICATED POSTS R R INLAY - RESIN - ONE SURFACE R INLAY/ONLAY - RESIN - TWO SURFACES R INLAY/ONLAY - RESIN - THREE SURFACES R INLAY/ONLAY - RESIN - FOUR OR MORE SURFACES R CAST CORE WITH SINGLE POST * R R CAST POST (EACH ADDITIONAL) R R CAST CORE WITH PINS (ANY NUMBER OF PINS) * R R CORE BUILD-UP WITH PINS R R CROWN - FULL CAST METAL * R R CROWN - 3/4 CAST METAL * R R CROWN - 3/4 PORCELAIN/CERAMIC * R R CROWN - RESIN LABORATORY * R R CROWN - RESIN WITH METAL * R R CROWN - PORCELAIN/CERAMIC * R R PROVISIONAL CROWN R CROWN - PORCELAIN VENEERED TO METAL * R R REPAIR CROWN (PERMANENT OR PROVISIONAL) R R ADDITIONAL FEE FOR PROVISION OF CROWN WITHIN AN EXISTING CLASP OR REST R R PONTIC - CERAMIC * R R PONTIC - CAST METAL * R R PONTIC - RESIN WITH METAL * R R PONTIC - PORCELAIN VENEERED TO METAL * R R PROVISIONAL PONTIC R INLAY/ONLAY RETAINER - METAL - TWO SURFACES * R R

5 Therapist 8433 INLAY/ONLAY RETAINER - METAL - THREE SURFACES * R R INLAY/ONLAY RETAINER - METAL - FOUR OR MORE SURFACES * R R INLAY/ONLAY RETAINER - PORCELAIN - TWO SURFACES * R R SURFACES * R R INLAY/ONLAY RETAINER - PORCELAIN - FOUR OR MORE SURFACES * R R CROWN RETAINER - FULL CAST METAL * R R CROWN RETAINER - 3/4 CAST METAL * R R CROWN RETAINER - CERAMIC * R R CROWN RETAINER - 3/4 CERAMIC * R R CROWN RETAINER - PORCELAIN VENEERED TO METAL * R R CROWN RETAINER - RESIN WITH METAL * R R PROVISIONAL CROWN RETAINER R GENERAL ANAESTHETIC CONSULTATION - PROSTHODONTIS OCCLUSION ANALYSIS MOUNTED R PANTOGRAPHIC RECORDING R DETAILED CONSULTATION - PROSTHODONTIST COMPREHENSIVE CONSULTATION - PROSTHODONTIST ELECTROGNATHOGRAPHIC RECORDING R ELECTROGNATHOGRAPHIC RECORDING WITH COMPUTER ANALYSIS R RECEMENT BRIDGE R R REMOVE BRIDGE R R REIMPLANTATION OF AVULSED TOOTH (INCLUDE STABILISATION) R R REPAIR BRIDGE R R IMPLANT SUPPORTED REMOVABLE COMPLETE OVERDENTURE R R IMPLANT SUPPORTED REMOVABLE PARTIAL OVERDENTURE R R CROWN-IMPLANT/ABUTMENT SUPPORTED CROWN - PORCELAIN/CERAMIC * R R CROWN-IMPLANT/ABUTMENT SUPPORTED CROWN - PORCELAIN WITH METAL * R R CROWN-IMPLANT/ABUTMENT SUPPORTED CROWN - CAST METAL * R R IMPLANT SUPPORTED CROWN RETAINER - CERAMIC * R R IMPLANT SUPPORTED CROWN RETAINER - PORCELAIN VENEERED TO METAL * R R CROWN RETAINER - IMPLANT/ABUTMENT SUPPORTED - CAST METAL * R R OCCLUSAL ADJUSTMENT - MAJOR R VENEER - PORCELAIN (LABORATORY) R OCCLUSAL ADJUSTMENT - MINOR R VENEER - RESIN (LABORATORY) R COST OF CERAMIC BLOCK * R GOLD FOIL CLASS I OR IV R GOLD FOIL CLASS V R GOLD FOIL CLASS III R FABRICATION OF COMPUTER GENERATED CERAMIC RESTORATION * R PREFABRICATED ABUTMENT R R CUSTOM ABUTMENT R R CUSTOMISED PREFABRICATED ABUTMENT * * - - -

6 8581 CAST CORE WITH SINGLE POST CAST CORE WITH DOUBLE POST CAST CORE WITH TRIPLE POST CONNECTOR BAR - IMPLANT SUPPORTED - Therapist 8585 CONNECTOR BAR STRESS BREAKER COPING METAL R R IMPLANT MAINTENANCE PROCEDURES - PER IMPLANT R R CROWN - IMPLANT/ABUTMENT SUPPORTED * R * REPAIR OF IMPLANT SUPPORTED PROSTHESIS R R REPAIR OF IMPLANT ABUTMENT R R LOCKS AND MILLED RESTS R PRECISION ATTACHMENT (REMOVABLE DENTURE) R COST OF IMPLANT COMPONENTS * * PONTIC - SANITARY PONTIC - POSTERIOR PONTIC - ANTERIOR/PREMOLAR RETAINER CAST METAL (MARYLAND TYPE RETAINER) * R R ROOT CANAL THERAPY - FIRST CANAL SPECIALIST PROSTHODONTIST ROOT CANAL THERAPY - EACH ADDITIONAL CANAL SPECIALIST PROSTHODONTIST APEXIFICATION/APEXOGENESIS/RECALCIFICATION PER VISIT R R REMOVAL OF FRACTURED ROOT CANAL INSTRUMENT R COMPLETE DENTURES - MAXILLARY AND MANDIBULAR. ONLY FOR PROSTHODONTISTS COMPLETE DENTURES - MAXILLARY OR MANDIBULAR. ONLY FOR PROSTHODONTISTS IMMEDIATE DENTURE - MAXILLARY. ONLY FOR PROSTHODONTIST IMMEDIATE DENTURE - MANDIBULAR. ONLY FOR PROSTHODONTIST OVERDENTURE - COMPLETE R R OVERDENTURE - PARTIAL R R IMPLANT SUPPORTED FIXED-DETACHABLE COMPLETE OVERDENTURE R R IMPLANT SUPPORTED FIXED-DETACHABLE PARTIAL OVERDENTURE R R REPLACEMENT OF PRECISION ATTACHMENT R INTERIM COMPLETE DENTURE R R INTERIM PARTIAL DENTURE R R ADDITIONAL FEE TO IMPLANT SUPPORTED FIXED- DETACHABLE DENTURE - PER IMPLANT R R DIAGNOSTIC DENTURES (INCLUDING TISSUE CONDITIONING) ADJUST COMPLETE OR PARTIAL DENTURES (REMOUNTING) R METAL BASE TO COMPLETE DENTURE R REMOUNT CROWN OR BRIDGE FOR ADJUSTMENT R SOFT BASE TO DENTURE (HEAT CURED) R PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASE ALTERED CAST TECHNIQUE (IN ADDITION TO PARTIAL DENTURE) R R ADDITIVE PARTIAL DENTURE R

7 Therapist 8701 CONSULTATION - PERIODONTIST CONSULTATION - PERIODONTIST (DETAILED) RE-EXAMINATION - PERIODONTIST PERIODONTAL SCREENING - PERIODONTIST PROVISIONAL SPLINTING - EXTRACORONAL (WIRE) - PER SEXTANT R R PROVISIONAL SPLINTING - EXTRACORONAL (WIRE PLUS RESIN) - PER SEXTANT R R PROVISIONAL SPLINTING - INTRACORONAL - PER TOOTH R R INCISION & DRAINAGE OF ABSCESS - INTRA-ORAL R R QUADRANT * R R R ROOT PLANING - ONE TO THREE TEETH PER QUADRANT * R R R GINGIVECTOMY/GINGIVOPLASTY - FOUR OR MORE TEETH PER QUADRANT R GINGIVECTOMY OR GINGIVOPLASTY - ONE TO THREE TEETH PER QUADRANT R FLAP PROCEDURE, ROOT PLANING AND ONE TO THREE SURGICAL SERVICES - PER QUADRANT R FLAP PROCEDURE, ROOT PLANING AND ONE TO THREE SURGICAL SERVICES - PER SEXTANT R FLAP PROCEDURE, ROOT PLANING AND FOUR OR MORE SURGICAL SERVICES - PER QUADRANT R FLAP PROCEDURE, ROOT PLANING AND FOUR OR MORE SURGICAL SERVICES - PER SEXTANT R CLINICAL CROWN LENGTHENING (ISOLATED PROCEDURE) * R R PEDICLE FLAPPED GRAFT (ISOLATED PROCEDURE) R MASTICATORY MUCOSAL AUTOGRAFT - ONE TO FOUR TEETH (ISOLATED PROCEDURE) R MASTICATORY MUCOSAL AUTOGRAFT - FOUR OR MORE TEETH (ISOLATED PROCEDURE) R WEDGE RESECTION (ISOLATED PROCEDURE) * R R HEMISECTION OF A TOOTH, RESECTION OF A ROOT OR TUNNEL PREPARATION (ISOLATED PROCEDURE) R BONE REGENERATION/REPAIR PROCEDURE - AS PART OF A FLAP OPERATION R BONE REGENERATION/REPAIR PROCEDURE - AT A SINGLE SITE R UNLISTED PERIODONTAL PROCEDURE R MEMBRANE REMOVAL (USED FOR GUIDED TISSUE REGENERATION) R COST OF BONE REGENERATIVE/REPAIR MATERIAL SUBMUCOSAL CONNECTIVE TISSUE AUTOGRAFT (ISOLATED PROCEDURE) R COST OF INTRAPOCKET CHEMOTHERAPEUTIC AGENT CONSULTATION - ORAL MEDICINE (SIMPLE) CONSULTATION - ORAL MEDICINE (COMPLEX) CONSULTATION - ORAL MEDICINE (SUBSEQUENT) UNLISTED ORAL MEDICINE PROCEDURE R CONSULTATION - ORTHODONTIST CONSULTATION - ORTHODONTIS (SUBSEQUENT, RETENTION AND POST TREATMENT) TRACING AND ANALYSIS OF EXTRA-ORAL FILM R R DIAGNOSIS AND TREATMENT PLANNING - ORTHODONTIST DIAGNOSTIC SETUP R R

8 Therapist 8840 TREATMENT PLANNING FOR ORTHOGNATHIC SURGERY - ALL R ORTHO TX - FIXED LINGUAL APPLIANCE - ONE ARCH * * - * ORTHO TX - FIXED LINGUAL APPLIANCE - ONE ARCH, MODEATE * * - * ORTHO TX - FIXED LINGUAL APPLIANCE - ONE ARCH, SEVERE * * - * REPAIR ORTHODONTIC APPLIANCE - REMOVABLE R R REPLACE ORTHODONTIC APPLIANCE - REMOVABLE R R REPAIR ORTHODONTIC APPLIANCE - FIXED R R RETAINER (ORTHODONTIC) R R TREATMENT OF MPDS - FIRST VISIT R R TREATMENT OF MPDS - SUBSEQUENT VISIT R R OCCLUSAL ORTHOTIC APPLIANCE R R CONSULTATION - CLEFT PALATE THERAPY (HOUSE OR HOSPITAL) R CONSULTATION - CLEFT PALATE (SUBSEQUENT) R CONSULTATION - CLEFT PALATE (MAXIMUM) R ORTHO TX - FUNCTIONAL APPLIANCE * * - * ORTHO TX - PARTIAL FIXED APPLIANCE - MINOR * * - * ORTHO TX - REMOVABLE APPLIANCE * * - * ORTHO TX - EACH ADDITIONAL REMOVABLE APPLIANCE * * - * ORTHO TX - PARTIAL FIXED APPLIANCE - ONE ARCH * * - * ORTHO TX - PARTIAL FIXED APPLIANCE - BOTH ARCHES * * - * ORTHO TX - FIXED APPLIANCE - ONE ARCH * * - * ORTHO TX - FIXED APPLIANCE - ONE ARCH, MODEATE * * - * ORTHO TX - FIXED APPLIANCE - ONE ARCH, SEVERE * * - * ORTHO TX - FIXED APPLIANCE - BOTH ARCHES, CLASS 1 MILD * * - * ORTHO TX - FIXED LINGUAL APPLIANCE - BOTH ARCHES, CLASS 1 MILD * * - * ORTHO TX - FIXED APPLIANCE - BOTH ARCHES, CLASS 1 MODERATE * * - * ORTHO TX - FIXED LINGUAL APPLIANCE - BOTH ARCHES, CLASS 1 MODERATE * * - * ORTHO TX - FIXED APPLIANCE - BOTH ARCHES, CLASS 1 SEVERE * * - * ORTHO TX - FIXED LINGUAL APPLIANCE - BOTH ARCHES, CLASS 1 SEVERE * * - * ORTHO TX - FIXED APPLIANCE - BOTH ARCHES, CLASS 1 SEVERE W/ COMPLICATIONS * * - * ORTHO TX - FIXED LINGUAL APPLIANCE - BOTH ARCHES, CLASS 1 SEVERE W/ COMPLICATIONS * * - * ORTHO TX - FIXED APPLIANCE - BOTH ARCHES, CLASS 2/3 MILD * * - * ORTHO TX - FIXED LINGUAL APPLIANCE - BOTH ARCHES, CLASS 2/3 MILD * * - * ORTHO TX - FIXED APPLIANCE - BOTH ARCHES, CLASS 2/3 MODERATE * * - * ORTHO TX - FIXED LINGUAL APPLIANCE - BOTH ARCHES, CLASS 2/3 MODERATE * * - * ORTHO TX - FIXED APPLIANCE - BOTH ARCHES, CLASS 2/3 SEVERE * * - * ORTHO TX - FIXED LINGUAL APPLIANCE - BOTH ARCHES, CLASS 2/3 SEVERE * * - * ORTHO TX - FIXED APPLIANCE - BOTH ARCHES, CLASS 2/3 SEVERE W/ COMPLICATIONS * * - * -

9 Therapist 8888 ORTHO TX - FIXED LINGUAL APPLIANCE - BOTH ARCHES, CLASS 2/3 SEVERE W/ COMPLICATIONS * * - * MONTHLY INSTALMENT ORTHO TX * * - * ORTHODONTIC TRANSFER * * - * ORTHODONTIC RE-TREATMENT * * - * CONSULTATION - MFOS CONSULTATION - MFOS (DETAILED) HOUSE/HOSP/NURSING HOME CONSULTATION - MFOS HOUSE/HOSP/NURSING HOME CONSULTATION (SUBSEQUENT) - MFOS AFTER REGULARLY HOURS CONSULTATION - MFOS HOUSE/HOSP/NURSING HOME CONSULTATION (MAXIMUM PER WEEK) - MFOS SURGICAL REMOVAL OF ROOTS FROM MAXILLARY ANTRUM R R ORAL ANTRAL FISTULA CLOSURE R R CALDWELL-LUC PROCEDURE R R BIOPSY OF ORAL TISSUE - SOFT R R BIOPSY OF BONE - NEEDLE * R R BIOPSY EXTRA-ORAL BONE/SOFT TISSUE * R R TREATMENT OF POST-EXTRACTION HAEMORRHAGE R R R TREATMENT OF HAEMORRHAGE (BLOOD DYSCRACIAS) R R TREATMENT OF SEPTIC SOCKET R R R SURGICAL REMOVAL OF TOOTH R R SURGICAL REMOVAL OF IMPACTED TOOTH - FIRST TOOTH R R SURGICAL REMOVAL OF IMPACTED TOOTH - SECOND TOOTH R R SURGICAL REMOVAL OF IMPACTED TOOTH - THIRD AND SUBSEQUENT TEETH R R SURGICAL REMOVAL OF RESIDUAL ROOTS, FIRST TOOTH - PER TOOTH R ALVEOLOTOMY OR ALVEOLECTOMY (INCLUDING EXTRACTIONS) R R EMERGENCY TRACHEOTOMY * * PHARYNGOSTOMY * * TOOTH TRANSPLANTATION R HARVEST ILIAC CREST GRAFT R HARVEST RIB GRAFT R HARVEST CRANIUM GRAFT R PERIPHERAL NEURECTOMY R REPAIR OF ORONASAL FISTULA (LOCAL FLAPS) * * SURGICAL REMOVAL OF JAW CYST - INTRA-ORAL APPROACH R R SURGICAL REMOVAL OF JAW CYST - EXTRA-ORAL APPROACH R EXCISION OF TUMOUR OF THE SOFT TISSUE R SURGICAL EXCISION OF TUMOURS OF THE JAW R HEMIRESECTION OF JAW EXCLUDING CONDYL * * SURGICAL REPAIR OF MAXILLA OR MANDIBLE - MAJOR R HARVESTING OF AUTOGENOUS GRAFTS (INTRA-ORAL) R SURGICAL EXPOSURE OF IMPACTED OR UNERUPTED TEETH TO AID ERUPTION R CORTICOTOMY - FIRST TOOTH R CORTICOTOMY - EACH ADDITIONAL TOOTH R FRENULECTOMY/FRENULOTOMY R R

10 Therapist 8987 REDUCTION OF MYLOHYOID RIDGES - PER SIDE R REMOVAL TORUS MANDIBULARIS R REMOVAL OF TORUS PALATINUS R SURGICAL REDUCTION OF OSSEOUS TUBEROSITY - PER SIDE R GINGIVECTOMY - PER JAW R SULCOPLASTY / VESTIBULOPLASTY R REPOSITION MENTAL FORAMEN AND NERVE - PER SIDE R LATERALIZATION OF INFERIOR DENTAL NERVE R ALVEOLAR RIDGE AUGMENTATION - TOTAL (BY BONE GRAFT) R ALVEOLAR RIDGE AUGMENTATION - TOTAL (BY ALLOPLASTIC MATERIAL) R ALVEOLAR RIDGE AUGMENTATION - ONE TO TWO TOOTH SITES R ALVEOLAR RIDGE AUGMENTATION - THREE ACROSS 3 OR MORE TOOTH SITES R SINUS LIFT PROCEDURE R INCISION & DRAINAGE OF ABSCESS - INTRA-ORAL (PYOGENIC) R R INCISION & DRAINAGE OF ABSCESS - EXTRA-ORAL (PYOGENIC) * * APICECTOMY/PERIRADICULAR SURGERY - ANTERIORS (INCLUDING RETROGRADE FILLING) R R APICECTOMY/PERIRADICULAR SURGERY - MOLARS (INCLUDING RETROGRADE FILLING) R R DECORTICATION, SAUCERISATION AND SEQUESTRECTOMY * * SEQUESTRECTOMY - INTRA ORAL PER SEXTANT AND OR RAMUS R SUTURE - RECONSTRUCTION, MINOR (EXCLUDES CLOSURE OF SURGICAL INCISIONS) R R SUTURE - RECONSTRUCTION, MAJOR (EXCLUDES CLOSURE OF SURGICAL INCISIONS) R R DENTO-ALVEOLAR FRACTURE - PER SEXTANT R MANDIBLE FRACTURE - CLOSED REDUCTION * * MANDIBLE FRACTURE - COMPOUND, WITH EYELET WIRING * * - * MANDIBLE FRACTURE - SPLINTS * * - * MANDIBLE FRACTURE - OPEN REDUCTION * * - * REDUCTION OF MASSETER MUSCLE AND BONE - EXTRA- ORAL APPROACH OPEN TREATMENT OF CONDYLAR FRACTURE MAXILLA FRACTURE - LE FORT I OR GUERIN * * OPEN TREATMENT OF MAXILLARY FRACTURE - LE FORT I MAXILLA FRACTURE - LE FORT II OR MIDDLE THIRD FACE * * OPEN TREATMENT OF MAXILLARY FRACTURE - LE FORT II MIDDLE THIRD OF FACE MAXILLA FRACTURE - LE FORT III OR CRANIOFACIAL 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 * * - - -

11 Therapist 9048 SURGICAL REMOVAL OF INTERNAL FIXATION DEVICES, PER SITE * * - * OSTEOTOMY - MANDIBLE BODY, ANTERIOR SEGMENTAL * * OSTEOTOMY - TOTAL SUBAPICAL * * GENIOPLASTY * * MIDFACIAL EXPOSURE * * CORONOIDECTOMY (INTRA-ORAL APPROACH) * * OSTEOTOMY - SEGMENTED, POSTERIOR * * OSTEOTOMY - SEGMENTED, ANTERIOR * * RECONSTRUCT MAXILLA - LE FORT I OSTEOTOMY, ONE PIECE * * RECONSTRUCT MAXILLA - LE FORT I OSTEOTOMY W/ REPOSITIONING AND GRAFT * * PALATAL OSTEOTOMY * * RECONSTRUCT MAXILLA - LE FORT I OSTEOTOMY, MULTIPLE SEGMENTS * * RECONSTRUCT MAXILLA - LE FORT 2 OSTEOTOMY (FACIAL AND POST-TRAUMATIC DEFORMITIES) * * RECONSTRUCT MAXILLA - LE FORT 3 OSTEOTOMY (SEVERE CONGENITAL DEFORMITIES) * * SURGICAL EXPANSION - MAXILLIARY OR MANDIBULAR * * DISTRACTION OSTEOGENESIS - ACROSS ONE TO TWO TOOTH SITES DISTRACTION OSTEOGENESIS - ACROSS THREE TO FIVE TOOTH SITES GLOSSECTOMY - PARTIAL * * DISTRACTION OSTEOGENESIS - FULL ARCH 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 * * - * REDUCTION OF TMJ DISLOC W/ ANAESTHETIC AND IMMOBOBILISATION * * - * REDUCTION OF TMJ DISLOCATION - OPEN REDUCTION * * JOINT RECONSTRUCTION * * REMOVAL OF SALIVARY STONE (SIALOLITHOTOMY) R R EXCISION OF SUBLINGLUAL SALIVARY GLAND * * - * EXCISION OF SALIVARY GLAND - EXTRA ORAL APPROACH * * REPORT) * * * * OBTURATOR PROSTHESIS, SURGICAL - MODIFIED DENTURE * * OBTURATOR PROSTHESIS, SURGICAL - CONTINUOUS BASE * * OBTURATOR PROSTHESIS, SURGICAL - SPLIT BASE * * OBTURATOR PROSTHESIS, INTERIM - ON EXISTING DENTURE * * OBTURATOR PROSTHESIS, INTERIM - ON NEW DENTURE * * - - -

12 Therapist 9106 OBTURATOR PROSTHESIS, DEFINITIVE - OPEN/HOLLOW BOX * * OBTURATOR PROSTHESIS, DEFINITIVE - SILICONE GLOVE * * MANDIBULAR RESECTION PROSTHESIS W/ GUIDE FLANGE * * MANDIBULAR RESECTION PROSTHESIS W/O GUIDE FLANGE * * MANDIBULAR RESECTION PROSTHESIS, PALATAL 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 * * ORTHOPAEDIC APPLIANCE, ACTIVE PRESURGICAL - MINOR * * ORTHOPAEDIC APPLIANCE, ACTIVE PRESURGICAL - MODERATE * * ORTHOPAEDIC APPLIANCE, ACTIVE PRESURGICAL - SEVERE * * ORTHOPAEDIC APPLIANCE, ACTIVE PRESURGICAL - MODIFICATION * * SPEECH AID/OBTURATOR PROSTHESIS - PALATAL ALTERATION * * SPEECH AID/OBTURATOR PROSTHESIS - VELAR ALTERATION * * SPEECH AID/OBTURATOR PROSTHESIS - PHARYNGEAL ALTERATION * * SPEECH AID/OBTURATOR PROSTHESIS - 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 * * 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 * * UNSPECIFIED BODY PROSTHESIS - SIMPLE * * UNSPECIFIED BODY PROSTHESIS - COMPLEX * * FACIAL PROSTHESIS, SURGICAL - SIMPLE * * FACIAL PROSTHESIS, SURGICAL - COMPLEX * * CRANIAL PROSTHESIS * * CRANIAL IMPLANT PROSTHESIS, CUSTOM MADE * * FACIAL IMPLANT PROSTHESIS, CUSTOM MADE - SIMPLE * * - - -

13 Therapist 9158 FACIAL IMPLANT PROSTHESIS, CUSTOM MADE - COMPLEX * * OCULAR IMPLANT PROSTHESIS, CUSTOM MADE * * BODY IMPLANT PROSTHESIS - CUSTOM MADE * * SURGICAL SPLINT - SIMPLE * * SURGICAL SPLINT - COMPLEX * * 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 * * UNSPECIFIED BURN APPLIANCE THEATRE ATTENDANCE (MAXFAC PROSTHOD) /HOUR SURGICAL PLACEMENT OF SUB-PERIOSTEAL IMPLANT - PREPARATORY STAGE * R SURGICAL PLACEMENT OF SUB-PERIOSTEAL IMPLANT - PLACEMENT STAGE * R SURGICAL PLACEMENT OF ENDOSTEAL IMPLANT PLATE * R SURGICAL PLACEMENT OF ENDOSSEUS IMPLANT - FIRST PER QUADRANT * R SURGICAL PLACEMENT OF ENDOSSEUS IMPLANT - SECOND PER QUADRANT * R SURGICAL PLACEMENT OF ENDOSSEUS IMPLANT - THIRD AND SUBSEQUENT PER QUADRANT * R COST OF ENDOSTEAL IMPLANT BODY * * COST OF PREFABRICATED ABUTMENT * * COST OF OTHER IMPLANT COMPNTS * * SURGICAL EXPOSURE OF ENDOSSEUS IMPLANT - FIRST PER QUADRANT * R SURGICAL EXPOSURE OF ENDOSSEUS IMPLANT - SECOND PER QUADRANT * R SURGICAL EXPOSURE OF ENDOSSEUS IMPLANT - THIRD AND SUBSEQUENT PER QUADRANT * R SURGICAL REMOVAL OF IMPLANT * R R CONSULTATION - ORAL PATHOLOGIST HOUSE/HOSP/NURSING HOME CONSULTATION - ORAL PATHOLOGIST CONSULTATION - ORAL PATHOLOGIST (SUBSEQUENT) AFTER HOURS VISIT - ORAL PATHOLOGIST REPAIR CLEFT HARD PALATE - UNILATERAL * * REPAIR CLEFT HARD PALATE - BILATERAL (ONE PROCEDURE) * * REPAIR CLEFT HARD PALATE - BILATERAL (TWO PROCEDURES) * * REPAIR CLEFT SOFT PALATE - W/O MUSCLE RECONSTRUCTION * * REPAIR CLEFT SOFT PALATE - W/ MUSCLE RECONSTRUCTION * * REPAIR SUBMUCOSAL CLEFT AND/OR BIFID UVULA - W/ MUSCLE RECONSTRUCTION * * UNCOMPLICATED * * - - -

14 Therapist 9234 VELOPHARYNGEAL RECONSTRUCTION - COMPLICATED * * REPAIR ORONASAL FISTULA (ONE PROCEDURE) * * REPAIR ORONASAL FISTULA (TWO PROCEDURES) * * SECONDARY PERIOSTEAL FLAPS * * LIPADHESION * * - * REPAIR CLEFT LIP - UNILATERAL W/O MUSCLE RECONSTRUCTION * * REPAIR CLEFT LIP - UNILATERAL W/ MUSCLE RECONSTRUCTION * * REPAIR CLEFT LIP - BILATERAL W/O MUSCLE RECONSTRUCTION * * REPAIR CLEFT LIP - BILATERAL W/ MUSCLE RECONSTRUCTION * * REPAIR ANTERIOR NASAL FLOOR * * REVISION OF SECONDARY CLEFT LIP DEFORMITY - PARTIAL * * REVISION OF SECONDARY CLEFT LIP DEFORMITY - TOTAL W/ MUSCLE RECONSTRUCTION * * ABBE-FLAP - TWO STAGES * * RECONSTRUCT COLUMELLA * * RECONSTRUCT NOSE DUE TO CLEFT DEFORMITY - PARTIAL * * RECONSTRUCT NOSE DUE TO CLEFT DEFORMITY - COMPLETE * * PARANASAL AUGMENTATION FOR NASAL BASE DEVIATION * * REPAIR ANTERIOR TABLE, FRONTAL SINUS AND/OR SUPRAORBITAL RIM REPAIR ANTERIOR AND POSTERIOR WALL W/ OBTURATION AND/OR CRANIALISATION OF FRONTAL SINUS REPAIR MEDIAL CANTHAL LIGAMENT (CANTHOPEXY), PER SIDE OPEN REDUCTION AND FIXATION OF NASAL FRACTURES MANIPULATION AND IMMOBILISATION OF NASAL FRACTURE MUSCULOFASCIAL FLAP MUSCULOCRANIAL FLAP BUCCAL FAT PAD (MAJOR REPAIR) MAXILLECTOMY - ALVEOLUS ONLY, LEVEL I MAXILLECTOMY - ALVEOLUS AND SINUS OR NASAL FLOOR, LEVEL II MAXILLECTOMY - ALVEOLUS, SINUS, NASAL FLOOR AND ZYGOMA EXCLUDING ORBITAL RIM LEVEL III MAXILLECTOMY - ALVEOLUS, SINUS, NASAL FLOOR AND ZYGOMA INCLUDING ORBITAL RIM LEVEL IV MAXILLECTOMY - ALVEOLUS, SINUS, NASAL FLOOR, ZYGOMA, ORBITAL RIM AND PTERYGOID PLATES LEVEL HEMIRESECTION OF JAW INCLUDING CONDYLE AND CORONOID PROCESS CASTING AND TRIMMING OF MODEL IN PLASTER (YELLOW/WHITE), PER MODEL R R CASTING AND TRIMMING OF MODEL IN SUPER-HARD STONE (DIE-STONE) PER MODEL R R MODEL R R CASTING AND TRIMMING OF GNATHOSTATIC MODEL, PER MODEL. R R NEW TRIMMED BASE TO SUPPLIED MODEL, PER MODEL R R

15 Therapist 9311 TRIMMING OF SUPPLIED MODEL, PER MODEL R R GINGIVAL TISSUE MASK PER IMPLANT R DUPLICATING MODEL, PER MODEL R REFRACTORY MODEL, PER UNIT R MODELS AND DUPLICATE MODELS (VIRGIN MODEL) FOR CROWN AND BRIDGE, WORK INCLUSIVE OF ONE REMOVABLE DIE R R SECTIONAL MODELS FOR CROWN AND BRIDGE, WORK INCLUSIVE OF ONE REMOVABLE DIE R EACH ADDITIONAL REMOVABLE DIE FOR ITEMS 9315 AND 9317 PER DIE R R INDEXED OR MODEL TRAY PER DIE (NOT MORE THAN 9319) R OCCLUSION BLOCK, PER BLOCK R R OCCLUSION BLOCK ON BASEPLATE, PER BLOCK R INFECTION CONTROL PER IMPRESSION, DENTURE (WAX OR ACRYLIC) OR ANY ITEM IN CONTACT WITH BODY FLUIDS R R FIT AND SUPPLY OF DISPOSABLE ARTICULATOR R DELIVERY / COLLECTION FEE PER COMPLETED PROCEDURE (MAXIMUM 4) FULL UPPER AND LOWER DENTURES R FULL UPPER OR LOWER DENTURE R R SET-UP AND WAXING OF FULL UPPER AND LOWER DENTURES R SET-UP AND WAXING OF FULL UPPER OR LOWER DENTURE R WAXING AND FINISHING OF FULL UPPER AND LOWER DENTURES R WAXING AND FINISHING OF FULL UPPER OR LOWER DENTURE R ADDITIONAL FEE FOR DENTURES ON FULLY ADJUSTABLE ARTICULATOR AT REQUEST OF DENTIST R ADDITIONAL FEE FOR IMMEDIATE DENTURES, OR TOOTH SOCKETED R ADDITIONAL FEE FOR IMMEDIATE DENTURES, PER TOOTH NOT SOCKETED. R ADDITIONAL FEE FOR EACH RETRY FROM THE THIRD AND UPWARDS AT AN AGREED QUANTUM OF TIME TO BE CALCULATED AT HOURLY RATE R SET-UP AND FINISH OF ONE-TOOTH DENTURE R SET-UP AND FINISH OF TWO-TOOTH DENTURE R SET-UP AND FINISH OF THREE-TOOTH DENTURE R SET-UP AND FINISH OF FOUR-TOOTH DENTURE R SET-UP AND FINISH OF FIVE-TOOTH DENTURE R SET-UP AND FINISH OF SIX-TOOTH DENTURE R SET-UP AND FINISH OF SEVEN-TOOTH DENTURE R SET-UP AND FINISH OF EIGHT-TOOTH DENTURE R SET-UP AND FINISH NINE OR MORE TOOTH DENTURE R SET-UP AND WAXING OF ONE-TOOTH DENTURE R SET-UP AND WAXING OF TWO-TOOTH DENTURE R SET-UP AND WAXING OF THREE-TOOTH DENTURE R SET-UP AND WAXING OF FOUR-TOOTH DENTURE R SET-UP AND WAXING OF FIVE-TOOTH DENTURE R SET-UP AND WAXING OF SIX-TOOTH DENTURE R SET-UP AND WAXING OF SEVEN-TOOTH DENTURE R

16 Therapist 9368 SET-UP AND WAXING OF EIGHT-TOOTH DENTURE R SET-UP AND WAXING OF NINE OR MORE TOOTH DENTURE R WAXING AND FINISHING OF ONE-TOOTH DENTURE R WAXING AND FINISHING OF TWO-TOOTH DENTURE R WAXING AND FINISHING OF THREE-TOOTH DENTURE R WAXING AND FINISHING OF FOUR-TOOTH DENTURE R WAXING AND FINISHING OF FIVE-TOOTH DENTURE R WAXING AND FINISHING OF SIX-TOOTH DENTURE R WAXING AND FINISHING OF SEVEN-TOOTH DENTURE R WAXING AND FINISHING OF EIGHTH-TOOTH DENTURE R WAXING AND FINISHING OF NINE OR MORE TOOTH DENTURE R ADDITIONAL FEE FOR FINISHING DENTURE IN TOOTH COLOUR MATERIAL, PER TOOTH R ADDITIONAL FEE FOR SUPPLYING FINISHED DENTURE ON DUPLICATE MODEL R BASIC CHARGE WHICH INCLUDES REPAIR OF ONE FRACTURE, OR ADDITION OF ONE TOOTH, OR ADDITION OF ONE CLASP R R ADDITIONAL CHARGE FOR EACH ADDITIONAL FRACTURE, OR TOOTH, OR CLASP R ADDITIONAL FEE FOR USING WIRE STRENGTHENER R ADDITIONAL FEE FOR USING PRE-FORMED STRENGTHENER R ADDITIONAL FEE FOR USING MESH STRENGTHENER IN REPAIR PROCEDURE R CLEAR BASE DOX GRINDING OF UPPER AND LOWER DENTURES R INLAY TO ARTIFICIAL TOOTH, ONE SURFACE ONLY, PER INLAY INLAY TO ARTIFICIAL TOOTH, MULTI-SURFACES E.G. HORSESHOE OR L-TYPE INLAY, PER INLAY DENTURE R FREGO FRAME R BLEACHING TRAY TEMPLATE PER UPPER OR LOWER DENTURE R RELINE/REBASE OF SINGLE DENTURE R REMODEL OF SINGLE DENTURE R SOFT BASE RELINE PER DENTURE R SOFT BASE TO NEW DENTURE, PER DENTURE R GUM TINTING PER DENTURE LINGUAL OR PALATAL BAR R CLEANING AND POLISHING OF EXISTING DENTURE, PER DENTURE R MESH STRENGTHENER R THEATRE/ CONSULTATION OUT OF LABORATORY PER HOUR OR PART THEREOF R SPECIAL TRAY, ACRYLIC, EACH R SPECIAL TRAY LIGHT CURE, EACH R SPECIAL TRAY IN BASE PLATE MATERIAL, EACH R PROVISION OF SINGLE ARM CLASP, TO PARTIAL DENTURE R PROVISION OF DOUBLE ARM CLASP, TO PARTIAL DENTURE R

17 Therapist 9439 PROVISION OF SINGLE ARM CLASP WITH REST, TO PARTIAL DENTURE R PROVISION OF DOUBLE ARM CLASP WITH REST, TO PARTIAL DENTURE R PROVISION OF PREFORMED ROACH CLASP, TO PARTIAL DENTURE R PROVISION OF REST ONLY TO PARTIAL DENTURE R CAST CLASP R CASTING AND TRIMMING OF MODEL FROM IMPRESSION INSIDE OCCLUSION BLOCK OR WAX TRY IN R FINISHING OF ACRYLIC WORK ON ANY CHROME COBALT OR GOLD PROSTHESIS R METAL BASE FOR FULL UPPER OR FULL LOWER DENTURE EACH BASIC CHARGE - WHICH EXCLUDES MODELS AND ANY SPECIAL TRAYS WHICH MAY BE REQUIRED BY THE DENTIST, BUT INCLUDES REFRACTORY MODEL R ADDITIONAL CHARGE FOR EACH ONE ARM CLASP R ADDITIONAL CHARGE FOR EACH ROACH CLASP R ADDITIONAL CHARGE FOR EACH REST R ADDITIONAL CHARGE FOR CONTINUOUS CLASP, PER TOOTH R ADDITIONAL CHARGE FOR LINGUAL BAR, PER TOOTH PASSED R ADDITIONAL CHARGE FOR PALATAL BAR R ADDITIONAL CHARGE FOR ONLAY ADDITIONAL CHARGE FOR SADDLE WITH FINISHING LINE, PER TOOTH R ADDITIONAL CHARGE FOR SADDLE WITHOUT FINISHING LINE, PER TOOTH R ADDITIONAL CHARGE FOR HORSESHOE SADDLE, PER TOOTH R ADDITIONAL CHARGE FOR FITTING OF TOOTH TO METAL BACKING, PER TOOTH R ADDITIONAL CHARGE FOR FITTING ONE DISTAL- EXTENSION HINGE R ADDITIONAL CHARGE PER MILLED EDGE PER TOOTH R ADDITIONAL CHARGE FOR EACH SOLDERING JOINT R ADDITIONAL CHARGE FOR SOLDERING RETENTION R ADDITIONAL CHARGE FOR EACH ADDITIONAL RETENTION SOLDERING JOINT R ADDITIONAL CHARGE FOR EACH WELDING JOINT R ADDITIONAL CHARGE FOR FITTING SWING LOCK R ADDITIONAL CHARGE FOR EACH BACKING CAST R ADDITIONAL CHARGE FOR EACH STEELS BACKING OR PONTIC CAST (PLASTIC WORK TO BE CHARGED IN ADDITION) R BASIC FEE FOR THE REPAIRING OF OR ADDITION TO ANY APPLIANCE NECESSITATING THE CASTING OF A MODEL (9301) R BASIC FEE IF A NEW SECTION IS TO BE FABRICATED AND WHERE ITEM 9495 DOES NOT APPLY (9301) R CERAMIC JACKET CROWN/CEROMER CROWN OR PONTIC * R CERAMIC METAL SUBSTITUTE COPING * R CERAMIC BONDED CROWN OR PONTIC * R R POST-SOLDER INVESTED JOINT, PER JOINT R INLAY IN PORCELAIN VENEER CROWN -

18 Therapist 9512 CERAMIC, INLAY/ONLAY, BRIDGE RETAINER * * CERAMIC POST * * PORCELAIN SHOULDER PER UNIT (NOT APPLICABLE TO PONTICS) R ADDITIONAL FEE FOR CROWN- & BRIDGE WORK PERFORMED ON A MOVABLE CONDYLE ARTICULATOR PER UNIT R FULL METAL CROWN, MOD, THREE-QUARTER CROWN * R INDIRECT COMPOSITE RESIN INLAY CLASS IV, MO, DO, CERVICAL/OCCLUSAL INLAY * R ADDITIONAL FEE FOR ONE PIECE CASTING OF CROWN OR INLAY ON POST R PIN-LEDGE INLAY FULL METAL PONTIC * R ABUTMENT THIMBLE CAST R PRECISION LOCK AND REST CAST LOCK AND REST CAST CASTING OF REST ONLY R METAL INLAY OR POST, CAST DIRECT GOLD/PRE-SOLDER INVESTED JOINT CAST POST WITH THIMBLE, INDIRECT * R MULTIPLE POST * R MANUFACTURE CAST POST AND CORE TO EXISTING CROWN * R C.S.P. ATTACHMENT (STEIGER) MILLING MILLED EDGE PER UNIT R TELESCOPE CROWN COMPOSITE/ACRYLIC VENEER CROWN/PONTIC, INDIRECT * R COMPOSITE/ACRYLIC JACKET CROWN, INDIRECT * R COMPOSITE/ACRYLIC VENEER POST CROWN * R INDIRECT COMPOSITE RESIN VENEER COMPOSITE/ACRYLIC JACKET CROWN, DIRECT * R TEMPORARY ACRYLIC/COMPOSITE CROWN PER UNIT HEAT FORMED TEMPLATE SUPPLIED TO DENTIST FOR THE MANUFACTURE OF TEMPORARY RESTORATIONS COMPOSITE/ACRYLIC-FACING REPLACED R PORCELAIN/ CEROMER FACING REPLACED R WAXING OF CROWN TO EXISTING DENTURE R ADDITIONAL FEE FOR EACH REMAKE AT AN AGREED QUANTUM OF TIME TO BE CALCULATED AT AN HOURLY RATE BASIC CHARGE WHICH INCLUDES ACRYLIC BASE R BASIC CHARGE NON ACRYLIC BASE R ADDITIONAL CHARGE FOR FITTING FIRST EXPANSION SCREW R ADDITIONAL FEE FOR FITTING SUBSEQUENT EXPANSION SCREWS R ADDITIONAL FEE FOR FULL ACLUSAL BITE PLATE R ADDITIONAL FEE FOR BITE PLATE ANTERIOR R ADDITIONAL FEE FOR BITE PLATE POSTERIOR R ADDITIONAL FEE FOR FITTING TONGUE GUARD R ADDITIONAL FEE FOR FLAT OR INCLINED PLANE R ADDITIONAL FEE FOR ADAMS CRIB R ADDITIONAL FEE FOR JACKSON CRIB R

19 Therapist 9587 ADDITIONAL FEE FOR BALL CLASP R ADDITIONAL FEE FOR SINGLE ARM CLASP R ADDITIONAL FEE FOR DOUBLE ARM CLASP R ADDITIONAL FEE FOR FITTING SINGLE LOOP FINGER SPRING R ADDITIONAL FEE FOR FITTING DOUBLE LOOP FINGER SPRING R ADDITIONAL FEE FOR FITTING BUCCAL RETRACTION SPRING R ADDITIONAL FEE FOR FITTING APRON SPRING R ADDITIONAL FEE FOR FITTING COFFIN SPRING R ADDITIONAL FEE FOR FITTING QUAD HELIX R ADDITIONAL FEE FOR FITTING FLAPPER OR T -SPRING R ADDITIONAL FEE FOR FITTING ALL SPRINGS WITH TUBING, EACH R ADDITIONAL FEE FOR FITTING LABIAL ARCH R ADDITIONAL FEE FOR FITTING BUCCAL ARCH R ADDITIONAL FEE FOR FITTING ROBERTS RETRACTOR R INVISIBLE RETAINER ADDITIONAL FEE FOR FITTING TWIN WIRE ARCH EXTRA- ORAL ARCH R ADDITIONAL FEE LIP BUMPER R ADDITIONAL FEE FOR FITTING EXTRA-ORAL ARCH R ADDITIONAL FEE FOR FITTING SPACE MAINTAINER ARCH R ADDITIONAL FEE FOR EACH SPOT-WELDING JOINT R ADDITIONAL FEE FOR EACH SOLDERING JOINT R ADDITIONAL FEE FOR EACH INVESTED SOLDERING JOINT R ADDITIONAL FEE FOR EACH HOOK FOR ELASTIC TRACTION R MOUTH PROTECTOR (GUM GUARD) ORAL SCREEN R ANDRESEN OR NORWEGIAN APPLIANCE R TOOTH POSITIONER R GUNNING SPLINT R FRANKEL APPLIANCE R CHIN CAP R BIONATOR R DIAGNOSTIC SET-UP SNORING APPLIANCE PINCHED OR SWAGED BAND WITH WELDED ATTACHMENT (EXCLUDING COST OF ATTACHMENT) R PINCHED OR SWAGED BAND WITH SOLDERED ATTACHMENT R ADDITIONAL FEE FOR EACH REMAKE AT AN AGREED QUANTUM OF TIME TO BE CALCULATED AT AN HOURLY RATE DIATORICS 1 X 6/8 R R DIATORICS, ODDS, ANTERIOR R DIATORICS, ODDS, POSTERIOR R R COST OF BLEACHING TRAY MATERIAL SOFT BASE MATERIAL PER DENTURE R R ACRYLIC PER DENTURE R COST OF PRECISION ATTACHMENT, PER ATTACHMENT PREFORMED BALL OR ROACH CLASP R COST OF LINGUAL / PALATAL BAR R

20 Therapist 9729 COST OF MESH STRENGTHENER R COST OF PRE-FABRICATED BURN-OUT COMPONENT, PER COMPONENT R COST OF OTHER ATTACHMENT COMPONENTS E.G. NYLON CAPS, SLEEVES ETC COST OF DOLDER BAR AND CLIPS, PER GRAM OR PER CLIP COST OF IMPLANT COMPONENTS * * COST OF PREFORMED STRENGTHENER R ADDITIONAL CHARGE GOLD PLATING COST OF GOLD WIRE, PER GRAM COST OF COBALT CHROME CASTING ALLOY R COST OF SPECIALISED COBALT CHROME CASTING METAL E G VITALLIUM, TITANIUM COST OF PRECIOUS CASTING ALLOY COST OF SEMI-PRECIOUS CASTING ALLOY COST OF NON-PRECIOUS CASTING ALLOY * * - * COST OF PLATINUM FOIL COST OF GOLD SOLDER, PER GRAM ETCHING FOR BONDING (METAL OR CERAMIC) COST OF SILVER SOLDER, PER GRAM R CEROMER MATERIAL - PER UNIT R FIBER RE-ENFORCED MATERIAL PER UNIT R FIBRE POST * * COMPOSITE RESTORATION MATERIAL CERAMIC MATERIAL COST OF ANTERIOR ORTHODONTIC ATTACHMENT, PER ATTACHMENT R ORTHODONTIC MATERIAL R COST OF POSTERIOR ORTHODONTIC ATTACHMENT, PER ATTACHMENT R PREFORMED COMPONENTS R COST OF EXPANSION SCREW, PER SCREW R SOLDERING MATERIAL R COST OF BUCCAL TUBE/TRANSFER TUBE, PER TUBE COST OF J-HOOK, PER HOOK R COST OF LINGUAL BUTTONS, PER BUTTON R COST OF INVISIBLE RETAINER MATERIAL R/A CASE COST OF MOUTH PROTECTOR MATERIAL COST OF ARCH WIRE R DUAL LAMINATE MATERIAL POSITIONING AND FINISHING OF COMPLETE (MALE AND FEMALE) PRE FABRICATED BURN-OUT ATTACHMENT POSITIONING AND SOLDERING OF COMPLETE (MALE AND FEMALE) PRECISION ATTACHMENT IMPLANT STENT PER UNIT ALIGNMENT OF DOLDER BAR AND CLIPS TRIMMING, WAXING AND FINISHING OF IMPLANT ABUTMENT - CROWN AND BRIDGE WORK ONLY, PER ABUTMENT R WAXING, MILLING AND FINISHING OF A CUSTOM ABUTMENT R IMPLANT SUPERSTRUCTURE (EDENTULOUS CASES) INCLUDING PLACING OF PREFORMED PARTS, PER SECTION CAST -