Schedule of Fees (Effective 1 April 2018) Dental (NT)

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The following fee structure applies for Dentists when treating Entitled Personnel. Item No. Diagnostic / Preventative Fee D011 Comprehensive oral examination $82.00 D012 Periodic oral examination $74.

1 The following fee structure applies for Dentists when treating Entitled Personnel. Item No. Diagnostic / Preventative Fee D011 Comprehensive oral examination $82.00 D012 Periodic oral examination $74.00 D013 Oral examination -- limited $56.00 D014 Consultation $65.00 D015 Consultation -- extended (30 minutes or more) $83.00 D016 Consultation by referral including examination $90.00 D017 Consultation by referral -- extended (30 minutes) -- including examination $ D018 Written report (not elsewhere included) $29.00 D019 Letter of referral $23.00 D022 Intraoral periapical or bitewing radiograph -- per exposure $45.00 D025 Intraoral radiograph -- occlusal, maxillary, mandibular -- per exposure $58.00 D026 Cone beam volumetric tomography - scan acquisition - per appointment $ D031 Extraoral radiograph -- maxillary, mandibular -- per exposure $40.00 D033 Lateral, antero-posterior, postero-anterior or submento-vertex radiograph $39.00 D035 Radiograph of temporomandibular joint -- per exposure $55.00 D036 Cephalometric radiograph -- lateral, antero-posterior, postero-anterior or submento-vertex -- per exposure $70.00 D037 Panoramic radiograph -- per exposure $ D038 Hand-wrist radiograph for skeletal age assessment $50.00 D039 Tomography of the skull or parts thereof $ D041 Bacteriologic examination $30.00 D042 Culture examination and identification $38.00 D043 Antibiotic sensitivity test $20.00 D044 Collection of specimen for pathology examination $20.00 D047 Saliva screening test $38.00 D048 Bacteriological screening test $40.00 D051 Biopsy of tissue $ D052 Histopathological examination of tissue $47.00 D053 Cytological investigation $47.00 D054 Oral mucosal screening $40.00 D055 Blood sample $47.00 D056 Haematological examination $47.00 D059 Comprehensive head and neck cancer examination and risk assessment $25.00 D061 Pulp testing -- per appointment $31.00 D071 Diagnostic model -- per model $55.00 D072 Photographic records -- intraoral -- per appointment $32.00 D073 Photographic records -- extraoral -- per appointment $32.00 D074 Diagnostic wax-up $ D075 Diagnostic modelling - use of diagnostic images for simulation of treatment $40.00 D081 Cephalometric analysis -- excluding radiographs $42.00 D082 Tooth-jaw size prediction analysis $35.00 D083 Tomographic analysis $ D085 Electromyographic recording $28.00 D086 Electromyographic analysis $27.00 D111 Removal of plaque/and or stain $83.00 D113 Recontouring of pre-existing restoration(s) -- per appointment $30.00 D114 Removal of calculus -- first appointment $ D115 Removal of calculus -- subsequent appointment $ D116 Enamel micro-abrasion -- per tooth $50.00 D117 Bleaching, internal -- per tooth $ D118 Bleaching, external -- per tooth $80.00 P a g e 1 7

2 Item No. Diagnostic / Preventative (continued) Fee D119 Bleaching, home application -- per arch $ D121 Topical application of remineralizing and/or cariostatic agents, one treatment $27.00 D122 Topical remineralizing and/or cariostatic agent,home application-per arch $70.00 D123 Concentrated remineralizing and/or cariostatic agent, application -- single tooth $40.00 D131 Dietary advice $25.00 D141 Oral hygiene instruction $27.00 D151 Provision of a mouthguard -- indirect $ D153 Bimaxillary mouthguard -- indirect $ D161 Fissure and or tooth surface sealing -- per tooth $75.00 D165 Desensitising procedure -- per appointment $35.00 Item No. Periodontics Fee D171 Odontoplasty -- per tooth $45.00 D213 Treatment of acute periodontal infection -- per appointment $ D221 Clinical periodontal analysis and recording $76.00 D222 Periodontal Debridement -- per tooth $56.00 D223 Nonsurgical treatment of peri implant disease per implant $70.00 D231 Gingivectomy -- per tooth $85.00 D232 Periodontal flap surgery -- per tooth $97.00 D233 Surgical treatment of peri-implant disease per implant $ D234 Application of biologically active material $ 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 $85.00 D241 Root resection -- per root $ D242 Osseous surgery -- per tooth or implant $ D243 Osseous graft -- per tooth or implant $ D244 Osseous graft -- block $ D245 Periodontal surgery involving one tooth or implant $ D246 Maxillary sinus augmentation transalveolar technique - per sinus $ D247 Maxillary sinus augmentation lateral wall approach - per sinus $ D250 Active non-surgical periodontal therapy - per quadrant $ D251 Supportive periodontal therapy - per appointment $ Item No. Oral Surgery Fee D311 Removal of a tooth or part(s) thereof $ D314 Sectional removal of a tooth or parts thereof $ 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 $ D337 Reduction of fibrous tuberosity $80.00 D338 Reduction of flabby ridge -- per segment $80.00 D341 Removal of hyperplastic tissue $ D343 Repositioning of muscle attachment $ D344 Vestibuloplasty $ D345 Skin or mucosal graft $ D351 Repair of skin and subcutaneous tissue or mucous membrane $ D352 Fracture of maxilla or mandible -- not requiring fixation $ D353 Fracture of maxilla or mandible -- with wiring of teeth or intra-oral fixation $ P a g e 2 7

3 Item No. Oral Surgery (continued) Fee 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) $ D378 Surgical removal of foreign body $ D379 Marsupialisation of cyst $80.00 D381 Surgical exposure of unerupted tooth -- per 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 -- per tooth $ D386 Splinting of displaced tooth/teeth -- per tooth $ D387 Replantation and splinting of a tooth -- per tooth $ D388 Transplantation of tooth or tooth bud $ D389 Surgery to isolate and preserve neurovascular tissue $80.00 D391 Frenectomy $ D392 Drainage of abscess $60.00 D393 Surgery involving the maxillary antrum $ D394 Surgery for osteomyelitis $ D395 Repair of nerve trunk $ D399 Control of reactionary or secondary post-operative haemorrhage $25.00 Item No. Endodontic / Restorative Fee D411 Direct pulp capping $40.00 D412 Incomplete endodontic therapy (tooth not suitable for further treatment) $ D414 Pulpotomy $ 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 $ 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 appointment $ D451 Removal of root filling -- per canal $ D452 Removal of a cemented root canal post or post crown $85.00 D453 Removal or bypassing fractured endodontic instrument $80.00 D455 Additional visit for irrigation and/or dressing of the root canal system -- per tooth $ D457 Obturation of resorption defect or perforation (non-surgical) $61.00 D458 Interim therapeutic root filling -- per tooth $ P a g e 3 7

4 Item No. Endodontic / Restorative (continued) Fee 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 $ D526 Adhesive restoration - veneer - 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 $ D536 Adhesive restoration - veneer - 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 $ 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 $ D556 Tooth-coloured - veneer -- indirect $1, D571 Adaptation of new restoration to existing removable prosthesis - per tooth $15.00 D572 Provisional (intermediate/temporary) restoration -- per tooth $96.00 D574 Metal band $95.00 D575 Pin retention -- per pin $42.00 D577 Cusp capping -- per cusp $36.00 D578 Restoration of an incisal corner -- per corner $36.00 D579 Bonding of tooth fragment $ D586 Crown - metallic - with tooth preparation - preformed $ D587 Metallic crown minimal tooth preparation preformed $95.00 D588 Crown - tooth-coloured - preformed $ D595 Removal of indirect restoration $ D596 Recementing of indirect restoration $95.00 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 -- per tooth $ D632 Provisional bridge -- per pontic $ D633 Provisional implant abutment - per abutment $ P a g e 4 7

5 Item No. Prosthodontics (continued) Fee D634 Provisional implant restoration - per implant abutment $ D642 Bridge pontic -- direct -- per pontic $ D643 Bridge pontic -- indirect -- per pontic $1, 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 $ D658 Repair of crown, bridge or splint -- indirect $85.00 D659 Repair of crown, bridge or splint -- direct $ D661 Fitting of implant abutment -- per abutment $ D663 Removal of implant and/or retention device $ D664 Fitting of bar for denture -- per abutment $ D665 Prosthesis with resin base attached to implants - removable - per arch $ D666 Prosthesis with metal frame attached to implants -- per arch $ D667 Prosthesis with metal frame attached to implants - removable - per arch $ 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 $ D690 Provisional retention or anchorage device $ D691 Second stage surgery of two-stage endosseous implant -- per implant $ D711 Complete maxillary denture $1, D712 Complete mandibular denture $1, D713 Provisional complete maxillary denture $ D714 Provisional complete mandibular denture $ D715 Provisional complete maxillary and mandibular dentures $ D716 Metal palate or plate $ D719 Complete maxillary and mandibular dentures $1, D721 Partial maxillary denture -- resin base $ D722 Partial mandibular denture -- resin base $ D723 Provisional partial maxillary denture $ D724 Provisional partial mandibular denture $ D727 Partial maxillary denture -- cast metal framework $1, D728 Partial mandibular denture -- cast metal framework $1, D731 Retainer -- per tooth $49.00 D732 Occlusal rest -- per rest $42.00 D733 Tooth/teeth (partial denture) $44.00 D734 Overlays -- per tooth $40.00 D735 Precision or magnetic denture attachment $ D736 Immediate tooth replacement -- per tooth $50.00 D737 Resilient lining $ D738 Wrought bar $50.00 P a g e 5 7

6 Item No. Prosthodontics (continued) Fee D739 Metal backing -- per backing $50.00 D741 Adjustment of a denture $62.00 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 $95.00 D753 Cleaning and polishing of pre-existing denture $50.00 D754 Denture base modification $ D761 Reattaching pre-existing 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/adding new tooth on denture -- per tooth $ D766 Reattaching existing tooth on denture - per tooth $90.00 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 $74.00 D772 Splint -- resin -- indirect $ D773 Splint -- metal -- indirect $ D774 Obturator $ D775 Characterization of denture base $ D776 Impression -- denture repair/modification $55.00 D777 Identification $50.00 Item No. Orthodontics Fee D778 Inlay for denture tooth $ D779 Surgical guide for an immediate denture $ 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, D833 Removal of banding - per arch $ D841 Fixed palatal or lingual arch appliance $ D842 Partial banding for inter-maxillary elastics (vertical and/or cross elastics) $1, D843 Expansion appliance fixed -- per arch $ D845 Passive appliance - fixed $ D846 Minor tooth guidance -- fixed $ D851 Extraoral appliance $ D862 Bonding of attachment for application of orthodontic force $95.00 D871 Orthodontic adjustment $ D872 Reattachment of passive appliance - fixed $99.00 D873 Repair of passive appliance - fixed $ D874 Removal of passive appliance - fixed $ 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 $ P a g e 6 7

7 Item No. General Services Fee D911 Palliative care $71.00 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 $70.00 D941 Local anaesthesia $42.00 D942 Sedation -- intravenous -- per 30 minutes or part thereof $ D943 Sedation -- inhalation -- per 30 minutes or part thereof $90.00 D944 Relaxation therapy $ D949 Treatment under general anaesthesia/sedation $ D961 Minor occlusal adjustment -- per appointment $40.00 D963 Clinical occlusal analysis including muscle and joint palpation $75.00 D964 Registration and mounting of models for occlusal analysis $ D965 Occlusal splint $ D966 Adjustment of pre-existing occlusal splint -- per appointment $65.00 D967 Pantographic tracing $85.00 D968 Occlusal adjustment following occlusal analysis -- per appointment $ D971 Adjunctive physical therapy for temporomandibular joint and associated structures -- per appointment $85.00 D972 Repair/addition -- occlusal splint $ D981 Splinting and stabilisation -- direct -- per tooth $ D982 Enamel stripping -- per appointment $35.00 D983 Single arch oral appliance-diagnosed snoring, obstructive snoring, sleep apnoea $ D984 Bi-maxillary oral appliance-diagnosed snoring, obstructive snoring, sleep apnoea $1, D985 Repair/additional - snoring or sleep apnoea device $ D986 Post-operative care not otherwise included $40.00 D990 Treatment not otherwise included (specify) $32.00 For more information regarding invoicing and payments please visit our web site or call the GHS Provider Support team on P a g e 7 7

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