Premier Extras dental schedule As at 1 April 2019 011 Comprehensive oral examination $47.00 1 per financial year Preventive 2 months 012 Periodic oral examination $48.00 2 per financial year Preventive 2 months 013 Oral examination - limited $35.00 2 per financial year Preventive 2 months 014 Consultation $47.00 2 per financial year Preventive 2 months 015 Consultation - extended (30 minutes or more) $64.00 Preventive 2 months 016 Consultation by referral $66.80 General 2 months 017 Consultation by referral - extended (30 minutes or more) $72.00 General 2 months 018 Written report $0.00 General 2 months 019 Letter of referral $0.00 General 2 months 022 Intraoral periapical or bitewing radiograph $30.00 General 2 months - reduced benefit for each subsequent radiogaph in a visit n/a 025 Intraoral radiograph - occlusal, maxillary, mandibular - per $34.00 2 per financial year General 2 months exposure 026 Cone Beam Volumetric Tomography Scan Acquisition per $108.00 1 per appointment, 2 per financial year General 2 months appointment 031 Extraoral radiograph - maxillary, mandibular - per exposure $34.00 2 per financial year General 2 months 033 Lateral, antero-posterior or postero-anterior or submento-vertex $51.40 2 per financial year General 2 months radiograph of the skull - per exposure 035 Radiograph of temporomandibular joint - per exposure $56.60 2 per financial year General 2 months 036 Cephalometric radiograph - lateral, antero-posterior, posteroanterior $56.60 2 per financial year General 2 months or submento-vertex - per exposure 037 Panoramic radiograph - per exposure $66.80 1 per financial year General 2 months 038 Hand-wrist radiograph for skeletal age assessment $39.20 1 per appointment General 2 months 039 Tomograghy of the skull or parts thereof $110.00 1 per appointment General 2 months 041 Bacteriological examination $0.00 General 2 months 042 Culture examination and identification $0.00 General 2 months 043 Antibiotic sensitivity test $0.00 General 2 months 044 Collection of specimen for pathology examination $0.00 General 2 months 047 Saliva screening test $0.00 General 2 months 048 Bacteriological screening test $0.00 General 2 months 051 Biopsy of tissue $97.60 General 2 months 052 Histopathological examination of tissue $0.00 General 2 months 053 Cytological examination $0.00 General 2 months 054 Mucosal screening $15.60 1 per financial year General 2 months 055 Blood sample $0.00 General 2 months 056 Haematological examination $0.00 General 2 months 059 Comprehensive head and neck cancer examination and risk $0.00 General 2 months assessment 061 Pulp testing - per visit $0.00 General 2 months 071 Diagnostic model - per model $38.20 2 per financial year General 2 months 072 Photographic records - intraoral $20.80 1 per financial year General 2 months 073 Photographic records - extraoral $20.80 1 per financial year General 2 months 074 Diagnostic wax-up $97.60 1 per financial year General 2 months 075 Diagnostic modelling $98.00 1 per financial year General 2 months 081 Cephalometric analysis - excluding radiographs $38.20 1 per financial year General 2 months 082 Tooth-jaw size prediction analysis $22.80 1 per financial year General 2 months 083 Tomographic analysis $31.00 1 per appointment General 2 months 085 Electromyographic recording $0.00 General 2 months 086 Electromyographic analysis $77.20 1 per financial year General 2 months 087 Cone Beam Volumetric Tomography analysis and/or interpretation small field of view (less than one complete dental arch) $29.00 1 per appointment General 2 months 088 Cone Beam Volumetric Tomography analysis and/or interpretation maxillary or mandibular dentition (single arch) 089 Cone Beam Volumetric Tomography analysis and/or interpretation maxillary and mandibular dentition (both arches) $29.00 1 per appointment General 2 months $29.00 1 per appointment General 2 months 090 Cone Beam Volumetric Tomography analysis and/or interpretation $29.00 1 per appointment General 2 months temporomandibular joints only 091 Cone Beam Volumetric Tomography analysis and/or interpretation $29.00 1 per appointment General 2 months orofacial structures 111 Removal of plaque and/or stain $43.00 1 per appointment, 2 per financial year Preventive 2 months 113 Recontouring of pre-existing restoration(s) $18.00 Preventive 2 months 114 Removal of calculus - first visit $87.00 2 per financial year Preventive 2 months 115 Removal of calculus - subsequent visit $84.00 2 per financial year Preventive 2 months 116 Enamel micro-abrasion - per tooth $32.60 Preventive 2 months 117 Bleaching, internal - per tooth $148.80 1 per tooth, 2 per financial year General 2 months 118 Bleaching, external - per tooth $20.80 6 per financial year General 2 months 119 Bleaching, home application -per arch $72.00 2 per financial year General 2 months
121 Topical application of remineralising and/or cariostatic agents, one $26.20 1 per appointment, 2 per financial year Preventive 2 months treatment 122 Topical remineralising and/or cariostatic agent, home application - $25.80 2 per financial year General 2 months per arch 123 Concentrated remineralising and/or cariostatic agent, application - $22.00 Preventive 2 months single tooth 131 Dietary advice $0.00 General 2 months 141 Oral hygiene instruction $0.00 General 2 months 142 Tobacco counselling $0.00 General 2 months 151 Provision of a mouthguard - indirect $102.80 General 2 months 153 Bimaxillary mouthguard - indirect $128.40 General 2 months 161 Fissure sealing - per tooth $33.00 Preventive 2 months 165 Desensitising procedure-per visit $20.80 General 2 months 171 Odontoplasty - per tooth $0.00 General 2 months 213 Treatment of acute ontal infection - per visit $51.40 1 per appointment General 2 months 221 Clinical ontal analysis and recording $27.80 1 per financial year General 2 months 222 Periodontal Debridement - per tooth $18.60 223 Non-surgical treatment of peri-implant disease per implant $53.00 231 Gingivectomy - per tooth $74.80 232 Periodontal flap surgery - per tooth $144.00 233 Surgical treatment of peri-implant disease - per implant $144.00 234 Application of biologically active material $143.00 235 Gingival graft - per tooth or implant $340.00 236 Guided tissue regeneration - per tooth or implant $298.60 237 Guided tissue regeneration - membrane removal $134.00 238 Periodontal flap surgery for crown lengthening - per tooth $146.20 241 Root resection - per root $146.20 242 Osseous surgery - per tooth $226.00 243 Osseous graft - per tooth or implant $318.60 244 Osseous graft - block $350.20 245 Periodontal surgery involving one tooth or implant $71.60 246 Maxillary sinus augmentation - Trans-alveolar technique per $495.20 sinus 247 Maxillary sinus augmentation - Lateral wall approach per sinus $503.20 250 Active non-surgical ontal therapy - per quadrant $148.00 4 per appointment, 4 per financial year 251 Supportive ontal therapy - per appointment $148.00 1 per appointment 311 Removal of a tooth or part(s) thereof $107.80 General 2 months 314 Sectional removal of a tooth $123.20 General 2 months 322 Surgical removal of a tooth or tooth fragment not requiring $158.40 removal of bone or tooth division 323 Surgical removal of a tooth or tooth fragment requiring removal of $197.20 Major 12months bone 324 Surgical removal of a tooth or tooth fragment requiring both $217.60 removal of bone and tooth division 331 Alveolectomy - per segment $110.40 332 Ostectomy - per jaw $156.40 337 Reduction of fibrous tuberosity $155.40 338 Reduction of flabby ridge - per segment $155.40 341 Removal of hyperplastic tissue $113.60 343 Repositioning of muscle attachment $227.80 344 Vestibuloplasty $300.60 345 Skin or mucosal graft $280.20 351 Repair of skin and subcutaneous tissue or mucous membrane $154.40 352 Fracture of maxilla or mandible - not requiring splinting $105.40 353 Fracture of maxilla or mandible - with wiring of teeth or intra-oral $370.20 fixation 354 Fracture of maxilla or mandible - with external fixation $403.20 355 Fracture of the zygoma $484.80 359 Fracture of the maxilla or mandible requiring open reduction $811.20 361 Mandible - relocation following dislocation $51.20 1 per appointment 363 Mandible - relocation requiring open operation $102.20 365 Osteotomy - maxilla $1,100.00 1 per appointment 366 Osteotomy - mandible $1,100.00 1 per appointment 371 Removal of tumour, cyst or scar - cutaneous, subcutaneous or in $146.20 mucous membrane 373 Removal of tumour, cyst or scar involving muscle, bone or other $245.20 deep tissue 375 Surgery to salivary duct $156.40 376 Surgery to salivary gland $321.60 377 Removal or repair of soft tissue (not elsewhere defined) $95.20 378 Surgical removal of foreign body $146.20
379 Marsupialisation of cyst $135.20 381 Surgical exposure of unerupted tooth $248.00 1 per tooth, per appointment 382 Surgical exposure and attachment of device for orthodontic $299.20 1 per tooth, per appointment traction 384 Repositioning of displaced tooth/teeth - per tooth $56.40 1 per tooth, per appointment 385 Surgical repositioning of unerupted tooth $183.80 1 per tooth, per appointment 386 Splinting of displaced tooth/teeth - per tooth $115.00 1 per tooth, per appointment 387 Replantation and splinting of a tooth $146.00 1 per tooth, per appointment 388 Transplantation of tooth or tooth bud $301.20 1 per tooth, per appointment 389 Surgery to isolate and preserve neurovascular tissue $94.20 391 Frenectomy $166.60 392 Drainage of abscess $44.20 393 Surgery involving the maxillary antrum $495.20 394 Surgery for osteomyelitis $350.20 1 per appointment 395 Repair of nerve trunk $480.20 399 Control of reactionary or secondary post-operative haemorrhage $15.60 411 Direct pulp capping $0.00 412 Incomplete endodontic therapy (inoperable or fractured tooth) $79.80 414 Pulpotomy $64.40 1 per tooth, per appointment 415 Complete chemo-mechanical preparation of root canal - one canal $146.20 1 per tooth, per appointment 416 Complete chemo-mechanical preparation of root canal - each $54.40 additional canal 417 Root canal obturation - one canal $153.20 1 per tooth, per appointment 418 Root canal obturation - each additional canal $54.40 419 Extirpation of pulp or debridement of root canal(s) - emergency or $97.20 1 per tooth, per appointment palliative 421 Resorbable root canal filling - primary tooth $95.20 1 per tooth, per appointment 431 Periapical curettage - per root $156.40 - reduced benefit for each subsequent root in same tooth $78.80 432 Apicectomy - per root $197.20 Major 12 months - reduced benefit for each subsequent root in same tooth $99.20 433 Exploratory periradicular surgery $101.80 434 Apical seal - per canal $350.20 - reduced benefit for each subsequent canal in same tooth $175.60 436 Sealing of perforation $105.40 437 Surgical treatment and repair of external root resorption - per $135.00 1 per tooth, per appointment tooth 438 Hemisection $125.80 1 per tooth, per appointment 445 Exploration and/or negotiation of calcified canal - per canal, per $56.40 visit - reduced benefit for each subsequent canal in same tooth $27.80 451 Removal of root filling - per canal $56.40 - reduced benefit for each subsequent canal in same tooth $27.80 452 Removal of a cemented root canal post or post crown $69.60 453 Removal or bypassing fractured endodontic instrument $95.20 455 Additional visit for irrigation and/or dressing of the root canal $79.80 1 per tooth, per appointment system - per tooth 457 Obturation of resorption defect or perforation (non-surgical) $95.20 1 per tooth, per appointment 458 Interim therapeutic root filling - per tooth $79.80 1 per tooth, per appointment 511 Metallic restoration - one surface - direct $63.80 1 per tooth, per appointment General 2 months 512 Metallic restoration - two surfaces - direct $85.40 1 per tooth, per appointment General 2 months 513 Metallic restoration - three surfaces - direct $107.80 1 per tooth, per appointment General 2 months 514 Metallic restoration - four surfaces - direct $113.00 1 per tooth, per appointment General 2 months 515 Metallic restoration - five surfaces - direct $118.20 1 per tooth, per appointment General 2 months 521 Adhesive restoration - one surface - anterior tooth - direct $82.20 1 per tooth, per appointment General 2 months 522 Adhesive restoration - two surfaces - anterior tooth - direct $97.60 1 per tooth, per appointment General 2 months 523 Adhesive restoration - three surfaces - anterior tooth - direct $118.20 1 per tooth, per appointment General 2 months 524 Adhesive restoration - four surfaces - anterior tooth - direct $128.40 1 per tooth, per appointment General 2 months 525 Adhesive restoration - five surfaces - anterior tooth - direct $159.20 1 per tooth, per appointment General 2 months 526 Adhesive restoration Veneer direct $189.80 1 per tooth, per financial year General 2 months 531 Adhesive restoration - one surface - posterior tooth - direct $97.60 1 per tooth, per appointment General 2 months 532 Adhesive restoration - two surfaces - posterior tooth - direct $123.20 1 per tooth, per appointment General 2 months 533 Adhesive restoration - three surfaces - posterior tooth - direct $148.80 1 per tooth, per appointment General 2 months 534 Adhesive restoration - four surfaces - posterior tooth - direct $164.20 1 per tooth, per appointment General 2 months 535 Adhesive restoration - five surfaces - posterior tooth - direct $174.60 1 per tooth, per appointment General 2 months 536 Adhesive restoration Veneer posterior tooth direct $189.80 1 per tooth, per financial year General 2 months 541 Metallic restoration - one surface - indirect $229.80 1 per tooth, per financial year 542 Metallic restoration - two surfaces - indirect $370.60 1 per tooth, per financial year 543 Metallic restoration - three surfaces - indirect $447.00 1 per tooth, per financial year
544 Metallic restoration - four surfaces - indirect $625.60 1 per tooth, per financial year 545 Metallic restoration - five surfaces - indirect $697.00 1 per tooth, per financial year 551 Tooth-coloured restoration - one surface - indirect $401.20 1 per tooth, per financial year 552 Tooth-coloured restoration - two surfaces - indirect $605.20 1 per tooth, per financial year 553 Tooth-coloured restoration - three surfaces - indirect $656.20 1 per tooth, per financial year 554 Tooth-coloured restoration - four surfaces - indirect $707.20 1 per tooth, per financial year 555 Tooth-coloured restoration - five surfaces - indirect $732.60 1 per tooth, per financial year 556 Tooth coloured restoration Veneer indirect $656.20 1 per tooth, per financial year 571 Adaptation of new restoration to existing removable prosthesis $23.80 1 per tooth, per appointment General 2 months per tooth 572 Provisional (intermediate/temporary) restoration $46.40 1 per tooth, per appointment General 2 months 574 Metal band $66.80 1 per tooth, per financial year General 2 months 575 Pin retention - per pin $19.60 General 2 months 577 Cusp capping - per cusp $23.80 General 2 months 578 Restoration of an incisal corner - per corner $23.80 General 2 months 579 Bonding of tooth fragment $97.60 General 2 months 586 Crown Metallic with tooth preparation preformed $138.60 1 per tooth, per visit General 2 months 587 Crown Metallic minimal tooth preparation preformed $95.00 1 per tooth, per visit General 2 months 588 Crown Non-metallic - preformed $138.60 1 per tooth, per visit General 2 months 595 Removal of inlay/onlay $68.00 General 2 months 596 Recementing of inlay/onlay $72.00 General 2 months 597 Post - direct $99.60 General 2 months 611 Full crown - acrylic resin - indirect $416.40 1 per tooth, per financial year 613 Full crown - non-metallic - indirect $1,013.20 1 per tooth, per financial year 615 Full crown - veneered - indirect $1,015.20 1 per tooth, per financial year 618 Full crown - metallic - indirect $1,013.20 1 per tooth, per financial year 625 Post and core for crown - indirect $248.20 1 per tooth, per financial year 627 Preliminary restoration for crown - direct $115.60 1 per tooth, per financial year 629 Post and root cap - indirect $274.80 1 per tooth, per financial year 631 Provisional crown $95.20 1 per tooth, per appointment 632 Provisional bridge - per pontic $39.00 633 Provisional implant abutment - per abutment $115.60 634 Provisional implant restoration - per implant abutment $85.00 1 per tooth, per appointment 642 Bridge pontic - direct - per pontic $400.60 1 per tooth, per financial year 643 Bridge pontic - indirect - per pontic $676.60 1 per tooth, per financial year 644 Semi-fixed attachment $181.00 645 Precision or magnetic attachment $187.00 649 Retainer for bonded fixture - indirect - per tooth $176.80 651 Recementing crown or veneer $77.20 General 2 months 652 Recementing bridge or splint - per abutment $77.20 General 2 months 653 Rebonding of bridge or splint where retreatment of bridge surface $87.40 General 2 months is required 655 Removal of crown $56.60 General 2 months 656 Removal of bridge or splint $72.00 General 2 months 658 Repair of crown, bridge or splint - indirect $107.80 General 2 months 659 Repair of crown, bridge or splint - direct $97.60 General 2 months 661 Fitting of implant abutment - per abutment $503.20 663 Removal of implant $187.00 664 Fitting of bar for denture - per abutment $166.60 665 Prosthesis with resin base attached to implants - removable per $1,013.20 arch 666 Prosthesis with metal frame attached to implants - per tooth $1,100.00 667 Prosthesis with metal frame attached to implants - removable per $1,100.00 arch 668 Fixture or abutment screw removal and replacement $66.60 669 Removal and reattachment of prosthesis fixed to implant(s) - per $115.60 implant - reduced benefit for each subsequent implant $61.40 671 Full crown attached to osseointegrated implant - non-metallic - $1,100.00 indirect 672 Full crown attached to osseointegrated implant - veneered - $1,100.00 indirect 673 Full crown attached to osseointegrated implant - metallic - indirect $1,100.00 678 Diagnostic template $115.60 679 Surgical implant guide $222.60 684 Insertion of first stage of two stage endosseous implant - per $1,100.00 implant 688 Insertion of one stage endosseous implant - per implant $1,100.00 689 Provisional implant $136.00 690 Provisional retention device $115.60 691 Second stage surgery of two stage endosseous implant - per implant $345.60
711 Complete maxillary denture $727.60 712 Complete mandibular denture $727.60 1 every financial year 713 Provisional complete maxillary denture $358.00 1 every financial year 714 Provisional complete mandibular denture $358.00 1 every financial year 715 Provisional complete maxillary and mandibular dentures $545.00 1 every financial year 716 Metal palate or plate $255.80 2 per appointment 719 Complete maxillary and mandibular dentures $1,100.00 1 every 3 financial years 721 Partial maxillary denture - resin base $401.20 1 every financial year 722 Partial mandibular denture - resin base $401.20 1 every financial year 723 Provisional partial maxillary denture $243.00 1 every financial year 724 Provisional partial mandibular denture $243.00 1 every financial year 727 Partial maxillary denture - cast metal framework $809.20 1 every financial year 728 Partial mandibular denture - cast metal framework $809.20 1 every financial year 730 Veteran Affairs Item number only $0.00 0 731 Retainer - per tooth $22.60 732 Occlusal rest - per rest $21.60 733 Tooth/teeth (partial denture) $24.60 734 Overlays - per tooth $32.80 735 Precision or magnetic denture attachment $115.60 736 Immediate tooth replacement - per tooth $25.80 737 Resilient lining $125.80 738 Wrought bar $66.60 739 Metal backing - per backing $36.00 741 Adjustment of a denture $30.80 743 Relining - complete denture - processed $248.20 744 Relining - partial denture - processed $217.60 745 Remodelling - complete denture $268.60 746 Remodelling - partial denture $255.40 751 Relining - complete denture - direct $136.00 752 Relining - partial denture - direct $115.60 753 Cleaning and polishing of pre-existing denture $18.60 2 per financial year 754 Denture base modification $71.60 761 Reattaching pre-existing tooth or clasp to denture $74.80 762 Replacing/adding clasp to denture - per clasp $85.00 763 Repairing broken base of a complete denture $74.80 764 Repairing broken base of a partial denture $74.80 765 Replacing tooth on denture - per tooth $74.80 766 Reattaching existing tooth on denture - per tooth $64.60 768 Adding tooth to partial denture to replace an extracted or $95.20 decoronated tooth - per tooth 769 Repair or addition to metal casting $115.60 771 Tissue conditioning preparatory to impressions - per application $46.20 772 Splint - resin - indirect $207.40 773 Splint - metal - indirect $237.00 774 Obturator $250.20 775 Characterisation of denture base $0.00 776 Impression - denture repair/modification $33.00 2 per financial year General 2 months 777 Identification $0.00 778 Inlay for denture tooth $95.20 779 Surgical guide for an immediate denture $145.20 811 Passive removable appliance - per arch $170.60 2 per financial year Orthodontics 12 months 821 Active removable appliance - per arch $401.20 2 per financial year Orthodontics 12 months 823 Functional orthopaedic appliance $503.20 1 per financial year Orthodontics 12 months 824 Functional orthopaedic appliance prefabricated $393.00 1 per financial year Orthodontics 12 months 825 Sequential Plastic Aligners - per arch $452.20 Orthodontics 12 months 829 Partial banding - per arch $430.80 Orthodontics 12 months 831 Full arch banding - per arch $569.40 Orthodontics 12 months 833 Removal of banding per arch $118.00 2 per financial year Orthodontics 12 months 841 Fixed palatal or lingual arch appliance $257.00 2 per financial year Orthodontics 12 months 842 Partial banding for inter-maxillary elastics (cross elastics) $299.20 2 per financial year Orthodontics 12 months 843 Maxillary expansion appliance $431.80 1 per financial year Orthodontics 12 months 845 Passive fixed appliance $197.20 2 per financial year Orthodontics 12 months 846 Minor tooth guidance - fixed $175.80 Orthodontics 12 months 851 Extraoral appliance $197.80 1 per appointment Orthodontics 12 months 862 Bonding of attachment for application of orthodontic force $104.60 Orthodontics 12 months 871 Orthodontic adjustment $71.60 1 per appointment Orthodontics 12 months 872 Re-attachment of passive appliance fixed $63.00 1 per appointment Orthodontics 12 months 873 Repair of passive appliance fixed $93.00 1 per appointment Orthodontics 12 months 874 Removal of passive appliance fixed $92.00 1 per appointment Orthodontics 12 months 875 Repair of removable appliance, resin base $76.80 2 per financial year Orthodontics 12 months 876 Repair of removable appliance - clasp, spring or tooth $56.40 Orthodontics 12 months 877 Addition to removable appliance - clasp, spring or tooth $56.40 Orthodontics 12 months
878 Relining -removable appliance - processed $146.20 2 per financial year Orthodontics 12 months 881 Complete course of orthodontic treatment $1,000.00 Orthodontics 12 months 911 Palliative care $38.20 1 per appointment General 2 months 915 After hours callout $66.80 1 per appointment General 2 months 916 Travel to provide services $46.40 1 per appointment General 2 months 926 Individually made tray - medicament(s) $0.00 General 2 months 927 Provision of medication/medicament $0.00 General 2 months 928 Intravenous cannulation and establishment of infusion $61.80 1 per appointment General 2 months 941 Local anaesthesia $0.00 General 2 months 942 Sedation - intravenous - per 30 minutes or part thereof $97.60 2 per appointment General 2 months 943 Sedation - inhalation - per 30 minutes or part thereof $41.20 2 per appointment General 2 months 944 Relaxation therapy $0.00 General 2 months 945 Low level laser therapy per appointment $0.00 General 2 months 948 Dental acupuncture per appointment $0.00 General 2 months 949 Treatment under general anaesthesia/sedation $87.40 1 per appointment General 2 months 961 Minor occlusal adjustment - per visit $5.40 1 per appointment General 2 months 963 Clinical occlusal analysis including muscle and joint palpation $51.40 1 per financial year General 2 months 964 Registration and mounting of models for occlusal analysis $0.00 General 2 months 965 Occlusal splint $329.80 1 per financial year 966 Adjustment of pre-existing occlusal splint - per visit $51.40 2 per financial year General 2 months 967 Pantographic tracing $97.60 1 per financial year General 2 months 968 Occlusal adjustment following occlusal analysis - per visit $77.20 1 per appointment General 2 months 971 Adjunctive physical therapy for temporomandibular joint and $0.00 General 2 months associated structures 972 Repair/addition - occlusal splint $87.40 1 per financial year General 2 months 981 Splinting and stabilisation - direct - per tooth $66.80 General 2 months 982 Enamel stripping - per visit $25.80 1 per appointment General 2 months 983 Single arch oral appliance for diagnosed snoring and obstructive $452.20 1 every 3 financial years snoring and sleep apnoea 984 Bi-maxillary oral appliance for diagnosed snoring and obstructive $829.60 1 every 3 financial years snoring and sleep apnoea 985 Repair/addition snoring or sleep apnoea device $87.40 1 every financial year General 2 months 986 Post-operative care not otherwise included $0.00 General 2 months 987 Re-contour tissue per appointment $45.00 1 per appointment General 2 months 990 Treatment not otherwise included (specify) $0.00 General 2 months Financial year maximum Preventive General Dental Major Dental No annual limit No annual limit $1100 per person Orthodontic limit $1000 per person Important: Some services are not payable in combination with others. Some are limited by the number of times they attract a benefit per year. Others may not attract a benefit at all.