Top Extras dental schedule As at 1 April 2018

Top Extras dental schedule As at 1 April 2018 Item Description Benefit Service limit Category Waiting 011 Comprehensive oral examination $39.60 1 per Preventive 012 Periodic oral examination $36.40 2 per Preventive 013 Oral examination - limited $30.00 2 per Preventive 014 Consultation $37.40 2 per Preventive 015 Consultation - extended (30 minutes or more) $54.00 Preventive 016 Consultation by referral $56.00 017 Consultation by referral - extended (30 minutes or more) $63.60 018 Written report $0.00 019 Letter of referral $0.00 022 Intraoral periapical or bitewing radiograph $23.80 - reduced benefit for each subsequent radiogaph in a visit $16.40 025 Intraoral radiograph - occlusal, maxillary, mandibular - per exposure $31.00 2 per 026 Cone Beam Volumetric Tomography Scan Acquisition per $79.80 1 per, 2 per 031 Extraoral radiograph - maxillary, mandibular - per exposure $53.60 2 per 033 Lateral, antero-posterior or postero-anterior or submento-vertex radiograph of the skull - per exposure $53.60 2 per 035 Radiograph of temporomandibular joint - per exposure $53.60 2 per 036 Cephalometric radiograph - lateral, antero-posterior, posteroanterior or submento-vertex - per exposure $53.60 2 per 037 Panoramic radiograph - per exposure $61.60 1 per 038 Hand-wrist radiograph for skeletal age assessment $97.60 1 per 039 Tomograghy of the skull or parts thereof $109.00 1 per 041 Bacteriological examination $0.00 042 Culture examination and identification $0.00 043 Antibiotic sensitivity test $69.00 044 Collection of specimen for pathology examination $0.00 047 Saliva screening test $0.00 048 Bacteriological screening test $0.00 051 Biopsy of tissue $88.00 052 Histopathological examination of tissue $0.00 053 Cytological examination $0.00 054 Mucosal screening $0.00 1 per 055 Blood sample $106.00 056 Haematological examination $24.60 059 Comprehensive head and neck cancer examination and risk $0.00 assessment 061 Pulp testing - per visit $0.00 071 Diagnostic model - per model $31.60 2 per 072 Photographic records - intraoral $17.60 1 per

073 Photographic records - extraoral $17.60 1 per 074 Diagnostic wax-up $85.60 1 per 075 Diagnostic modelling $76.20 1 per 081 Cephalometric analysis - excluding radiographs $28.60 1 per 082 Tooth-jaw size prediction analysis $17.20 1 per 083 Tomographic analysis $27.60 1 per 085 Electromyographic recording $0.00 086 Electromyographic analysis $86.60 1 per 087 Cone Beam Volumetric Tomography analysis and/or interpretation small field of view (less than one complete dental arch) 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) 090 Cone Beam Volumetric Tomography analysis and/or interpretation temporomandibular joints only 091 Cone Beam Volumetric Tomography analysis and/or interpretation orofacial structures $22.20 1 per $22.20 1 per $22.20 1 per $22.20 1 per $22.20 1 per 111 Removal of plaque and/or stain $36.60 1 per, 2 per Preventive 113 Recontouring of pre-existing restoration(s) $16.00 Preventive 114 Removal of calculus - first visit $69.20 2 per Preventive 115 Removal of calculus - subsequent visit $68.60 2 per Preventive 116 Enamel micro-abrasion - per tooth $34.60 Preventive 117 Bleaching, internal - per tooth $0.00 1 per tooth, 2 per 118 Bleaching, external - per tooth $0.00 6 per 119 Bleaching, home application -per arch $0.00 2 per 121 Topical application of remineralising and/or cariostatic agents, one treatment $21.00 1 per, 2 per Preventive 122 Topical remineralising and/or cariostatic agent, home application - per arch $0.00 2 per 123 Concentrated remineralising and/or cariostatic agent, application - $31.60 Preventive single tooth 131 Dietary advice $0.00 141 Oral hygiene instruction $0.00 142 Tobacco counselling $0.00 151 Provision of a mouthguard - indirect $75.80

153 Bimaxillary mouthguard - indirect $126.60 161 Fissure sealing - per tooth $29.80 Preventive 165 Desensitising procedure-per visit $18.00 171 Odontoplasty - per tooth $0.00 213 Treatment of acute ontal infection - per visit $38.80 1 per 221 Clinical ontal analysis and recording $22.60 1 per 222 Periodontal Debridement - per tooth $17.00 223 Non-surgical treatment of peri-implant disease per implant $35.50 231 Gingivectomy - per tooth $71.60 232 Periodontal flap surgery - per tooth $101.60 233 Surgical treatment of peri-implant disease - per implant $97.60 234 Application of biologically active material $96.70 235 Gingival graft - per tooth or implant $201.20 236 Guided tissue regeneration - per tooth or implant $358.00 237 Guided tissue regeneration - membrane removal $252.00 238 Periodontal flap surgery for crown lengthening - per tooth $107.00 241 Root resection - per root $118.00 242 Osseous surgery - per tooth $104.60 243 Osseous graft - per tooth or implant $223.80 244 Osseous graft - block $246.00 245 Periodontal surgery involving one tooth or implant $44.00 246 Maxillary sinus augmentation - Trans-alveolar technique per $339.70 sinus 247 Maxillary sinus augmentation - Lateral wall approach per sinus $339.70 250 Active non-surgical ontal therapy - per quadrant $105.00 4 per 251 Supportive ontal therapy - per $105.00 1 per 311 Removal of a tooth or part(s) thereof $73.20 314 Sectional removal of a tooth $99.60 322 Surgical removal of a tooth or tooth fragment not requiring $129.00 removal of bone or tooth division 323 Surgical removal of a tooth or tooth fragment requiring removal of $140.60 12months bone 324 Surgical removal of a tooth or tooth fragment requiring both $173.60 removal of bone and tooth division 331 Alveolectomy - per segment $84.60 332 Ostectomy - per jaw $58.80 337 Reduction of fibrous tuberosity $195.60 338 Reduction of flabby ridge - per segment $229.60 341 Removal of hyperplastic tissue $214.00 343 Repositioning of muscle attachment $463.60 344 Vestibuloplasty $463.60 345 Skin or mucosal graft $463.60 351 Repair of skin and subcutaneous tissue or mucous membrane $146.00 352 Fracture of maxilla or mandible - not requiring splinting $100.60 353 Fracture of maxilla or mandible - with wiring of teeth or intra-oral $552.60 fixation 354 Fracture of maxilla or mandible - with external fixation $318.60 355 Fracture of the zygoma $431.60 359 Fracture of the maxilla or mandible requiring open reduction $719.60 361 Mandible - relocation following dislocation $34.60 1 per 363 Mandible - relocation requiring open operation $90.00 365 Osteotomy - maxilla $573.40 1 per 366 Osteotomy - mandible $573.40 1 per 371 Removal of tumour, cyst or scar - cutaneous, subcutaneous or in $102.40 mucous membrane 373 Removal of tumour, cyst or scar involving muscle, bone or other $195.60 deep tissue 375 Surgery to salivary duct $306.00 376 Surgery to salivary gland $347.60 377 Removal or repair of soft tissue (not elsewhere defined) $97.60 378 Surgical removal of foreign body $216.00 379 Marsupialisation of cyst $214.00

381 Surgical exposure of unerupted tooth $167.40 1 per tooth, per 382 Surgical exposure and attachment of device for orthodontic traction $246.00 1 per tooth, per 384 Repositioning of displaced tooth/teeth - per tooth $45.60 1 per tooth, per 385 Surgical repositioning of unerupted tooth $162.60 1 per tooth, per 386 Splinting of displaced tooth/teeth - per tooth $101.60 1 per tooth, per 387 Replantation and splinting of a tooth $102.40 1 per tooth, per 388 Transplantation of tooth or tooth bud $209.40 1 per tooth, per 389 Surgery to isolate and preserve neurovascular tissue $151.60 391 Frenectomy $135.00 392 Drainage of abscess $105.00 393 Surgery involving the maxillary antrum $352.20 394 Surgery for osteomyelitis $279.60 1 per 395 Repair of nerve trunk $299.00 399 Control of reactionary or secondary post-operative haemorrhage $51.60 411 Direct pulp capping $0.00 412 Incomplete endodontic therapy (inoperable or fractured tooth) $55.80 414 Pulpotomy $62.60 1 per tooth, per 415 Complete chemo-mechanical preparation of root canal - one canal $121.60 1 per tooth, per 416 Complete chemo-mechanical preparation of root canal - each $53.00 additional canal 417 Root canal obturation - one canal $133.00 1 per tooth, per 418 Root canal obturation - each additional canal $51.00 419 Extirpation of pulp or debridement of root canal(s) - emergency or $67.00 1 per tooth, per palliative 421 Resorbable root canal filling - primary tooth $95.60 1 per tooth, per 431 Periapical curettage - per root $129.00 - reduced benefit for each subsequent root in same tooth n/a 432 Apicectomy - per root $162.60 - reduced benefit for each subsequent root in same tooth n/a 433 Exploratory periradicular surgery $101.60 434 Apical seal - per canal $296.00 - reduced benefit for each subsequent canal in same tooth n/a 436 Sealing of perforation $113.00 437 Surgical treatment and repair of external root resorption - per tooth $129.00 1 per tooth, per 438 Hemisection $129.00 1 per tooth, per 445 Exploration and/or negotiation of calcified canal - per canal, per $45.60 visit - reduced benefit for each subsequent canal in same tooth n/a 451 Removal of root filling - per canal $45.60 - reduced benefit for each subsequent canal in same tooth n/a 452 Removal of a cemented root canal post or post crown $107.00 453 Removal or bypassing fractured endodontic instrument $107.00

455 Additional visit for irrigation and/or dressing of the root canal system - per tooth $54.80 1 per tooth, per 457 Obturation of resorption defect or perforation (non-surgical) $79.00 1 per tooth, per 458 Interim therapeutic root filling - per tooth $54.80 1 per tooth, per 511 Metallic restoration - one surface - direct $56.00 1 per tooth, per 512 Metallic restoration - two surfaces - direct $69.40 1 per tooth, per 513 Metallic restoration - three surfaces - direct $84.60 1 per tooth, per 514 Metallic restoration - four surfaces - direct $94.60 1 per tooth, per 515 Metallic restoration - five surfaces - direct $103.60 1 per tooth, per 521 Adhesive restoration - one surface - anterior tooth - direct $63.60 1 per tooth, per 522 Adhesive restoration - two surfaces - anterior tooth - direct $76.80 1 per tooth, per 523 Adhesive restoration - three surfaces - anterior tooth - direct $88.20 1 per tooth, per 524 Adhesive restoration - four surfaces - anterior tooth - direct $103.60 1 per tooth, per 525 Adhesive restoration - five surfaces - anterior tooth - direct $123.20 1 per tooth, per 526 Adhesive restoration Veneer direct $135.00 1 per tooth, per 531 Adhesive restoration - one surface - posterior tooth - direct $68.60 1 per tooth, per 532 Adhesive restoration - two surfaces - posterior tooth - direct $89.80 1 per tooth, per 533 Adhesive restoration - three surfaces - posterior tooth - direct $120.20 1 per tooth, per 534 Adhesive restoration - four surfaces - posterior tooth - direct $132.40 1 per tooth, per 535 Adhesive restoration - five surfaces - posterior tooth - direct $140.80 1 per tooth, per 536 Adhesive restoration Veneer posterior tooth direct $135.00 1 per tooth, per 541 Metallic restoration - one surface - indirect $173.60 1 per tooth, per 542 Metallic restoration - two surfaces - indirect $318.60 1 per tooth, per 543 Metallic restoration - three surfaces - indirect $374.00 1 per tooth, per 544 Metallic restoration - four surfaces - indirect $419.20 1 per tooth, per 545 Metallic restoration - five surfaces - indirect $465.60 1 per tooth, per 551 Tooth-coloured restoration - one surface - indirect $318.60 1 per tooth, per 552 Tooth-coloured restoration - two surfaces - indirect $384.80 1 per tooth, per 553 Tooth-coloured restoration - three surfaces - indirect $453.20 1 per tooth, per 554 Tooth-coloured restoration - four surfaces - indirect $495.00 1 per tooth, per 555 Tooth-coloured restoration - five surfaces - indirect $519.00 1 per tooth, per 556 Tooth coloured restoration Veneer indirect $441.80 1 per tooth, per 571 Adaptation of new restoration to existing removable prosthesis $18.60 1 per tooth, per per tooth 572 Provisional (intermediate/temporary) restoration $38.20 1 per tooth, per 574 Metal band $55.00 1 per tooth, per

575 Pin retention - per pin $14.00 577 Cusp capping - per cusp $15.20 578 Restoration of an incisal corner - per corner $33.60 579 Bonding of tooth fragment $66.60 586 Crown Metallic with tooth preparation preformed $103.60 1 per tooth, per visit 587 Crown Metallic minimal tooth preparation preformed $69.00 1 per tooth, per visit 588 Crown Non-metallic - preformed $100.50 1 per tooth, per visit 595 Removal of inlay/onlay $36.80 596 Recementing of inlay/onlay $55.20 597 Post - direct $64.60 611 Full crown - acrylic resin - indirect $278.80 1 per tooth, per 613 Full crown - non-metallic - indirect $652.60 1 per tooth, per 615 Full crown - veneered - indirect $673.80 1 per tooth, per 618 Full crown - metallic - indirect $585.40 1 per tooth, per 625 Post and core for crown - indirect $167.40 1 per tooth, per 627 Preliminary restoration for crown - direct $90.00 1 per tooth, per 629 Post and root cap - indirect $121.60 1 per tooth, per 631 Provisional crown $95.60 1 per tooth, per 632 Provisional bridge - per pontic $58.60 633 Provisional implant abutment - per abutment $86.00 634 Provisional implant restoration - per implant abutment $86.00 1 per tooth, per 642 Bridge pontic - direct - per pontic $496.60 1 per tooth, per 643 Bridge pontic - indirect - per pontic $496.60 1 per tooth, per 644 Semi-fixed attachment $127.80 645 Precision or magnetic attachment $118.60 649 Retainer for bonded fixture - indirect - per tooth $110.40 651 Recementing crown or veneer $51.60 652 Recementing bridge or splint - per abutment $55.20 653 Rebonding of bridge or splint where retreatment of bridge surface $66.60 is required 655 Removal of crown $50.00 656 Removal of bridge or splint $55.20 658 Repair of crown, bridge or splint - indirect $49.20 659 Repair of crown, bridge or splint - direct $57.80 661 Fitting of implant abutment - per abutment $374.00 663 Removal of implant $130.80 664 Fitting of bar for denture - per abutment $162.60 665 Prosthesis with resin base attached to implants - removable per $618.20 arch 666 Prosthesis with metal frame attached to implants - per tooth $850.00 667 Prosthesis with metal frame attached to implants - removable per $850.00 arch 668 Fixture or abutment screw removal and replacement $30.00 669 Removal and reattachment of prosthesis fixed to implant(s) - per $90.00 implant - reduced benefit for each subsequent implant n/a 671 Full crown attached to osseointegrated implant - non-metallic - $850.00 indirect 672 Full crown attached to osseointegrated implant - veneered - $850.00 indirect 673 Full crown attached to osseointegrated implant - metallic - indirect $850.00 678 Diagnostic template $202.00 679 Surgical implant guide $207.00 684 Insertion of first stage of two stage endosseous implant - per $850.00 implant 688 Insertion of one stage endosseous implant - per implant $850.00 689 Provisional implant $135.00 690 Provisional retention device $116.60

691 Second stage surgery of two stage endosseous implant - per $329.60 implant 711 Complete maxillary denture $453.20 1 every 712 Complete mandibular denture $453.20 1 every 713 Provisional complete maxillary denture $241.60 1 every 714 Provisional complete mandibular denture $241.60 1 every 715 Provisional complete maxillary and mandibular dentures $366.70 1 every 716 Metal palate or plate $265.60 2 per 719 Complete maxillary and mandibular dentures $850.00 1 every 3 financial years 721 Partial maxillary denture - resin base $259.40 1 every 722 Partial mandibular denture - resin base $259.40 1 every 723 Provisional partial maxillary denture $164.20 1 every 724 Provisional partial mandibular denture $164.20 1 every 727 Partial maxillary denture - cast metal framework $493.80 1 every 728 Partial mandibular denture - cast metal framework $493.80 1 every 730 Veteran Affairs Item number only $0.00 0 731 Retainer - per tooth $15.60 732 Occlusal rest - per rest $18.00 733 Tooth/teeth (partial denture) $15.20 734 Overlays - per tooth $25.60 735 Precision or magnetic denture attachment $77.40 736 Immediate tooth replacement - per tooth $21.60 737 Resilient lining $105.00 738 Wrought bar $45.00 739 Metal backing - per backing $43.60 741 Adjustment of a denture $21.60 743 Relining - complete denture - processed $145.80 744 Relining - partial denture - processed $127.80 745 Remodelling - complete denture $167.40 746 Remodelling - partial denture $178.60 751 Relining - complete denture - direct $466.00 752 Relining - partial denture - direct $135.00 753 Cleaning and polishing of pre-existing denture $0.00 2 per 754 Denture base modification $47.00 761 Reattaching pre-existing tooth or clasp to denture $52.20 762 Replacing/adding clasp to denture - per clasp $57.40 763 Repairing broken base of a complete denture $52.20 764 Repairing broken base of a partial denture $52.20 765 Replacing tooth on denture - per tooth $55.60 766 Reattaching existing tooth on denture - per tooth $50.60 768 Adding tooth to partial denture to replace an extracted or $63.60 decoronated tooth - per tooth 769 Repair or addition to metal casting $79.40 771 Tissue conditioning preparatory to impressions - per application $34.60 772 Splint - resin - indirect $202.00 773 Splint - metal - indirect $318.60 774 Obturator $552.60 775 Characterisation of denture base $0.00 776 Impression - denture repair/modification $20.80 2 per 777 Identification $0.00 778 Inlay for denture tooth $95.60 779 Surgical guide for an immediate denture $202.00 811 Passive removable appliance - per arch $169.60 2 per Orthodontics 821 Active removable appliance - per arch $299.00 2 per Orthodontics 823 Functional orthopaedic appliance $474.60 1 per Orthodontics 824 Functional orthopaedic appliance prefabricated $283.00 1 per Orthodontics 825 Sequential Plastic Aligners - per arch $339.00 Orthodontics 829 Partial banding - per arch $282.00 Orthodontics 831 Full arch banding - per arch $355.00 Orthodontics

833 Removal of banding per arch $85.00 2 per Orthodontics 841 Fixed palatal or lingual arch appliance $173.60 2 per Orthodontics 842 Partial banding for inter-maxillary elastics (cross elastics) $173.60 2 per Orthodontics 843 Maxillary expansion appliance $252.20 1 per Orthodontics 845 Passive fixed appliance $168.60 2 per Orthodontics 846 Minor tooth guidance - fixed $135.00 Orthodontics 851 Extraoral appliance $173.60 1 per Orthodontics 862 Bonding of attachment for application of orthodontic force $129.00 Orthodontics 871 Orthodontic adjustment $55.00 1 per Orthodontics 872 Re-attachment of passive appliance fixed $45.40 1 per Orthodontics 873 Repair of passive appliance fixed $67.00 1 per Orthodontics 874 Removal of passive appliance fixed $67.00 1 per Orthodontics 875 Repair of removable appliance, resin base $41.40 2 per Orthodontics 876 Repair of removable appliance - clasp, spring or tooth $41.20 Orthodontics 877 Addition to removable appliance - clasp, spring or tooth $43.60 Orthodontics 878 Relining -removable appliance - processed $135.00 2 per Orthodontics 881 Complete course of orthodontic treatment $800.00 Orthodontics 911 Palliative care $30.60 1 per 915 After hours callout $39.80 1 per 916 Travel to provide services $42.00 1 per 926 Individually made tray - medicament(s) $84.60 927 Provision of medication/medicament $26.60 928 Intravenous cannulation and establishment of infusion $46.00 1 per 941 Local anaesthesia $22.00 942 Sedation - intravenous - per 30 minutes or part thereof $88.00 2 per 943 Sedation - inhalation - per 30 minutes or part thereof $28.60 2 per 944 Relaxation therapy $0.00 945 Low level laser therapy per $0.00 948 Dental acupuncture per $0.00 949 Treatment under general anaesthesia/sedation $75.60 1 per 961 Minor occlusal adjustment - per visit $0.00 1 per 963 Clinical occlusal analysis including muscle and joint palpation $60.00 1 per 964 Registration and mounting of models for occlusal analysis $0.00 965 Occlusal splint $295.00 1 per 966 Adjustment of pre-existing occlusal splint - per visit $44.60 2 per 967 Pantographic tracing $159.60 1 per 968 Occlusal adjustment following occlusal analysis - per visit $67.00 1 per 971 Adjunctive physical therapy for temporomandibular joint and $0.00 associated structures 972 Repair/addition - occlusal splint $92.00 1 per 981 Splinting and stabilisation - direct - per tooth $64.60 982 Enamel stripping - per visit $25.00 1 per 983 Single arch oral appliance for diagnosed snoring and obstructive $445.00 1 every 3 financial snoring and sleep apnoea years 984 Bi-maxillary oral appliance for diagnosed snoring and obstructive $595.00 1 every 3 financial snoring and sleep apnoea years 985 Repair/addition snoring or sleep apnoea device $63.60 1 every 986 Post-operative care not otherwise included $0.00 987 Re-contour tissue per $33.00 1 per 990 Treatment not otherwise included (specify) $0.00 Preventive Dental limit Dental limit Dental limit Orthodontic limit Financial year maximum No annual limit No annual limit $850 per person $800 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.