Dental fees
Effective 1 July 2024
Dental services can be invoiced online via HICAPS Digital Claims for next business day payments.
| General | Specialist | ||
|---|---|---|---|
| Service Description | ADA Number | Maximum Payment Rate | Maximum Payment Rate |
| Diagnostic services | |||
| Comprehensive Oral Examination | 011 | $115.61 | $115.61 |
| Periodic Oral Examination | 012 | $73.08 | $73.08 |
| Consultation | 014 | $115.61 | $115.61 |
| Written report (not elsewhere included) | 018 | $160.85 | $211.74 |
| Intraoral periapical or bitewing radiograph - per exposure | 022 | $56.95 | $56.95 |
| Cone Beam Volumetric Tomography - scan acquisition - per appointment | 026 | $181.79 | $181.79 |
| Cephalometric Radiograph - per exposure | 036 | $128.52 | $128.52 |
| Panoramic radiograph - per exposure | 037 | $128.52 | $128.52 |
| Pulp Testing - per appointment | 061 | $41.34 | $41.34 |
| Diagnostic model - per model | 071 | $79.98 | $79.98 |
| Photographic records - intraoral - per appointment | 072 | $45.68 | $45.68 |
| Cone Beam Volumetric Tomography analysis and/or interpretation - maxillary or mandibular dentition (both arches) | 089 | $84.84 | $84.84 |
| Preventive Services | |||
| (Prior approval from TAC required for these services) | |||
| Removal Of Calculus - first appointment | 114 | $143.64 | $143.64 |
| Bleaching, Internal - per tooth | 117 | $254.87 | $254.87 |
| Topical application of remineralisation and/or cariostatic agents - one treatment | 121 | $52.41 | $52.41 |
| Oral hygiene instruction | 141 | $57.28 | $57.28 |
| Desensitising Procedure - per appointment | 165 | $53.96 | $53.96 |
| Odontoplasty - per tooth | 171 | $57.72 | $57.72 |
| Periodontal Debridement - per tooth | 222 | $65.44 | $75.25 |
| Periodontal Flap Surgery - per tooth - Limit of 10 per visit, 20 per 12 month period | 232 | $323.18 | $323.18 |
| Surgical treatment of Peri-implant Disease - per implant | 233 | $389.93 | $389.93 |
| Gingival Graft - per tooth, implant or extraction | 235 | $562.73 | $662.05 |
| Guided Tissue Regeneration - per tooth or implant | 236 | $562.73 | $662.05 |
| Guided Tissue Regeneration - membrane removal | 237 | $653.71 | $769.10 |
| Periodontal Surgery for Crown Lengthening - per tooth | 238 | $565.38 | $665.15 |
| Osseous Graft- per tooth or implant | 243 | $562.73 | $662.05 |
| Oral Surgery | |||
| Removal of a tooth or part(s) thereof | 311 | $239.33 | $258.82 |
| Sectional removal of tooth or part(s) thereof | 314 | $315.41 | $321.97 |
| Surgical removal of a tooth or tooth fragment not requiring removal of bone or tooth division | 322 | $354.83 | $371.48 |
| Surgical removal of a tooth or tooth fragment requiring removal of bone | 323 | $427.26 | $456.92 |
| Splinting of displaced tooth/teeth - per tooth | 386 | $235.29 | $294.56 |
| Replantation and splinting of a tooth - per tooth | 387 | $473.02 | $543.97 |
| Endodontics | |||
| (These fees include the cost of x-rays where required) | |||
| Direct Pulp Capping | 411 | $63.72 | $66.87 |
| Pulpotomy | 414 | $157.20 | $214.80 |
| Complete chemo-mechanical preparation of root canal - one canal | 415 | $367.58 | $422.70 |
| Complete chemo-mechanical preparation of root canal - each additional canal | 416 | $180.93 | $209.65 |
| Root canal obturation - one canal | 417 | $360.76 | $414.87 |
| Root canal obturation - each additional canal | 418 | $177.96 | $204.65 |
| Extirpation of pulp or debridement of root canal(s) - emergency or palliative | 419 | $252.43 | $252.43 |
| Removal Of Root Filling - Per Canal | 451 | $172.08 | $197.91 |
| Additional Visit For Irrigation And/Or Dressing Of The Root Canal System - per tooth | 455 | $190.54 | $219.12 |
| Restorative Services | |||
| Metallic Restoration - One Surface - direct | 511 | $187.99 | $216.18 |
| Metallic Restoration - Two Surfaces - direct | 512 | $224.67 | $258.36 |
| Metallic Restoration - Three Surfaces - direct | 513 | $263.05 | $302.52 |
| Metallic Restoration - Four Surfaces - direct | 514 | $301.75 | $347.02 |
| Metallic Restoration - Five Surfaces - direct | 515 | $342.67 | $394.06 |
| Adhesive Restoration - One Surface - Anterior Tooth - direct | 521 | $202.13 | $232.44 |
| Adhesive Restoration - Two Surfaces - Anterior tooth - direct | 522 | $237.71 | $273.40 |
| Adhesive Restoration - Three Surfaces - Anterior tooth - direct | 523 | $278.97 | $320.82 |
| Adhesive Restoration - Four Surfaces - Anterior tooth - direct | 524 | $313.87 | $360.97 |
| Adhesive Restoration - Five Surfaces - Anterior tooth - direct | 525 | $369.19 | $424.56 |
| Adhesive Restoration - Veneer - Anterior tooth- direct | 526 | $416.01 | $456.87 |
| Adhesive restoration - one surface - posterior tooth - direct | 531 | $213.10 | $245.06 |
| Adhesive restoration - two surfaces - posterior tooth - direct | 532 | $253.85 | $291.93 |
| Adhesive restoration - three surfaces - posterior tooth - direct | 533 | $296.91 | $341.45 |
| Adhesive restoration - four surfaces - posterior tooth - direct | 534 | $334.48 | $384.66 |
| Adhesive restoration - five surfaces - posterior tooth - direct | 535 | $398.56 | $458.34 |
| Adhesive Restoration - Veneer - Posterior tooth - direct | 536 | $408.40 | $456.87 |
| Tooth coloured restoration - one surface - indirect | 551 | $1,028.86 | $1,183.21 |
| Tooth coloured restoration - two surfaces - indirect | 552 | $1,140.36 | $1,311.42 |
| Tooth coloured restoration - three surfaces - indirect | 553 | $1,317.30 | $1,514.89 |
| Tooth coloured restoration - four surfaces - indirect | 554 | $1,429.99 | $1,644.50 |
| Tooth coloured restoration - five surfaces - indirect | 555 | $1,568.15 | $1,803.37 |
| Tooth - coloured restoration - Veneer - indirect | 556 | $1,505.14 | $1,730.91 |
| Provisional (intermediate/temporary) restoration - per tooth | 572 | $110.29 | $110.29 |
| Pin retention - per pin | 575 | $49.84 | $49.84 |
| Post - Direct | 597 | $204.33 | $229.77 |
| Crown and Bridgework | |||
| (If these procedures are to be carried out in a hospital under general anaesthesia, prior approval must be obtained from the TAC) | |||
| Full crown - non metallic - indirect | 613 | $1,771.26 | $2,036.96 |
| Full crown - veneered - indirect | 615 | $1,747.26 | $2,009.35 |
| Full crown - metallic indirect | 618 | $1,758.17 | $2,021.89 |
| Post and core for crown - indirect | 625 | $553.13 | $665.15 |
| Preliminary restoration for crown - direct | 627 | $309.20 | $328.55 |
| Provisional bridge pontic - per pontic | 632 | $350.43 | $350.43 |
| Bridge pontic - direct - per pontic | 642 | $456.24 | $524.69 |
| Bridge pontic - indirect - per pontic | 643 | $1,317.62 | $1,778.78 |
| Retainer for bonded fixture - indirect - per tooth | 649 | $782.75 | $900.16 |
| Implant Procedures | |||
| Fitting of an implant abutment - per abutment | 661 | $1,130.02 | $1,130.02 |
| Prosthesis with metal frame attached to implants - fixed - per arch | 666 | $4,071.85 | $5,966.03 |
| Removal and reattachment of prosthesis fixed to implant(s) – per implant | 669 | $196.19 | $196.19 |
| Full crown attached to osseointegrated implant - veneered indirect | 672 | $2,252.85 | $2,957.40 |
| Surgical implant guide | 679 | $267.62 | $267.62 |
| Insertion of first stage of two-stage endosseous implant - per implant | 684 | $2,423.72 | $2,423.72 |
|
Insertion of one stage endosseous implant - per implant Includes the cost of hardware | 688 | $2,924.83 | $2,924.83 |
|
Second stage surgery of two stage endosseous implant - per implant Includes the cost of hardware | 691 | $500.98 | $500.98 |
| Prosthodontics | |||
| Complete Maxillary Denture | 711 | $1624.07 | $1,867.67 |
| Complete Mandibular Denture | 712 | $1624.07 | $1,867.67 |
| Complete Maxillary and Mandibular Denture | 719 | $2,945.02 | $3,386.76 |
| Partial maxillary denture - resin base | 721 | $1,042.80 | $1,042.80 |
| Partial mandibular denture - resin base | 722 | $1,042.80 | $1,042.80 |
| Partial maxillary denture - cast metal framework including rests and retainers | 727 | $1,809.30 | $2,080.72 |
| Partial mandibular denture - cast metal framework including rests and retainers | 728 | $1,809.30 | $2,080.72 |
| Additional items for Acrylic Dentures only | |||
| Retainer - Per Tooth | 731 | $65.35 | $65.35 |
| Occlusal Rest - per rest | 732 | $18.95 | $18.95 |
| Tooth/teeth partial denture | 733 | $64.24 | $64.24 |
| Immediate tooth replacement - per tooth | 736 | $12.75 | $12.75 |
| Relining - complete denture - processed | 743 | $511.41 | $511.41 |
| Relining - partial denture - processed | 744 | $497.79 | $497.79 |
| Adding tooth to partial denture to replace an extracted or decoronated tooth - per tooth | 768 | $221.66 | $257.56 |
| Splint - Resin - Indirect | 772 | $334.22 | $473.02 |
| Orthodontics | |||
| Active removable appliance therapy - per arch | 821 | $1,169.55 | $1,341.07 |
| Full arch banding - per arch | 831 | $3,224.76 | $4,609.37 |
| Minor tooth guidance - fixed | 846 | $1,045.78 | $1,045.78 |
| Complete course of orthodontic treatment | 881 | $6,661.60 | $8,625.87 |
| General | |||
| Travel to provide services | 916 | FBN* | FBN* |
| Clinical occlusal analysis, including muscle and joint palpation - limit one per three year period | 963 | $110.29 | $154.33 |
| Occlusal splint | 965 | $734.02 | $752.37 |
| Adjustment of pre-existing occlusal splint - per appointment | 966 | $104.55 | $133.73 |
| General | Specialist | ||
|---|---|---|---|
| Service Description | ADA Number | Maximum Payment Rate | Maximum Payment Rate |
| Diagnostic services | |||
| Comprehensive Oral Examination | 011 | $111.37 | $111.37 |
| Periodic Oral Examination | 012 | $70.40 | $70.40 |
| Consultation | 014 | $111.37 | $111.37 |
| Written report (not elsewhere included) | 018 | $154.95 | $203.97 |
| Intraoral periapical or bitewing radiograph - per exposure | 022 | $54.86 | $54.86 |
| Cone Beam Volumetric Tomography - scan acquisition - per appointment | 026 | $175.12 | $175.12 |
| Cephalometric Radiograph - per exposure | 036 | $123.80 | $123.80 |
| Panoramic radiograph - per exposure | 037 | $123.80 | $123.80 |
| Pulp Testing - per appointment | 061 | $39.82 | $39.82 |
| Diagnostic model - per model | 071 | $77.04 | $77.04 |
| Photographic records - intraoral - per appointment | 072 | $44.00 | $44.00 |
| Cone Beam Volumetric Tomography analysis and/or interpretation - maxillary or mandibular dentition (both arches) | 089 | $81.73 | $81.73 |
| Preventive Services | |||
| (Prior approval from TAC required for these services) | |||
| Removal Of Calculus - first appointment | 114 | $ 138.37 | $138.37 |
| Bleaching, Internal - per tooth | 117 | $245.52 | $245.52 |
| Topical application of remineralisation and/or cariostatic agents - one treatment | 121 | $50.49 | $50.49 |
| Oral hygiene instruction | 141 | $55.18 | $55.18 |
| Desensitising Procedure - per appointment | 165 | $51.98 | $51.98 |
| Odontoplasty - per tooth | 171 | $55.60 | $55.60 |
| Periodontal Debridement - per tooth | 222 | $63.04 | $72.49 |
| Periodontal Flap Surgery - per tooth - Limit of 10 per visit, 20 per 12 month period | 232 | $311.32 | $311.32 |
| Surgical treatment of Peri-implant Disease - per implant | 233 | $375.62 | $375.62 |
| Gingival Graft - per tooth, implant or extraction | 235 | $542.08 | $637.75 |
| Guided Tissue Regeneration - per tooth or implant | 236 | $542.08 | $637.75 |
| Guided Tissue Regeneration - membrane removal | 237 | $629.72 | $740.87 |
| Periodontal Surgery for Crown Lengthening - per tooth | 238 | $544.63 | $640.74 |
| Osseous Graft- per tooth or implant | 243 | $542.08 | $637.75 |
| Oral Surgery | |||
| Removal of a tooth or part(s) thereof | 311 | $230.55 | $249.32 |
| Sectional removal of tooth or part(s) thereof | 314 | $303.83 | $310.15 |
| Surgical removal of a tooth or tooth fragment not requiring removal of bone or tooth division | 322 | $341.81 | $357.85 |
| Surgical removal of a tooth or tooth fragment requiring removal of bone | 323 | $411.58 | $440.15 |
| Splinting of displaced tooth/teeth - per tooth | 386 | $226.65 | $283.75 |
| Replantation and splinting of a tooth - per tooth | 387 | $455.66 | $524.01 |
| Endodontics | |||
| (These fees include the cost of x-rays where required) | |||
| Direct Pulp Capping | 411 | $61.38 | $64.42 |
| Pulpotomy | 414 | $151.43 | $206.92 |
| Complete chemo-mechanical preparation of root canal - one canal | 415 | $354.09 | $407.19 |
| Complete chemo-mechanical preparation of root canal - each additional canal | 416 | $174.29 | $201.96 |
| Root canal obturation - one canal | 417 | $347.52 | $399.64 |
| Root canal obturation - each additional canal | 418 | $171.43 | $197.14 |
| Extirpation of pulp or debridement of root canal(s) - emergency or palliative | 419 | $243.17 | $243.17 |
| Removal Of Root Filling - Per Canal | 451 | $165.76 | $190.65 |
| Additional Visit For Irrigation And/Or Dressing Of The Root Canal System - per tooth | 455 | $183.55 | $211.08 |
| Restorative Services | |||
| Metallic Restoration - One Surface - direct | 511 | $181.09 | $208.25 |
| Metallic Restoration - Two Surfaces - direct | 512 | $216.42 | $248.88 |
| Metallic Restoration - Three Surfaces - direct | 513 | $253.40 | $291.42 |
| Metallic Restoration - Four Surfaces - direct | 514 | $290.68 | $334.28 |
| Metallic Restoration - Five Surfaces - direct | 515 | $330.09 | $379.60 |
| Adhesive Restoration - One Surface - Anterior Tooth - direct | 521 | $194.71 | $223.91 |
| Adhesive Restoration - Two Surfaces - Anterior tooth - direct | 522 | $228.99 | $263.37 |
| Adhesive Restoration - Three Surfaces - Anterior tooth - direct | 523 | $268.73 | $309.05 |
| Adhesive Restoration - Four Surfaces - Anterior tooth - direct | 524 | $302.35 | $347.72 |
| Adhesive Restoration - Five Surfaces - Anterior tooth - direct | 525 | $355.64 | $408.98 |
| Adhesive Restoration - Veneer - Anterior tooth- direct | 526 | $400.74 | $440.10 |
| Adhesive restoration - one surface - posterior tooth - direct | 531 | $205.28 | $236.07 |
| Adhesive restoration - two surfaces - posterior tooth - direct | 532 | $244.53 | $281.22 |
| Adhesive restoration - three surfaces - posterior tooth - direct | 533 | $286.01 | $328.92 |
| Adhesive restoration - four surfaces - posterior tooth - direct | 534 | $322.20 | $370.54 |
| Adhesive restoration - five surfaces - posterior tooth - direct | 535 | $383.93 | $441.52 |
| Adhesive Restoration - Veneer - Posterior tooth - direct | 536 | $393.41 | $440.10 |
| Tooth coloured restoration - one surface - indirect | 551 | $991.10 | $1,139.78 |
| Tooth coloured restoration - two surfaces - indirect | 552 | $1,098.51 | $1,263.29 |
| Tooth coloured restoration - three surfaces - indirect | 553 | $1,268.95 | $1,459.29 |
| Tooth coloured restoration - four surfaces - indirect | 554 | $1,377.51 | $1,584.14 |
| Tooth coloured restoration - five surfaces - indirect | 555 | $1,510.60 | $1,737.18 |
| Tooth - coloured restoration - Veneer - indirect | 556 | $1,449.90 | $1,667.38 |
| Provisional (intermediate/temporary) restoration - per tooth | 572 | $106.24 | $106.24 |
| Pin retention - per pin | 575 | $48.01 | $48.01 |
| Post - Direct | 597 | $196.83 | $221.34 |
| Crown and Bridgework | |||
| (If these procedures are to be carried out in a hospital under general anaesthesia, prior approval must be obtained from the TAC) | |||
| Full crown - non metallic - indirect | 613 | $1,706.25 | $1,962.20 |
| Full crown - veneered - indirect | 615 | $1,683.13 | $1,935.60 |
| Full crown - metallic indirect | 618 | $1,693.64 | $1,947.68 |
| Post and core for crown - indirect | 625 | $532.83 | $640.74 |
| Preliminary restoration for crown - direct | 627 | $297.85 | $316.49 |
| Provisional bridge pontic - per pontic | 632 | $337.57 | $337.57 |
| Bridge pontic - direct - per pontic | 642 | $439.50 | $505.43 |
| Bridge pontic - indirect - per pontic | 643 | $1,269.26 | $1,713.50 |
| Retainer for bonded fixture - indirect - per tooth | 649 | $754.02 | $867.12 |
| Implant Procedures | |||
| Fitting of an implant abutment - per abutment | 661 | $1,088.55 | $1,088.55 |
| Prosthesis with metal frame attached to implants - fixed - per arch | 666 | $3,922.41 | $5,747.07 |
| Removal and reattachment of prosthesis fixed to implant(s) – per implant | 669 | $188.99 | $188.99 |
| Full crown attached to osseointegrated implant - veneered indirect | 672 | $2,170.17 | $2,848.86 |
| Surgical implant guide | 679 | $257.80 | $257.80 |
| Insertion of first stage of two-stage endosseous implant - per implant | 684 | $2,334.77 | $2,334.77 |
|
Insertion of one stage endosseous implant - per implant Includes the cost of hardware | 688 | $2,817.48 | $2,817.48 |
|
Second stage surgery of two stage endosseous implant - per implant Includes the cost of hardware | 691 | $482.59 | $482.59 |
| Prosthodontics | |||
| Complete Maxillary Denture | 711 | $1,564.46 | $1,799.12 |
| Complete Mandibular Denture | 712 | $1,564.46 | $1,799.12 |
| Complete Maxillary and Mandibular Denture | 719 | $2,836.93 | $3,262.46 |
| Partial maxillary denture - resin base | 721 | $1,004.53 | $1,004.53 |
| Partial mandibular denture - resin base | 722 | $1,004.53 | $1,004.53 |
| Partial maxillary denture - cast metal framework including rests and retainers | 727 | $1,742.90 | $2,004.35 |
| Partial mandibular denture - cast metal framework including rests and retainers | 728 | $1,742.90 | $2,004.35 |
| Additional items for Acrylic Dentures only | |||
| Retainer - Per Tooth | 731 | $62.95 | $62.95 |
| Occlusal Rest - per rest | 732 | $18.25 | $18.25 |
| Tooth/teeth partial denture | 733 | $61.88 | $61.88 |
| Immediate tooth replacement - per tooth | 736 | $12.28 | $12.28 |
| Relining - complete denture - processed | 743 | $492.64 | $492.64 |
| Relining - partial denture - processed | 744 | $479.52 | $479.52 |
| Adding tooth to partial denture to replace an extracted or decoronated tooth - per tooth | 768 | $213.52 | $248.11 |
| Splint - Resin - Indirect | 772 | $321.95 | $455.66 |
| Orthodontics | |||
| Active removable appliance therapy - per arch | 821 | $1,126.63 | $1,291.85 |
| Full arch banding - per arch | 831 | $3,106.41 | $4,440.20 |
| Minor tooth guidance - fixed | 846 | $1,007.40 | $1,007.40 |
| Complete course of orthodontic treatment | 881 | $6,417.11 | $8,309.29 |
| General | |||
| Travel to provide services | 916 | FBN* | FBN* |
| Clinical occlusal analysis, including muscle and joint palpation - limit one per three year period | 963 | $106.24 | $148.67 |
| Occlusal splint | 965 | $707.08 | $724.76 |
| Adjustment of pre-existing occlusal splint - per appointment | 966 | $100.71 | $128.82 |
| General | Specialist | ||
|---|---|---|---|
| Service Description | ADA Number | Maximum Payment Rate | Maximum Payment Rate |
| Diagnostic services | |||
| Comprehensive Oral Examination | 011 | $115.61 | $115.61 |
| Periodic Oral Examination | 012 | $73.08 | $73.08 |
| Consultation | 014 | $115.61 | $115.61 |
| Written report (not elsewhere included) | 018 | $160.85 | $211.74 |
| Intraoral periapical or bitewing radiograph - per exposure | 022 | $56.95 | $56.95 |
| Cone Beam Volumetric Tomography - scan acquisition - per appointment | 026 | $181.79 | $181.79 |
| Cephalometric Radiograph - per exposure | 036 | $128.52 | $128.52 |
| Panoramic radiograph - per exposure | 037 | $128.52 | $128.52 |
| Pulp Testing - per appointment | 061 | $41.34 | $41.34 |
| Diagnostic model - per model | 071 | $79.98 | $79.98 |
| Photographic records - intraoral - per appointment | 072 | $45.68 | $45.68 |
| Cone Beam Volumetric Tomography analysis and/or interpretation - maxillary or mandibular dentition (both arches) | 089 | $84.84 | $84.84 |
| Preventive Services | |||
| (Prior approval from TAC required for these services) | |||
| Removal Of Calculus - first appointment | 114 | $143.64 | $143.64 |
| Bleaching, Internal - per tooth | 117 | $254.87 | $254.87 |
| Topical application of remineralisation and/or cariostatic agents - one treatment | 121 | $52.41 | $52.41 |
| Oral hygiene instruction | 141 | $57.28 | $57.28 |
| Desensitising Procedure - per appointment | 165 | $53.96 | $53.96 |
| Odontoplasty - per tooth | 171 | $57.72 | $57.72 |
| Periodontal Debridement - per tooth | 222 | $65.44 | $75.25 |
| Periodontal Flap Surgery - per tooth - Limit of 10 per visit, 20 per 12 month period | 232 | $323.18 | $323.18 |
| Surgical treatment of Peri-implant Disease - per implant | 233 | $389.93 | $389.93 |
| Gingival Graft - per tooth, implant or extraction | 235 | $562.73 | $662.05 |
| Guided Tissue Regeneration - per tooth or implant | 236 | $562.73 | $662.05 |
| Guided Tissue Regeneration - membrane removal | 237 | $653.71 | $769.10 |
| Periodontal Surgery for Crown Lengthening - per tooth | 238 | $565.38 | $665.15 |
| Osseous Graft- per tooth or implant | 243 | $562.73 | $662.05 |
| Oral Surgery | |||
| Removal of a tooth or part(s) thereof | 311 | $239.33 | $258.82 |
| Sectional removal of tooth or part(s) thereof | 314 | $315.41 | $321.97 |
| Surgical removal of a tooth or tooth fragment not requiring removal of bone or tooth division | 322 | $354.83 | $371.48 |
| Surgical removal of a tooth or tooth fragment requiring removal of bone | 323 | $427.26 | $456.92 |
| Splinting of displaced tooth/teeth - per tooth | 386 | $235.29 | $294.56 |
| Replantation and splinting of a tooth - per tooth | 387 | $473.02 | $543.97 |
| Endodontics | |||
| (These fees include the cost of x-rays where required) | |||
| Direct Pulp Capping | 411 | $63.72 | $66.87 |
| Pulpotomy | 414 | $157.20 | $214.80 |
| Complete chemo-mechanical preparation of root canal - one canal | 415 | $367.58 | $422.70 |
| Complete chemo-mechanical preparation of root canal - each additional canal | 416 | $180.93 | $209.65 |
| Root canal obturation - one canal | 417 | $360.76 | $414.87 |
| Root canal obturation - each additional canal | 418 | $177.96 | $204.65 |
| Extirpation of pulp or debridement of root canal(s) - emergency or palliative | 419 | $252.43 | $252.43 |
| Removal Of Root Filling - Per Canal | 451 | $172.08 | $197.91 |
| Additional Visit For Irrigation And/Or Dressing Of The Root Canal System - per tooth | 455 | $190.54 | $219.12 |
| Restorative Services | |||
| Metallic Restoration - One Surface - direct | 511 | $187.99 | $216.18 |
| Metallic Restoration - Two Surfaces - direct | 512 | $224.67 | $258.36 |
| Metallic Restoration - Three Surfaces - direct | 513 | $263.05 | $302.52 |
| Metallic Restoration - Four Surfaces - direct | 514 | $301.75 | $347.02 |
| Metallic Restoration - Five Surfaces - direct | 515 | $342.67 | $394.06 |
| Adhesive Restoration - One Surface - Anterior Tooth - direct | 521 | $202.13 | $232.44 |
| Adhesive Restoration - Two Surfaces - Anterior tooth - direct | 522 | $237.71 | $273.40 |
| Adhesive Restoration - Three Surfaces - Anterior tooth - direct | 523 | $278.97 | $320.82 |
| Adhesive Restoration - Four Surfaces - Anterior tooth - direct | 524 | $313.87 | $360.97 |
| Adhesive Restoration - Five Surfaces - Anterior tooth - direct | 525 | $369.19 | $424.56 |
| Adhesive Restoration - Veneer - Anterior tooth- direct | 526 | $416.01 | $456.87 |
| Adhesive restoration - one surface - posterior tooth - direct | 531 | $213.10 | $245.06 |
| Adhesive restoration - two surfaces - posterior tooth - direct | 532 | $253.85 | $291.93 |
| Adhesive restoration - three surfaces - posterior tooth - direct | 533 | $296.91 | $341.45 |
| Adhesive restoration - four surfaces - posterior tooth - direct | 534 | $334.48 | $384.66 |
| Adhesive restoration - five surfaces - posterior tooth - direct | 535 | $398.56 | $458.34 |
| Adhesive Restoration - Veneer - Posterior tooth - direct | 536 | $408.40 | $456.87 |
| Tooth coloured restoration - one surface - indirect | 551 | $1,028.86 | $1,183.21 |
| Tooth coloured restoration - two surfaces - indirect | 552 | $1,140.36 | $1,311.42 |
| Tooth coloured restoration - three surfaces - indirect | 553 | $1,317.30 | $1,514.89 |
| Tooth coloured restoration - four surfaces - indirect | 554 | $1,429.99 | $1,644.50 |
| Tooth coloured restoration - five surfaces - indirect | 555 | $1,568.15 | $1,803.37 |
| Tooth - coloured restoration - Veneer - indirect | 556 | $1,505.14 | $1,730.91 |
| Provisional (intermediate/temporary) restoration - per tooth | 572 | $110.29 | $110.29 |
| Pin retention - per pin | 575 | $49.84 | $49.84 |
| Post - Direct | 597 | $204.33 | $229.77 |
| Crown and Bridgework | |||
| (If these procedures are to be carried out in a hospital under general anaesthesia, prior approval must be obtained from the TAC) | |||
| Full crown - non metallic - indirect | 613 | $1,771.26 | $2,036.96 |
| Full crown - veneered - indirect | 615 | $1,747.26 | $2,009.35 |
| Full crown - metallic indirect | 618 | $1,758.17 | $2,021.89 |
| Post and core for crown - indirect | 625 | $553.13 | $665.15 |
| Preliminary restoration for crown - direct | 627 | $309.20 | $328.55 |
| Provisional bridge pontic - per pontic | 632 | $350.43 | $350.43 |
| Bridge pontic - direct - per pontic | 642 | $456.24 | $524.69 |
| Bridge pontic - indirect - per pontic | 643 | $1,317.62 | $1,778.78 |
| Retainer for bonded fixture - indirect - per tooth | 649 | $782.75 | $900.16 |
| Implant Procedures | |||
| Fitting of an implant abutment - per abutment | 661 | $1,130.02 | $1,130.02 |
| Prosthesis with metal frame attached to implants - fixed - per arch | 666 | $4,071.85 | $5,966.03 |
| Removal and reattachment of prosthesis fixed to implant(s) – per implant | 669 | $196.19 | $196.19 |
| Full crown attached to osseointegrated implant - veneered indirect | 672 | $2,252.85 | $2,957.40 |
| Surgical implant guide | 679 | $267.62 | $267.62 |
| Insertion of first stage of two-stage endosseous implant - per implant | 684 | $2,423.72 | $2,423.72 |
|
Insertion of one stage endosseous implant - per implant Includes the cost of hardware | 688 | $2,924.83 | $2,924.83 |
|
Second stage surgery of two stage endosseous implant - per implant Includes the cost of hardware | 691 | $500.98 | $500.98 |
| Prosthodontics | |||
| Complete Maxillary Denture | 711 | $1624.07 | $1,867.67 |
| Complete Mandibular Denture | 712 | $1624.07 | $1,867.67 |
| Complete Maxillary and Mandibular Denture | 719 | $2,945.02 | $3,386.76 |
| Partial maxillary denture - resin base | 721 | $1,042.80 | $1,042.80 |
| Partial mandibular denture - resin base | 722 | $1,042.80 | $1,042.80 |
| Partial maxillary denture - cast metal framework including rests and retainers | 727 | $1,809.30 | $2,080.72 |
| Partial mandibular denture - cast metal framework including rests and retainers | 728 | $1,809.30 | $2,080.72 |
| Additional items for Acrylic Dentures only | |||
| Retainer - Per Tooth | 731 | $65.35 | $65.35 |
| Occlusal Rest - per rest | 732 | $18.95 | $18.95 |
| Tooth/teeth partial denture | 733 | $64.24 | $64.24 |
| Immediate tooth replacement - per tooth | 736 | $12.75 | $12.75 |
| Relining - complete denture - processed | 743 | $511.41 | $511.41 |
| Relining - partial denture - processed | 744 | $497.79 | $497.79 |
| Adding tooth to partial denture to replace an extracted or decoronated tooth - per tooth | 768 | $221.66 | $257.56 |
| Splint - Resin - Indirect | 772 | $334.22 | $473.02 |
| Orthodontics | |||
| Active removable appliance therapy - per arch | 821 | $1,169.55 | $1,341.07 |
| Full arch banding - per arch | 831 | $3,224.76 | $4,609.37 |
| Minor tooth guidance - fixed | 846 | $1,045.78 | $1,045.78 |
| Complete course of orthodontic treatment | 881 | $6,661.60 | $8,625.87 |
| General | |||
| Travel to provide services | 916 | FBN* | FBN* |
| Clinical occlusal analysis, including muscle and joint palpation - limit one per three year period | 963 | $110.29 | $154.33 |
| Occlusal splint | 965 | $734.02 | $752.37 |
| Adjustment of pre-existing occlusal splint - per appointment | 966 | $104.55 | $133.73 |
| General | Specialist | ||
|---|---|---|---|
| Service Description | ADA Number | Maximum Payment Rate | Maximum Payment Rate |
| Diagnostic services | |||
| Comprehensive Oral Examination | 011 | $111.37 | $111.37 |
| Periodic Oral Examination | 012 | $70.40 | $70.40 |
| Consultation | 014 | $111.37 | $111.37 |
| Written report (not elsewhere included) | 018 | $154.95 | $203.97 |
| Intraoral periapical or bitewing radiograph - per exposure | 022 | $54.86 | $54.86 |
| Cone Beam Volumetric Tomography - scan acquisition - per appointment | 026 | $175.12 | $175.12 |
| Cephalometric Radiograph - per exposure | 036 | $123.80 | $123.80 |
| Panoramic radiograph - per exposure | 037 | $123.80 | $123.80 |
| Pulp Testing - per appointment | 061 | $39.82 | $39.82 |
| Diagnostic model - per model | 071 | $77.04 | $77.04 |
| Photographic records - intraoral - per appointment | 072 | $44.00 | $44.00 |
| Cone Beam Volumetric Tomography analysis and/or interpretation - maxillary or mandibular dentition (both arches) | 089 | $81.73 | $81.73 |
| Preventive Services | |||
| (Prior approval from TAC required for these services) | |||
| Removal Of Calculus - first appointment | 114 | $ 138.37 | $138.37 |
| Bleaching, Internal - per tooth | 117 | $245.52 | $245.52 |
| Topical application of remineralisation and/or cariostatic agents - one treatment | 121 | $50.49 | $50.49 |
| Oral hygiene instruction | 141 | $55.18 | $55.18 |
| Desensitising Procedure - per appointment | 165 | $51.98 | $51.98 |
| Odontoplasty - per tooth | 171 | $55.60 | $55.60 |
| Periodontal Debridement - per tooth | 222 | $63.04 | $72.49 |
| Periodontal Flap Surgery - per tooth - Limit of 10 per visit, 20 per 12 month period | 232 | $311.32 | $311.32 |
| Surgical treatment of Peri-implant Disease - per implant | 233 | $375.62 | $375.62 |
| Gingival Graft - per tooth, implant or extraction | 235 | $542.08 | $637.75 |
| Guided Tissue Regeneration - per tooth or implant | 236 | $542.08 | $637.75 |
| Guided Tissue Regeneration - membrane removal | 237 | $629.72 | $740.87 |
| Periodontal Surgery for Crown Lengthening - per tooth | 238 | $544.63 | $640.74 |
| Osseous Graft- per tooth or implant | 243 | $542.08 | $637.75 |
| Oral Surgery | |||
| Removal of a tooth or part(s) thereof | 311 | $230.55 | $249.32 |
| Sectional removal of tooth or part(s) thereof | 314 | $303.83 | $310.15 |
| Surgical removal of a tooth or tooth fragment not requiring removal of bone or tooth division | 322 | $341.81 | $357.85 |
| Surgical removal of a tooth or tooth fragment requiring removal of bone | 323 | $411.58 | $440.15 |
| Splinting of displaced tooth/teeth - per tooth | 386 | $226.65 | $283.75 |
| Replantation and splinting of a tooth - per tooth | 387 | $455.66 | $524.01 |
| Endodontics | |||
| (These fees include the cost of x-rays where required) | |||
| Direct Pulp Capping | 411 | $61.38 | $64.42 |
| Pulpotomy | 414 | $151.43 | $206.92 |
| Complete chemo-mechanical preparation of root canal - one canal | 415 | $354.09 | $407.19 |
| Complete chemo-mechanical preparation of root canal - each additional canal | 416 | $174.29 | $201.96 |
| Root canal obturation - one canal | 417 | $347.52 | $399.64 |
| Root canal obturation - each additional canal | 418 | $171.43 | $197.14 |
| Extirpation of pulp or debridement of root canal(s) - emergency or palliative | 419 | $243.17 | $243.17 |
| Removal Of Root Filling - Per Canal | 451 | $165.76 | $190.65 |
| Additional Visit For Irrigation And/Or Dressing Of The Root Canal System - per tooth | 455 | $183.55 | $211.08 |
| Restorative Services | |||
| Metallic Restoration - One Surface - direct | 511 | $181.09 | $208.25 |
| Metallic Restoration - Two Surfaces - direct | 512 | $216.42 | $248.88 |
| Metallic Restoration - Three Surfaces - direct | 513 | $253.40 | $291.42 |
| Metallic Restoration - Four Surfaces - direct | 514 | $290.68 | $334.28 |
| Metallic Restoration - Five Surfaces - direct | 515 | $330.09 | $379.60 |
| Adhesive Restoration - One Surface - Anterior Tooth - direct | 521 | $194.71 | $223.91 |
| Adhesive Restoration - Two Surfaces - Anterior tooth - direct | 522 | $228.99 | $263.37 |
| Adhesive Restoration - Three Surfaces - Anterior tooth - direct | 523 | $268.73 | $309.05 |
| Adhesive Restoration - Four Surfaces - Anterior tooth - direct | 524 | $302.35 | $347.72 |
| Adhesive Restoration - Five Surfaces - Anterior tooth - direct | 525 | $355.64 | $408.98 |
| Adhesive Restoration - Veneer - Anterior tooth- direct | 526 | $400.74 | $440.10 |
| Adhesive restoration - one surface - posterior tooth - direct | 531 | $205.28 | $236.07 |
| Adhesive restoration - two surfaces - posterior tooth - direct | 532 | $244.53 | $281.22 |
| Adhesive restoration - three surfaces - posterior tooth - direct | 533 | $286.01 | $328.92 |
| Adhesive restoration - four surfaces - posterior tooth - direct | 534 | $322.20 | $370.54 |
| Adhesive restoration - five surfaces - posterior tooth - direct | 535 | $383.93 | $441.52 |
| Adhesive Restoration - Veneer - Posterior tooth - direct | 536 | $393.41 | $440.10 |
| Tooth coloured restoration - one surface - indirect | 551 | $991.10 | $1,139.78 |
| Tooth coloured restoration - two surfaces - indirect | 552 | $1,098.51 | $1,263.29 |
| Tooth coloured restoration - three surfaces - indirect | 553 | $1,268.95 | $1,459.29 |
| Tooth coloured restoration - four surfaces - indirect | 554 | $1,377.51 | $1,584.14 |
| Tooth coloured restoration - five surfaces - indirect | 555 | $1,510.60 | $1,737.18 |
| Tooth - coloured restoration - Veneer - indirect | 556 | $1,449.90 | $1,667.38 |
| Provisional (intermediate/temporary) restoration - per tooth | 572 | $106.24 | $106.24 |
| Pin retention - per pin | 575 | $48.01 | $48.01 |
| Post - Direct | 597 | $196.83 | $221.34 |
| Crown and Bridgework | |||
| (If these procedures are to be carried out in a hospital under general anaesthesia, prior approval must be obtained from the TAC) | |||
| Full crown - non metallic - indirect | 613 | $1,706.25 | $1,962.20 |
| Full crown - veneered - indirect | 615 | $1,683.13 | $1,935.60 |
| Full crown - metallic indirect | 618 | $1,693.64 | $1,947.68 |
| Post and core for crown - indirect | 625 | $532.83 | $640.74 |
| Preliminary restoration for crown - direct | 627 | $297.85 | $316.49 |
| Provisional bridge pontic - per pontic | 632 | $337.57 | $337.57 |
| Bridge pontic - direct - per pontic | 642 | $439.50 | $505.43 |
| Bridge pontic - indirect - per pontic | 643 | $1,269.26 | $1,713.50 |
| Retainer for bonded fixture - indirect - per tooth | 649 | $754.02 | $867.12 |
| Implant Procedures | |||
| Fitting of an implant abutment - per abutment | 661 | $1,088.55 | $1,088.55 |
| Prosthesis with metal frame attached to implants - fixed - per arch | 666 | $3,922.41 | $5,747.07 |
| Removal and reattachment of prosthesis fixed to implant(s) – per implant | 669 | $188.99 | $188.99 |
| Full crown attached to osseointegrated implant - veneered indirect | 672 | $2,170.17 | $2,848.86 |
| Surgical implant guide | 679 | $257.80 | $257.80 |
| Insertion of first stage of two-stage endosseous implant - per implant | 684 | $2,334.77 | $2,334.77 |
|
Insertion of one stage endosseous implant - per implant Includes the cost of hardware | 688 | $2,817.48 | $2,817.48 |
|
Second stage surgery of two stage endosseous implant - per implant Includes the cost of hardware | 691 | $482.59 | $482.59 |
| Prosthodontics | |||
| Complete Maxillary Denture | 711 | $1,564.46 | $1,799.12 |
| Complete Mandibular Denture | 712 | $1,564.46 | $1,799.12 |
| Complete Maxillary and Mandibular Denture | 719 | $2,836.93 | $3,262.46 |
| Partial maxillary denture - resin base | 721 | $1,004.53 | $1,004.53 |
| Partial mandibular denture - resin base | 722 | $1,004.53 | $1,004.53 |
| Partial maxillary denture - cast metal framework including rests and retainers | 727 | $1,742.90 | $2,004.35 |
| Partial mandibular denture - cast metal framework including rests and retainers | 728 | $1,742.90 | $2,004.35 |
| Additional items for Acrylic Dentures only | |||
| Retainer - Per Tooth | 731 | $62.95 | $62.95 |
| Occlusal Rest - per rest | 732 | $18.25 | $18.25 |
| Tooth/teeth partial denture | 733 | $61.88 | $61.88 |
| Immediate tooth replacement - per tooth | 736 | $12.28 | $12.28 |
| Relining - complete denture - processed | 743 | $492.64 | $492.64 |
| Relining - partial denture - processed | 744 | $479.52 | $479.52 |
| Adding tooth to partial denture to replace an extracted or decoronated tooth - per tooth | 768 | $213.52 | $248.11 |
| Splint - Resin - Indirect | 772 | $321.95 | $455.66 |
| Orthodontics | |||
| Active removable appliance therapy - per arch | 821 | $1,126.63 | $1,291.85 |
| Full arch banding - per arch | 831 | $3,106.41 | $4,440.20 |
| Minor tooth guidance - fixed | 846 | $1,007.40 | $1,007.40 |
| Complete course of orthodontic treatment | 881 | $6,417.11 | $8,309.29 |
| General | |||
| Travel to provide services | 916 | FBN* | FBN* |
| Clinical occlusal analysis, including muscle and joint palpation - limit one per three year period | 963 | $106.24 | $148.67 |
| Occlusal splint | 965 | $707.08 | $724.76 |
| Adjustment of pre-existing occlusal splint - per appointment | 966 | $100.71 | $128.82 |
* Note: Where the terminology FBN appears in this schedule, the fee must be negotiated with the TAC before any dental treatment is commenced.