Sch 1Dental Benefits Schedule

Schedule 1 Dental Benefits Schedule (rule 5) ```html <table cellspacing="0" cellpadding="0" style="width:422.25pt; margin-left:0.7pt; border-collapse:collapse"><thead><tr><td style="width:30.6pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableColHead"><span>Item</span></p></td><td style="width:289.7pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableColHead"><span>Service</span></p></td><td style="width:69.55pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableColHead" style="text-align:right"><span>Benefit ($)</span></p></td></tr></thead><tbody><tr><td colspan="3" style="width:411.45pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableColHead"><span>Group U0 – Diagnostic Services</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 1 – Examinations</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88011</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Comprehensive oral examination</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Evaluation of all teeth, their supporting tissues and the oral tissues in order to record the condition of these structures. This evaluation includes recording an appropriate medical history and any other relevant information.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 18 and 19)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>60.95</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88012</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Periodic oral examination</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>An evaluation performed on a patient of record to determine any changes in the patient’s dental and medical health status since a previous comprehensive or periodic examination.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 18 and 19)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>50.70</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88013</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Oral examination – limited</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>A limited oral problem</span><span>‑</span><span>focussed evaluation carried out immediately prior to required treatment. This evaluation includes recording an appropriate medical history and any other relevant information.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 17 and 19)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>31.80</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 2 – Radiological examination and interpretation</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88022</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Intraoral periapical or bitewing radiograph – per exposure</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Taking and interpreting a radiograph made with the film inside the mouth.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 17)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>35.30</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88025</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Intraoral radiograph – occlusal, maxillary, mandibular – per exposure</span></p><p class="TableText" style="margin-top:6pt"><span>Taking and interpreting an occlusal, maxillary or mandibular intraoral radiograph. This radiograph shows a more extensive view of teeth and maxillary or mandibular bone.</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>71.30</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableColHead"><span>Group U1 – Preventive Services</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 1 – Dental Prophylaxis</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88111</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Removal of plaque and/or stain</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Removal of dental plaque and/or stain from the surfaces of all teeth and/or implants.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 17 and 20)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>62.30</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88114</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Removal of calculus – first visit</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Removal of calculus from the surfaces of teeth.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 17 and 20)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>103.90</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88115</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Removal of calculus – subsequent visit</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>This item describes procedures in item 88114 when, because of the extent or degree of calculus, an additional visit(s) is required to remove deposits from the teeth.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 17 and 20)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>67.50</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 2 – Remineralising Agents</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88121</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Topical application of remineralisation and/or cariostatic agents, one treatment</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Application of remineralisation and/or cariostatic agents to the surfaces of the teeth. This may include activation of the agent. Not to be used as an intrinsic part of the restoration.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 17)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>40.05</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 3 – Other Preventive Services</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88161</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Fissure and/or tooth surface sealing – per tooth (first four services on a day)</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Sealing of non</span><span>‑</span><span>carious pits, fissures, smooth surfaces or cracks in a tooth with an adhesive material. Any preparation prior to application of the sealant is included in this item number.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 17 and 20)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>53.35</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88162</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Fissure and/or tooth surface sealing – per tooth (subsequent services)</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Sealing of non</span><span>‑</span><span>carious pits, fissures, smooth surfaces or cracks in a tooth with an adhesive material. Any preparation prior to application of the sealant is included in this item number.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 20)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>26.70</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableColHead"><span>Group U2 – Periodontics</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88213</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Treatment of acute periodontal infection – per visit</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>This item describes the treatment of acute periodontal infection(s). It may include establishing drainage and the removal of calculus from the affected tooth (teeth). Inclusive of the insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 17 and 21)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>80.70</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88221</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Clinical periodontal analysis and recording</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>This is a special examination performed as part of the diagnosis and management of periodontal disease. The procedure consists of assessing and recording a patient's periodontal condition. All teeth and six sites per tooth must be recorded. Written documentation of these measurements must be retained.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 17)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>61.35</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableColHead"><span>Group U3 – Oral Surgery</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 1 – Extractions</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88311</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Removal of a tooth or part(s) thereof – first tooth extracted on a day</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>A procedure consisting of the removal of a tooth or part(s) thereof. Inclusive of the insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 17 and 22)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>152.05</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88314</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Sectional removal of a tooth or part(s) thereof – first tooth extracted on a day</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>The removal of a tooth or part(s) thereof in sections. Bone removal may be necessary. Inclusive of the insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 17 and 22)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>194.35</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88316</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Additional extraction requiring removal of a tooth or part(s) thereof, or sectional removal of a tooth.</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Additional extraction provided on the same day as a service described in item 88311 or 88314 is provided to the patient.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 22)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>95.85</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 2 – Surgical Extractions</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88322</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Surgical removal of a tooth or tooth fragment not requiring removal of bone or tooth division – first tooth extracted on a day</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Removal of a tooth or tooth fragment where an incision and the raising of a mucoperiosteal flap is required, but where removal of bone or sectioning of the tooth is not necessary to remove the tooth. Inclusive of the insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 17 and 22)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>246.80</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88323</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Surgical removal of a tooth or tooth fragment requiring removal of bone – first tooth extracted on a day</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Removal of a tooth or tooth fragment where removal of bone is required after an incision and a mucoperiosteal flap raised. Inclusive of the insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 17 and 22)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>281.85</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88324</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Surgical removal of a tooth or tooth fragment requiring both removal of bone and tooth division – first tooth extracted on a day</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Removal of a tooth or tooth fragment where both removal of bone and sectioning of the tooth are required after an incision and a mucoperiosteal flap raised. The tooth will be removed in portions. Inclusive of the insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 17 and 22)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>379.10</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88326</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Additional extraction requiring surgical removal of a tooth or tooth fragment</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Additional surgical extraction provided on the same day as a service described in item 88322, 88323 or 88324 is provided to the patient.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 22)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>201.90</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 5 – Treatment of Maxillo</span><span style="font-weight:normal; font-style:italic">‑</span><span style="font-weight:normal; font-style:italic">facial injuries</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88351</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Repair of skin and subcutaneous tissue or mucous membrane</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>The surgical cleaning and repair of a facial skin wound in the region of the mouth or jaws, or the repair of oral mucous membrane, where the wounds involve the subcutaneous tissues. Inclusive of the insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 22)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>185.25</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 8 – Other Surgical Procedures</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88384</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Repositioning of displaced tooth/teeth – per tooth</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>A procedure following trauma where the position of the displaced tooth/teeth is corrected by manipulation. Stabilising procedures are itemised separately. Inclusive of the insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 22)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>221.05</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88386</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Splinting of displaced tooth/teeth – per tooth</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>A procedure following trauma where the position of the displaced tooth/teeth may be stabilized by splinting. Inclusive of the insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 22)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>228.10</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88387</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Replantation and splinting of a tooth</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Replantation of a tooth which has been avulsed or intentionally removed. It may be held in the correct position by splinting. Inclusive of the insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 22)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>446.60</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88392</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Drainage of abscess</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Drainage and/or irrigation of an abscess other than through a root canal or at the time of extraction. The drainage may be through an incision or inserted tube. Inclusive of the insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 22)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>112.20</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableColHead"><span>Group U4 – Endodontics</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 1 – Pulp and Root Canal Treatments</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88411</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Direct pulp capping</span></p><p class="TableText" style="margin-top:6pt"><span>A procedure where an exposed pulp is directly covered with a protective dressing or cement.</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>40.35</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88412</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Incomplete endodontic therapy (tooth not suitable for further treatment)</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>A procedure where in assessing the suitability of a tooth for endodontic treatment a decision is made that the tooth is not suitable for restoration.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 23)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>138.25</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88414</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Pulpotomy</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Amputation within the pulp chamber of part of the vital pulp of a tooth. The pulp remaining in the canal(s) is then covered with a protective dressing or cement.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 23)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span></span><span>88.15</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88415</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Complete chemo</span><span style="font-weight:bold">‑</span><span style="font-weight:bold">mechanical preparation of root canal – one canal</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Complete chemo</span><span>‑</span><span>mechanical preparation including removal of pulp or necrotic debris from a canal.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 23)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>248.05</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88416</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Complete chemo</span><span style="font-weight:bold">‑</span><span style="font-weight:bold">mechanical preparation of root canal – each additional canal</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Complete chemo</span><span>‑</span><span>mechanical preparation including removal of pulp or necrotic debris from each additional canal of a tooth with multiple canals.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 23)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>118.15</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88417</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Root canal obturation – one canal</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>The filling of a root canal, following chemo</span><span>‑</span><span>mechanical preparation.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 23)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>241.60</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88418</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Root canal obturation – each additional canal</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>The filling, following chemo</span><span>‑</span><span>mechanical preparation, of each additional canal in a tooth with multiple canals.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 23)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>113.00</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88419</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Extirpation of pulp or debridement of root canal(s) – emergency or palliative</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>The partial or thorough removal of pulp and/or debris from the root canal system of a tooth. This is an emergency or palliative procedure distinct from visits for scheduled endodontic treatment.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 23)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>159.75</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88421</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Resorbable root canal filling – primary tooth</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>The placement of resorbable root canal filling material in a primary tooth.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 23)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>138.25</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 4 – Other Endodontic Services</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88455</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Additional visit for irrigation and/or dressing of the root canal system – per tooth</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Additional debridement irrigation and short</span><span>‑</span><span>term dressing required where evidence of infection or inflammation persists following prior opening of the root canal and removal of its contents.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 26)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>122.40</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88458</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Interim therapeutic root filling – per tooth</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>A procedure consisting of the insertion of a long</span><span>‑</span><span>term provisional (temporary) root canal filling with therapeutic properties which facilitates healing/development of the root and periradicular tissues over an extended time.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 17 and 23)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>163.25</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableColHead"><span>Group U5 – Restorative Services</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 1 – Metallic Restorations – Direct</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88511</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Metallic restoration – one surface – direct</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Direct metallic restoration involving one surface of a tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post</span><span>‑</span><span>operative care.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 24)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>120.70</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88512</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Metallic restoration – two surfaces – direct</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Direct metallic restoration involving two surfaces of a tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post</span><span>‑</span><span>operative care.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 24)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>148.05</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88513</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Metallic restoration – three surfaces – direct</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Direct metallic restoration involving three surfaces of a tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post</span><span>‑</span><span>operative care.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 24)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>176.65</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88514</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Metallic restoration – four surfaces – direct</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Direct metallic restoration involving four surfaces of a tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post</span><span>‑</span><span>operative care.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 24)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>201.35</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88515</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Metallic restoration – five surfaces – direct</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Direct metallic restoration involving five surfaces of a tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post</span><span>‑</span><span>operative care.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 24)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>229.85</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 2 – Adhesive Restorations – Anterior Teeth – direct</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88521</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Adhesive restoration – one surface – anterior tooth – direct</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Direct restoration, using an adhesive technique and a tooth</span><span>‑</span><span>coloured material, involving one surface of an anterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post</span><span>‑</span><span>operative care.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 24 and 27)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>133.70</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88522</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Adhesive restoration – two surfaces – anterior tooth – direct</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Direct restoration, using an adhesive technique and a tooth</span><span>‑</span><span>coloured material, involving two surfaces of an anterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post</span><span>‑</span><span>operative care.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 24)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>162.30</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88523</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Adhesive restoration – three surfaces – anterior tooth – direct</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Direct restoration, using an adhesive technique and a tooth</span><span>‑</span><span>coloured material, involving three surfaces of an anterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post</span><span>‑</span><span>operative care.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 24)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>192.25</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88524</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Adhesive restoration – four surfaces – anterior tooth – direct</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Direct restoration, using an adhesive technique and a tooth</span><span>‑</span><span>coloured material, involving four surfaces of an anterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post</span><span>‑</span><span>operative care.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 24)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>222.20</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88525</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Adhesive restoration – five surfaces – anterior tooth – direct</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Direct restoration, using an adhesive technique and a tooth</span><span>‑</span><span>coloured material, involving five surfaces of an anterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post</span><span>‑</span><span>operative care.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 24)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>261.10</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 3 – Adhesive Restorations – Posterior Teeth – direct</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88531</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Adhesive restoration – one surface – posterior tooth – direct</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Direct restoration, using an adhesive technique and a tooth</span><span>‑</span><span>coloured material, involving one surface of an posterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post</span><span>‑</span><span>operative care.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 24 and 27)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>142.75</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88532</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Adhesive restoration – two surfaces – posterior tooth – direct</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Direct restoration, using an adhesive technique and a tooth</span><span>‑</span><span>coloured material, involving two surfaces of an posterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post</span><span>‑</span><span>operative care.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 24)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>179.25</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88533</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Adhesive restoration – three surfaces – posterior tooth – direct</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Direct restoration, using an adhesive technique and a tooth</span><span>‑</span><span>coloured material, involving three surfaces of an posterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post</span><span>‑</span><span>operative care.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 24)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>215.50</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88534</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Adhesive restoration – four surfaces – posterior tooth – direct</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Direct restoration, using an adhesive technique and a tooth</span><span>‑</span><span>coloured material, involving four surfaces of an posterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post</span><span>‑</span><span>operative care.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 24)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>242.90</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88535</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Adhesive restoration – five surfaces – posterior tooth – direct</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Direct restoration, using an adhesive technique and a tooth</span><span>‑</span><span>coloured material, involving five surfaces of an posterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post</span><span>‑</span><span>operative care.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 24)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>280.50</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 7 – Other Restorative Services</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88572</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Provisional (intermediate/temporary) restoration – per tooth</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>The provisional (intermediate) restoration of a tooth designed to last until the definitive restoration can be constructed or the tooth is removed. This item should only be used where the provisional (intermediate) restoration is not an intrinsic part of treatment. It does not include provisional (temporary) sealing of the access cavity during endodontic treatment or during construction of indirect restorations.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 17 and 28)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>56.45</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88574</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Metal band</span></p><p class="TableText" style="margin-top:6pt"><span>The cementation of a metal band for diagnostic, protective purposes or for the placement of a provisional (intermediate) restoration.</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>47.55</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88575</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Pin retention – per pin</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Use of a pin to aid the retention and support of direct or indirect restorations in a tooth.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 17 and 24)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>32.45</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88579</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Bonding of tooth fragment</span></p><p class="TableText" style="margin-top:6pt"><span>The direct bonding of a tooth fragment as an alternative to placing a restoration.</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>112.20</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88586</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Crown </span><span style="font-weight:bold">‑</span><span style="font-weight:bold"> metallic </span><span style="font-weight:bold">‑</span><span style="font-weight:bold"> with tooth preparation – preformed</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Placing a preformed metallic crown as a coronal restoration for a tooth.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 27A)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>297.75</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88587</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Crown </span><span style="font-weight:bold">‑</span><span style="font-weight:bold"> metallic </span><span style="font-weight:bold">‑</span><span style="font-weight:bold"> minimal tooth preparation – preformed</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Placing a preformed metallic crown as a coronal restoration for a tooth and where minimal or no restoration of the tooth is required. Commonly referred to as a ‘Hall’ crown.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 27A)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>176.65</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88597</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Post – direct</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Insertion of a post into a prepared root canal to provide an anchor for an artificial crown or other restoration.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 24)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>102.10</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableColHead"><span>Group U7 – Prosthodontics</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 1 – Dentures and Denture Components</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88721</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Partial maxillary denture – resin, base only</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Provision of a resin base for a removable dental prosthesis for the maxilla where some natural teeth remain.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 17 and 24A)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>505.70</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88722</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Partial mandibular denture – resin, base only</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Provision of a resin base for a removable dental prosthesis for the mandible where some natural teeth remain.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 17 and 24A)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>505.70</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88723</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Provisional partial maxillary denture</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Provision of a patient removable partial dental prosthesis replacing the natural teeth and adjacent tissues in the maxilla which is designed to last until the definitive prosthesis can be constructed. This item should only be used where a provisional denture is not an intrinsic part of item 88721.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 24A and 25)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>379.25</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88724</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Provisional partial mandibular denture</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Provision of a patient removable partial dental prosthesis replacing the natural teeth and adjacent tissues in the mandible which is designed to last until the definitive prosthesis can be constructed. This item should only be used where a provisional denture is not an intrinsic part of item 88722.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rules 24A and 25)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>379.25</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88731</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Retainer – per tooth</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>A retainer or attachment fitted to a tooth to aid retention of a partial denture. The number of retainers should be indicated.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 25)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>51.05</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88733</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Tooth/teeth (partial denture)</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>An item to describe each tooth added to the base of a new partial denture. The number of teeth should be indicated.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 25)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>41.90</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88736</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Immediate tooth replacement – per tooth</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Provision within a denture to allow immediate replacement of an extracted tooth. The number of teeth so replaced should be indicated.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 25)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>10.55</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 4 – Denture Maintenance</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88741</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Adjustment of a denture</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Adjustment of a denture to improve comfort, function or aesthetics. This item does not apply to routine adjustments following the insertion of a new denture or the maintenance or repair of an existing denture.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 25)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>60.80</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 6 – Denture Repairs</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88761</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Reattaching pre</span><span style="font-weight:bold">‑</span><span style="font-weight:bold">existing clasp to denture</span></p><p class="TableText" style="margin-top:6pt"><span>Repair, insertion and adjustment of a denture involving re</span><span>‑</span><span>attachment of a pre</span><span>‑</span><span>existing clasp.</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>166.95</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88762</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Replacing/adding clasp to denture </span><span style="font-weight:bold">‑</span><span style="font-weight:bold"> per clasp</span></p><p class="TableText" style="margin-top:6pt"><span>Repair, insertion and adjustment of a denture involving replacement or addition of a new clasp or clasps.</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>174.45</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88764</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Repairing broken base of a partial denture</span></p><p class="TableText" style="margin-top:6pt"><span>Repair, insertion and adjustment of a broken resin partial denture base.</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>166.95</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88765</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Replacing/adding new tooth on denture – per tooth</span></p><p class="TableText" style="margin-top:6pt"><span>Repair, insertion and adjustment of a denture involving replacement with or addition of a new tooth or teeth to a previously existing denture.</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>174.45</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88766</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Reattaching existing tooth on denture – per tooth</span></p><p class="TableText" style="margin-top:6pt"><span>Repair, insertion and adjustment of a denture involving reattachment of a pre</span><span>‑</span><span>existing denture tooth or teeth.</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>166.95</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88768</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Adding tooth to partial denture to replace an extracted or decoronated tooth </span><span style="font-weight:bold">‑</span><span style="font-weight:bold"> per tooth</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Modification, insertion and adjustment of a partial denture involving an addition to accommodate the loss of a natural tooth or its coronal section.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 17)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>176.65</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 7 – Other Prosthodontic Services</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88776</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Impression </span><span style="font-weight:bold">‑</span><span style="font-weight:bold"> dental appliance repair/modification</span></p><p class="TableText" style="margin-top:6pt"><span>An item to describe taking an impression where required for the repair or modification of a dental appliance.</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>53.35</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableColHead"><span>Group U9 – General Services</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 1– Emergencies</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88911</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Palliative care</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>An item to describe interim care to relieve pain, infection, bleeding or other problems not associated with other treatment.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to Rule 29)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>79.20</span></p></td></tr><tr><td colspan="3" style="width:411.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="ColHead2"><span style="font-weight:normal; font-style:italic">Subgroup 4– Sedation</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88942</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Sedation </span><span style="font-weight:bold">‑</span><span style="font-weight:bold"> intravenous</span></p><p class="TableText" style="margin-top:6pt; margin-bottom:6pt"><span>Sedative drug(s) administered intravenously, usually in increments. The incremental administration may continue while dental treatment is being provided.</span></p><p class="TableText" style="margin-top:6pt"><span>(Item is subject to rule 17)</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>155.25</span></p></td></tr><tr><td style="width:30.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>88943</span></p></td><td style="width:289.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span style="font-weight:bold">Sedation </span><span style="font-weight:bold">‑</span><span style="font-weight:bold"> inhalation</span></p><p class="TableText" style="margin-top:6pt"><span>Nitrous oxide gas mixed with oxygen is inhaled by the patient while dental treatment is being provided.</span></p></td><td style="width:69.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:5.65pt; text-align:right"><span>77.60</span></p></td></tr></tbody></table> ```