CTHRepealedLegislation
Health Insurance (Dental Services) Determination 2007
Part 2Services provided by eligible dental specialists
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Part 2 Services provided by eligible dental specialists
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><thead><tr><td style="width:36.6pt; 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:301.2pt; 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:49.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableColHead"><span>Fee ($)</span></p></td></tr></thead><tbody><tr><td colspan="3" style="width:408.6pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">Group B1</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">— Diagnostic services</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 1</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Examinations</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86012</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Periodic oral examination and evaluation performed on a patient of record to determine any changes in the patient’s dental and medical health since a previous periodic examination</span></p><p class="TableText"><span>(Item is subject to section 14)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>39.50</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86013</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Oral examination, limited to a problem</span><span>‑</span><span>focused oral evaluation carried out immediately before required treatment, including recording an appropriate medical history and any other relevant information</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>24.85</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86014</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Consultation for advice about or discussion of treatment options for a particular dental or oral complaint, including recording an appropriate medical history and any other relevant information</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>57.30</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86015</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Extended consultation for advice about or discussion of treatment options for a particular dental or oral complaint, including recording an appropriate medical history and any other relevant information</span><span> </span><span>— consultation of at least 30 minutes</span></p><p class="TableText"><span>(Item subject to section 14)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>93.80</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 2</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Radiological examination and interpretation</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86022</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Intraoral periapical or bitewing radiograph</span><span> </span><span>— each exposure</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>31.15</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86025</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Intraoral radiograph (occlusal, maxillary or mandibular)</span><span> </span><span>— each exposure</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>55.55</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86031</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Extraoral radiograph (maxillary or mandibular)</span><span> </span><span>— each exposure</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>63.35</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86035</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Radiograph of temporomandibular joint</span><span> </span><span>— each exposure</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>91.35</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86036</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Cephalometric radiograph</span><span> </span><span>— lateral, antero</span><span>‑</span><span>posterior, postero</span><span>‑</span><span>anterior or submento</span><span>‑</span><span>vertex</span><span> </span><span>— each exposure</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>134.15</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86037</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Panoramic radiograph</span><span> </span><span>— each exposure</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>85.10</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86038</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Hand</span><span>‑</span><span>wrist radiograph for skeletal age assessment</span></p><p class="TableText"><span>(Item is subject to section 14)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>79.60</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86039</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Tomography of the skull or parts of the skull</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>134.25</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 3</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Other diagnostic services</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86047</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Caries activity screening test</span></p><p class="TableText"><span>(Item is subject to item 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>36.55</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86051</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Biopsy of tissue</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>111.85</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86071</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Diagnostic model</span><span> </span><span>— each model</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>54.55</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86082</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Tooth</span><span>‑</span><span>jaw size prediction analysis</span></p><p class="TableText"><span>(Item is subject to section 14)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>95.45</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">Group B2</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">— Preventive services</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 1</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Dental prophylaxis</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86111</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Removal of plaque, stain, or plaque and stain</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>48.60</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86113</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Recontouring pre</span><span>‑</span><span>existing restoration or restorations</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>18.35</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86114</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Removal of calculus</span><span> </span><span>— first visit</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>81.00</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86115</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Removal of calculus</span><span> </span><span>— subsequent visit</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>52.70</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86117</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Bleaching, internal, for non</span><span>‑</span><span>vital discoloured tooth</span><span> </span><span>— each tooth</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>256.25</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-inside:avoid; page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 2</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Remineralising agents</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86121</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Topical application of remineralising agent</span><span> </span><span>— 1 treatment</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>31.20</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86123</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Application of concentrated remineralising agent</span><span> </span><span>— single tooth</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>24.45</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 3</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Other preventive services</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86131</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Dietary advice</span><span> </span><span>— a consultation of at least 15 minutes</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>32.90</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86141</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Oral hygiene instruction</span><span> </span><span>— a consultation of at least 15 minutes</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>44.65</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86161</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Fissure sealing</span><span> </span><span>— each tooth</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>41.55</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86165</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Desensitizing procedure</span><span> </span><span>— each visit</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>24.45</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86171</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Odontoplasty</span><span> </span><span>— each tooth</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>45.85</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">Group B3</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">— Periodontics</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86213</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Treatment of acute periodontal infection</span><span> </span><span>— each visit</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>62.90</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86221</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Clinical periodontal analysis and recording</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>127.25</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86222</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Root planing and subgingival curettage</span><span> </span><span>— no more than 8 teeth</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>162.40</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86225</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Non</span><span>‑</span><span>surgical periodontal treatment if not provided for in another item</span><span> </span><span>— each visit</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>127.25</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86231</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Gingivectomy</span><span> </span><span>— no more than 8 teeth</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>214.20</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86232</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Periodontal flap surgery</span><span> </span><span>— no more than 8 teeth</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>354.90</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86233</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Osseous surgery</span><span> </span><span>— no more than 8 teeth</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>515.15</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86234</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Osseous graft</span><span> </span><span>— each tooth or implant</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>563.65</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86235</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Gingival graft</span><span> </span><span>— each tooth or implant</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>394.70</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86236</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Guided tissue regeneration</span><span> </span><span>— each tooth or implant</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>466.70</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86237</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Guided tissue regeneration</span><span> </span><span>— membrane removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>203.00</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86238</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Periodontal flap surgery for crown lengthening</span><span> </span><span>— each tooth</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>364.95</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86241</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Root resection</span><span> </span><span>— each root</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>225.50</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86245</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Periodontal surgery involving a tooth or an implant</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>143.20</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">Group B4</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">— Oral surgery</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 1</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Extractions</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86311</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Removal of a tooth or part or parts of a tooth, including local anaesthesia and routine post</span><span>‑</span><span>operative care</span><span> </span><span>— first tooth extracted on a day</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>147.30</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86314</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Sectional removal of a tooth, including local anaesthesia and routine post</span><span>‑</span><span>operative care</span><span> </span><span>— first sectional removal on a day</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>201.60</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86316</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Additional extraction requiring:</span></p><p class="TableP1a" style="margin-top:3pt"><span style="width:8.19pt; text-indent:0pt; display:inline-block"></span><span>(a)</span><span style="width:6.25pt; text-indent:0pt; display:inline-block"> </span><span>removal of a tooth or part or parts of a tooth; or</span></p><p class="TableP1a" style="margin-top:3pt; margin-bottom:6pt"><span style="width:7.57pt; text-indent:0pt; display:inline-block"></span><span>(b)</span><span style="width:6.25pt; text-indent:0pt; display:inline-block"> </span><span>sectional removal of a tooth;</span></p><p class="TableText" style="margin-top:6pt"><span>performed on the same day as a service described in item 86311 or</span><span> </span><span>86314</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>112.20</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 2</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Surgical extractions</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86322</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Surgical removal of a tooth or tooth fragment not requiring removal of bone or tooth division, including local anaesthesia and routine post</span><span>‑</span><span>operative care</span><span> </span><span>— first tooth extracted on a day</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>255.85</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86323</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Surgical removal of a tooth or tooth fragment requiring removal of bone, including local anaesthesia and routine post</span><span>‑</span><span>operative care</span><span> </span><span>— first tooth extracted on a day</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>317.65</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86324</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Surgical removal of a tooth or tooth fragment requiring both removal of bone and tooth division, including local anaesthesia and routine post</span><span>‑</span><span>operative care</span><span> </span><span>— first tooth extracted on a day</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>393.25</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86326</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Additional extraction requiring surgical removal of a tooth or tooth fragment, on the same day as a service described in item 86322, 86323 or 86324 is provided to the patient</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>245.20</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 3</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Surgery for prostheses</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86331</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Alveolectomy, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span><span> </span><span>— each segment</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>151.10</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86332</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Ostectomy, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span><span> </span><span>— each jaw</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>417.25</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86337</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Reduction of fibrous tuberosity, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>224.25</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86338</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Reduction of flabby ridge, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span><span> </span><span>— each segment</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>112.75</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86341</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Removal of hyperplastic tissue, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>246.75</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86343</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Repositioning of muscle attachment, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>304.50</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86344</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Vestibuloplasty, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>716.25</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86345</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Vestibuloplasty with skin or mucosal graft, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>716.25</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 4</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— General surgical</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86371</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Removal of tumour, cyst or scar</span><span> </span><span>— cutaneous, subcutaneous or in mucous membrane, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>185.55</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86373</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Removal of tumour, cyst or scar involving muscle, bone or other deep tissue, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>624.40</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86375</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Surgery to salivary duct, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>557.60</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86376</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Surgery to salivary gland, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>196.35</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86377</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Removal or repair of soft tissue not provided for in another item, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>243.55</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86378</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Surgical removal of foreign body, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>137.60</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86379</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Marsupialisation of cyst, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>293.20</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 5</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Other surgical procedures</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86381</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Surgical exposure of unerupted tooth, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>314.00</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86382</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Surgical exposure and attachment of device for orthodontic traction, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>356.15</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86384</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Repositioning of displaced tooth, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span><span> </span><span>— each tooth</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>229.75</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86385</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Surgical repositioning of unerupted tooth, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>356.15</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86386</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Splinting of displaced tooth, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span><span> </span><span>— each tooth</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>239.55</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86387</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Replantation and splinting of a tooth, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>459.00</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86388</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Transplantation of tooth or tooth bud, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>517.10</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86389</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Surgery to isolate and preserve neurovascular tissue, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>169.85</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86391</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Frenectomy, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>212.35</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86392</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Incision and drainage of abscess or cyst, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>111.45</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86393</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Surgery involving the maxillary antrum, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>715.75</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86394</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Surgery for osteomylitis, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>460.05</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86395</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Repair of nerve trunk, including insertion of sutures, normal post</span><span>‑</span><span>operative care and suture removal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>858.05</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">Group B5</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">— Endodontics</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 1</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Pulp and root canal treatments</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86411</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Direct pulp capping</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>41.75</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86412</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Incomplete endodontic therapy</span><span> </span><span>— inoperable or fractured</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>172.40</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86414</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Pulpotomy</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>79.60</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86415</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Complete chemo</span><span>‑</span><span>mechanical preparation of root canal</span><span> </span><span>— first canal on a tooth</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>358.00</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86416</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Complete chemo</span><span>‑</span><span>mechanical preparation of root canal</span><span> </span><span>— each additional canal on a tooth for which the service described in item 86415 has been performed</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>182.95</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86417</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Root canal obturation</span><span> </span><span>— first canal on a tooth</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>358.00</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86418</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Root canal obturation</span><span> </span><span>— each additional canal on a tooth for which the service described in item 86417 has been performed</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>182.95</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86419</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Extirpation of pulp or debridement of root canal or canals</span><span> </span><span>— emergency or palliative</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>149.50</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 2</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Periradicular surgery</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86431</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Periapical curettage</span><span> </span><span>— each root</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>304.05</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86432</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Apicectomy, including curettage</span><span> </span><span>— each root</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>304.50</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86433</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Exploratory periradicular surgery</span></p><p class="TableText"><span>(Item is subject to sections 13 and 20)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>143.65</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86434</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Apical seal, including apicectomy and periapical curettage</span><span> </span><span>— each canal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>473.65</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86436</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Sealing of perforation</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>281.90</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86437</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Surgical treatment and repair of an external root resorption</span><span> </span><span>— for each tooth</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>458.20</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86438</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Hemisection</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>338.30</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 3</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Other endodontic services</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86445</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-top:0pt"><span>Exploration for a calcified root canal</span><span> </span><span>— each canal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>127.25</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86451</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Removal of root filling</span><span> </span><span>— each canal</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>127.25</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86452</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Removal of cemented root canal post or post crown</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>119.30</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86453</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Removal of or bypassing fractured endodontic instrument</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>111.45</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86455</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Additional visit for irrigation or dressing, or irrigation and dressing of the root canal system</span><span> </span><span>— each tooth</span></p><p class="TableText"><span>(Item is subject to section 21)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>127.25</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86457</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Obturation of resorption defect or perforation, non</span><span>‑</span><span>surgical</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>127.25</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86458</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Interim therapeutic root filling</span><span> </span><span>— each tooth</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>143.20</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">Group B6</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">— Restorative services</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 1</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Metallic restorations</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— direct</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86511</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Metallic restoration, 1 surface</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>94.20</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86512</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Metallic restoration, 2 surfaces</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>115.45</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86513</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Metallic restoration, 3 surfaces</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>137.70</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86514</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Metallic restoration, 4 surfaces</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>157.00</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86515</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Metallic restoration, 5 surfaces</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>179.25</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 2</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Adhesive restorations</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— anterior teeth</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— direct</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86521</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Adhesive restoration, 1 surface, anterior tooth</span><span> </span><span>— direct</span></p><p class="TableText"><span>(Item is subject to section 22)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>104.30</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86522</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Adhesive restoration, 2 surfaces, anterior tooth</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>126.55</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86523</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Adhesive restoration, 3 surfaces, anterior tooth</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>149.85</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86524</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Adhesive restoration, 4 surfaces, anterior tooth</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>173.15</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86525</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Adhesive restoration, 5 surfaces, anterior tooth</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>242.05</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 3</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Adhesive restorations</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— posterior teeth</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— direct</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86531</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Adhesive restoration, 1 surface, posterior tooth</span><span> </span><span>— direct</span></p><p class="TableText"><span>(Item is subject to section 22)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>111.40</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86532</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Adhesive restoration, 2 surfaces, posterior tooth</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>139.75</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86533</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Adhesive restoration, 3 surfaces, posterior tooth</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>168.10</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86534</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Adhesive restoration, 4 surfaces, posterior tooth</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>189.40</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86535</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Adhesive restoration, 5 surfaces, posterior tooth</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>283.45</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 4</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Metallic restorations</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— indirect</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86541</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Metallic restoration, 1 surface</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>405.95</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86542</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Metallic restoration, 2 surfaces</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>536.45</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86543</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Metallic restoration, 3 surfaces</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>701.10</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86544</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Metallic restoration, 4 surfaces</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>819.15</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86545</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Metallic restoration, 5 surfaces</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>1</span><span> </span><span>014.15</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 5</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Tooth coloured restorations</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— indirect</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86551</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Tooth</span><span>‑</span><span>coloured restoration, 1 surface</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>640.38</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86552</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Tooth</span><span>‑</span><span>coloured restoration, 2 surfaces</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>717.05</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86553</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Tooth</span><span>‑</span><span>coloured restoration, 3 surfaces</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>889.55</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86554</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Tooth</span><span>‑</span><span>coloured restoration, 4 surfaces</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>956.65</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86555</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Tooth</span><span>‑</span><span>coloured restoration, 5 surfaces</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>1</span><span> </span><span>014.15</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 6</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Other restorative services</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86572</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Provisional restoration</span><span> </span><span>— intermediate or temporary</span></p><p class="TableText"><span>(Item is subject to sections 13 and 23)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>44.00</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86574</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Metal band</span><span> </span><span>— the cementation of a metal band for diagnostic purposes, protective purposes or for the placement of a provisional (intermediate) restoration</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>37.10</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86575</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Pin retention</span><span> </span><span>— each pin</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>25.30</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86576</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Stainless steel crown</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>259.35</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86577</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Cusp capping</span><span> </span><span>— each cusp</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>27.35</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86578</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Restoration of an incisal corner</span><span> </span><span>— each corner</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>27.35</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86595</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Removal of inlay or onlay</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>127.25</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86596</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Recementing of inlay or onlay</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>71.50</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86597</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Post, direct</span><span> </span><span>— insertion of a post into a prepared root canal to provide an anchor for an artificial crown or other restoration</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>159.35</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">Group B7</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">— Crown and bridge</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 1</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Crowns</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86613</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Full crown, non metallic</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>1</span><span> </span><span>436.75</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86615</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Full crown, veneered</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>1</span><span> </span><span>578.60</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86618</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Full crown, metallic</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>1</span><span> </span><span>275.90</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86625</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Core for crown including post</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>383.85</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86627</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Preliminary restoration for crown</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>159.15</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86629</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Post and root cap</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>389.85</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 2</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Temporary (provisional) crown and bridge</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86631</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Provisional crown</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>137.60</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86632</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Provisional bridge</span><span> </span><span>— each pontic</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>268.05</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 3</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Bridges</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86642</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Bridge pontic, direct</span><span> </span><span>— each pontic</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>695.90</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86643</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Bridge pontic, indirect</span><span> </span><span>— each pontic</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>1</span><span> </span><span>071.00</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86644</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Semi</span><span>‑</span><span>fixed attachment</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>383.40</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86645</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Precision or magnetic attachment</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>378.15</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86649</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Retainer for bonded fixture, indirect</span><span> </span><span>— each tooth</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>394.70</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 4</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Crown and bridge repairs and other services</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86651</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Recementing crown or veneer</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>105.95</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86652</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Recementing bridge or splint</span><span> </span><span>— each abutment</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>120.95</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86653</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Rebonding of bridge or splint if retreatment of bridge surface is required</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>113.00</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86655</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Removal of crown</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>71.65</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86656</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Removal of bridge or splint</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>167.05</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86658</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Repair of crown, bridge or splint, including labour and laboratory costs</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>422.20</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86659</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Repair of crown, bridge or splint</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>307.05</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 5</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Implant prostheses</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86661</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Fitting of implant abutment</span><span> </span><span>— each abutment</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>654.70</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86663</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Removal of implant</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>515.75</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86664</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Fitting of bar for denture</span><span> </span><span>— each abutment</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>777.10</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86666</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Prosthesis with metal frame attached to implants</span><span> </span><span>— each tooth</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>630.75</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86669</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Removal and reattachment of prosthesis fixed to implant or implants</span><span> </span><span>— each implant</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>203.00</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86671</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Full crown attached to osseointegrated implant, non metallic</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>1</span><span> </span><span>436.75</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86672</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Full crown attached to osseointegrated implant, veneered</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>1</span><span> </span><span>578.60</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86673</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Full crown attached to osseointegrated implant, metallic</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>1</span><span> </span><span>275.90</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86679</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Surgical implant guide</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>347.75</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86684</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Insertion of first stage of 2</span><span>‑</span><span>stage endosseous implant, including cost of hardware</span><span> </span><span>— each implant</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>1</span><span> </span><span>353.70</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86688</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Insertion of 1</span><span>‑</span><span>stage endosseous implant, including cost of hardware</span><span> </span><span>— each implant</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>1</span><span> </span><span>479.80</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86691</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Second stage surgery of 2</span><span>‑</span><span>stage endosseous implant, including hardware</span><span> </span><span>— each implant</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>501.10</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">Group B8</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">— Prosthodontics</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 1</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Denture and denture components</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86711</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Complete maxillary denture</span></p><p class="TableText"><span>(Item is subject to section 12)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>797.70</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86712</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Complete mandibular denture</span></p><p class="TableText"><span>(Item subject to section 12)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>797.70</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86716</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Metal palate or plate</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>285.20</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86719</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Complete maxillary and mandibular dentures</span></p><p class="TableText"><span>(Item is subject to section 12)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>1 364.10</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86721</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Partial maxillary denture</span><span> </span><span>— resin, base only</span></p><p class="TableText"><span>(Item is subject to section 12)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>383.80</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86722</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Partial mandibular denture</span><span> </span><span>— resin, base only</span></p><p class="TableText"><span>(Item is subject to section 12)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>383.80</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86727</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Partial maxillary denture, base only, consisting of cast metal framework and including provision of casting, clasps, retainers and occlusal rests</span></p><p class="TableText"><span>(Item is subject to section 12)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>1</span><span> </span><span>145.90</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86728</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Partial mandibular denture, base only, consisting of cast metal framework including provision of casting, clasps, retainers and occlusal rests</span></p><p class="TableText"><span>(Item is subject to section 12)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>1</span><span> </span><span>145.90</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86731</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Retainer</span><span> </span><span>— each tooth, if a service described in item 86721 or</span><span> </span><span>86722 has been provided to the patient</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>39.80</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86732</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Occlusal rest</span><span> </span><span>— each rest, if a service described in item 86721 or</span><span> </span><span>86722 has been provided to the patient</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>19.35</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86733</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Addition of tooth to the base of a new partial denture</span><span> </span><span>— each tooth</span></p><p class="TableText"><span>(Item is subject to item 19)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>41.10</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86735</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Precision or magnetic attachment</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>230.15</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86736</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Immediate tooth replacement</span><span> </span><span>— each tooth</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>8.20</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86737</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Resilient lining</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>170.80</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86738</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Wrought bar</span><span> </span><span>— joining sections of a partial prosthesis.</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>159.15</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86739</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Metal backing</span><span> </span><span>— an extension of the casting of a cast metal partial denture to provide a backing for the denture tooth</span><span> </span><span>— each backing</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>71.90</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 2</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Denture maintenance</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86741</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Adjustment of a denture to improve comfort and function</span><span> </span><span>— not including a routine adjustment following the insertion of a new denture or maintenance or repair of an existing denture</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>47.15</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86743</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Relining, complete denture</span><span> </span><span>— processed</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>436.20</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86744</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Relining, partial denture</span><span> </span><span>— processed</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>339.25</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86745</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Remodelling, complete denture</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>557.90</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86746</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Remodelling, partial denture</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>458.20</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86751</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Relining, complete denture, chair</span><span>‑</span><span>side only, hard or soft material</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>203.00</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86752</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Relining, partial denture</span><span> </span><span>— direct</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>159.00</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86753</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Cleaning and polishing of pre</span><span>‑</span><span>existing denture</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>50.90</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 3</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Denture repairs</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86761</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Reattaching pre</span><span>‑</span><span>existing tooth or clasp to denture including labour and laboratory costs</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>130.20</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86762</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Replacing clasp on denture</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>136.05</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86763</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Repairing broken base of a complete denture including labour and laboratory costs</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>117.50</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86764</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Repairing broken base of a partial denture including labour and laboratory costs</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>130.20</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86765</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Replacing first tooth on denture</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>136.05</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86767</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Any repair or tooth replacement in addition to other repairs, alterations or modifications for the same denture on the same day, including labour and laboratory costs</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>53.80</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86768</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Adding tooth to partial denture to replace an extracted or decoronated tooth</span><span> </span><span>— each tooth</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>137.70</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86769</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Repair or addition to metal casting</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>164.70</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 4</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Other prosthodontic services</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86771</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Tissue conditioning treatment before impressions</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>62.50</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86772</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Splint, resin</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>338.30</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86773</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Splint, metal</span><span> </span><span>— indirect</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>338.30</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86776</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Impression if required for denture repair or modification</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>41.55</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86777</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Identification</span><span> </span><span>— marking a dental appliance with a patient’s name or other form of enduring patient identification</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>33.25</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">Group B9</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">— Orthodontics</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 1</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Removable appliances</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86811</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Passive removable appliance</span><span> </span><span>— each arch</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>394.70</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86821</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Active removable appliance</span><span> </span><span>— each arch</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>717.05</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86823</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Functional orthopaedic appliance</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>563.65</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 2</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Fixed appliances</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86829</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Partial banding</span><span> </span><span>— each arch</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>678.70</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86831</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Full arch banding</span><span> </span><span>— each arch</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>1</span><span> </span><span>747.25</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86862</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Bonding of attachment for application of orthodontic force</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>146.60</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">Group B10</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-weight:bold">— General services</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 1</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Emergencies</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86911</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Palliative care</span><span> </span><span>— interim care to relieve pain, infection, bleeding or other problems not associated with other treatment</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>82.15</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 2</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Drug therapy</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86926</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Individually made tray for the application of medicaments to the teeth or supporting tissues, other than for bleaching</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>143.20</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86927</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Supply, prescription or administration of medications and medicaments required for a service</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>24.85</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 3</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Anaesthesia and sedation</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86949</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Treatment under general anaesthesia, if the anaesthetic is administered by a specialist anaesthetist</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>150.20</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 4</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Occlusal therapy</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86963</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Clinical occlusal analysis including muscle and joint palpation</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>111.45</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86964</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Registration and mounting of casts for occlusal analysis</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>84.50</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86965</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Occlusal splint</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>656.65</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86966</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Adjustment of pre</span><span>‑</span><span>existing occlusal splint</span><span> </span><span>— each visit</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>83.00</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86968</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Occlusal adjustment following occlusal analysis</span><span> </span><span>— each visit</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>116.90</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86971</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Adjunctive physical therapy for temporomandibular joint and associated structures</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>67.70</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86972</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Repair or addition</span><span> </span><span>— occlusal splint</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>199.20</span></p></td></tr><tr><td colspan="3" style="width:408.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="page-break-after:avoid"><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">Subgroup 5</span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic"> </span><span style="font-family:Arial, sans-serif; font-size:9pt; font-style:italic">— Miscellaneous</span></p></td></tr><tr><td style="width:36.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86981</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Splinting and stabilisation, direct</span><span> </span><span>— each tooth</span></p></td><td style="width:49.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>111.45</span></p></td></tr><tr><td style="width:36.6pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>86986</span></p></td><td style="width:301.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Post</span><span>‑</span><span>operative care if not provided for in another item</span></p><p class="TableText"><span>(Item is subject to section 13)</span></p></td><td style="width:49.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-right:11.35pt; text-align:right"><span>79.60</span></p></td></tr></tbody></table> ```