Part 3Services provided by eligible dental prosthetists

Part 3 Services provided by eligible dental prosthetists

<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 C1</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 and 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>87011</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText"><span>Initial denture examination, including:</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>assessment of any existing dentures and any teeth, supporting tissues and oral tissues to construct a removable dental prosthesis or refer to an appropriate clinician; and</span></p><p class="TableP1a" style="margin-top:3pt"><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>recording an appropriate medical history and any other relevant information</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>42.85</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>87014</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 removable dental prosthesis, including the recording of 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>34.55</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>87071</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>49.05</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 C2</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">— Dentures 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>87711</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>724.50</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>87712</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 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>724.50</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>87716</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>87719</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</span><span> </span><span>234.25</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>87721</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>342.65</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>87722</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>342.65</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>87727</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>067.70</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>87728</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 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>067.70</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>87731</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 87721 or</span><span> </span><span>87722 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>35.80</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>87732</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 87721 or</span><span> </span><span>87722 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>17.40</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>87733</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 section 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>37.15</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>87736</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>7.35</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>87737</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>153.70</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>87738</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>— bar 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>143.25</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>87739</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>— 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>64.70</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 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>87741</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 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>42.40</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>87743</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>270.65</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>87744</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>230.70</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>87745</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>431.40</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>87746</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>363.65</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>87751</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>148.05</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>87752</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>124.80</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>87753</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>34.45</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 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>87761</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>117.25</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>87762</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>122.45</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>87763</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>105.70</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>87764</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>117.25</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>87765</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>122.45</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>87767</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>48.35</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>87768</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>123.90</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>87769</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><span style="width:4.91pt; display:inline-block"></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>87771</span></p></td><td style="width:301.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="TableText" style="margin-bottom:6pt"><span>Tissue conditioning treatment before impressions</span></p><p class="TableText" style="margin-top:6pt"><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>56.25</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>87776</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</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>37.35</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>87777</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>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; 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>29.95</span></p></td></tr></tbody></table> ```