Part 1 Group C1 Orthodontic services andPart 1 Group C1 Orthodontic services and fees

Schedule ‑ Specified health services

Part 1 Group C1 Orthodontic services and fees

<table cellspacing="0" cellpadding="0" style="width:100%; border-collapse:collapse"><thead><tr><td colspan="3" style="border-top:1.5pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; page-break-after:avoid; line-height:10pt"><span style="font-size:10pt; font-weight:bold">Category 7 – Cleft Lip and Cleft Palate Services</span></p></td></tr><tr><td colspan="3" style="border-top:1.5pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; page-break-after:avoid; line-height:10pt"><span style="font-size:10pt; font-weight:bold">Group C1 – Orthodontic Services</span></p></td></tr><tr><td style="width:9.16%; border-top:1.5pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; page-break-after:avoid; line-height:10pt"><span style="font-size:10pt; font-weight:bold">Item</span></p></td><td style="width:80.26%; border-top:1.5pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; page-break-after:avoid; line-height:10pt"><span style="font-size:10pt; font-weight:bold">Service</span></p></td><td style="width:10.58%; border-top:1.5pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; page-break-after:avoid; line-height:10pt"><span style="font-size:10pt; font-weight:bold">Fee ($)</span></p></td></tr></thead><tbody><tr><td style="width:9.16%; border-top:1.5pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75001</span></p></td><td style="width:80.26%; border-top:1.5pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Initial professional attendance in a single course of treatment by an eligible orthodontist (AO)</span></p></td><td style="width:10.58%; border-top:1.5pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">89.00</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75004</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Professional attendance by an eligible orthodontist after the first professional attendance by the orthodontist in a single course of treatment (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">44.75</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75006</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Production of dental study models (other than a service associated with a service to which item 75004 applies) before provision of a service to which:</span></p><p style="margin-left:26.65pt; margin-bottom:3pt; text-indent:-26.65pt; line-height:12pt"><span style="width:9.3pt; text-indent:0pt; display:inline-block"></span><span style="font-size:10pt">(a)</span><span style="width:6.25pt; text-indent:0pt; display:inline-block"> </span><span style="font-size:10pt">item 75030, 75033, 75034, 75036, 75037, 75039, 75045 or 75051 applies; or</span></p><p style="margin-left:26.65pt; margin-bottom:3pt; text-indent:-26.65pt; line-height:12pt"><span style="width:8.74pt; text-indent:0pt; display:inline-block"></span><span style="font-size:10pt">(b)</span><span style="width:6.25pt; text-indent:0pt; display:inline-block"> </span><span style="font-size:10pt">an item in Group T8 or Groups O3 to O9 applies;</span></p><p style="margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">in a single course of treatment (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">79.30</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75009</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Orthodontic radiography</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— orthopantomography (panoramic radiography), including any consultation on the same occasion (AOS) (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">70.95</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75012</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Orthodontic radiography</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— anteroposterior cephalometric radiography with cephalometric tracings or lateral cephalometric radiography with cephalometric tracings including any consultation on the same occasion (AOS) (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">112.45</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75015</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Orthodontic radiography</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— anteroposterior and lateral cephalometric radiography, with cephalometric tracings including any consultation on the same occasion (AOS)</span><span style="font-size:10pt"> </span><span style="font-size:10pt">(AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">154.60</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75018</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Orthodontic radiography</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— anteroposterior and lateral cephalometric radiography, with cephalometric tracings and orthopantomography including any consultation on the same occasion (AOS) (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">196.95</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75021</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Orthodontic radiography</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— hand</span><span style="font-size:10pt">‑</span><span style="font-size:10pt">wrist studies (including growth prediction) including any consultation on the same occasion (AOS) (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">241.45</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75023</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Intraoral radiography</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— single area, periapical or bitewing film (AOS) (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">48.35</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75024</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Pre</span><span style="font-size:10pt">‑</span><span style="font-size:10pt">surgical infant maxillary arch repositioning, including supply of appliances and all adjustments of appliances and supervision</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— if 1 appliance is used (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">624.40</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75027</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Pre</span><span style="font-size:10pt">‑</span><span style="font-size:10pt">surgical infant maxillary arch repositioning, including supply of appliances and all adjustments of appliances and supervision</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— if 2 appliances are used (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">856.25</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75030</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Maxillary ach expansion other than a service associated with a service to which item 75039, 75042, 75045 or</span><span style="font-size:10pt"> </span><span style="font-size:10pt">75048 applies, including supply of appliances, all adjustments of the appliances, removal of the appliances and retention (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">762.35</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75033</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Mixed dentition treatment</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— incisor alignment using fixed appliances in maxillary arch, including supply of appliances, all adjustments of appliances, removal of the appliances and retention (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">1,249.60</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75034</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Mixed dentition treatment</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— incisor alignment with or without lateral arch expansion using a removable appliance in the maxillary arch, including supply of appliances, associated adjustments and retention (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">636.00</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75036</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Mixed dentition treatment</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— lateral arch expansion and incisor alignment using fixed appliances in maxillary arch, including supply of appliances, all adjustments of appliances, removal of appliances and retention (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">1,726.00</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75037</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Mixed dentition treatment</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— lateral arch expansion and incisor correction</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— 2 arch (maxillary and mandibular) using fixed appliances in both maxillary and mandibular arches, including supply of appliances, all adjustments of appliances, removal of appliances and retention (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">2,173.85</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75039</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Permanent dentition treatment</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— single arch (mandibular or maxillary) treatment (correction and alignment) using fixed appliances, including supply of appliances</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— initial 3</span><span style="font-size:10pt"> </span><span style="font-size:10pt">months of active treatment (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">577.75</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75042</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Permanent dentition treatment</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— single arch (mandibular or maxillary) treatment (correction and alignment) using fixed appliances, including supply of appliances</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— each 3</span><span style="font-size:10pt"> </span><span style="font-size:10pt">months of active treatment (including all adjustments and maintenance and removal of the appliances) after the first for a maximum of a further 33 months (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">215.95</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75045</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Permanent dentition treatment</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— 2 arch (mandibular and maxillary) treatment (correction and alignment) using fixed appliances, including supply of appliances</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— initial 3</span><span style="font-size:10pt"> </span><span style="font-size:10pt">months of active treatment (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">1,156.60</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75048</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Permanent dentition treatment</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— 2 arch (mandibular and maxillary) treatment (correction and alignment) using fixed appliances, including supply of appliances</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— each subsequent 3 months of active treatment (including all adjustments and maintenance, and removal of the appliances) after the first for a maximum of a further 33</span><span style="font-size:10pt"> </span><span style="font-size:10pt">months (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">296.60</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75049</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Retention, fixed or removable, single arch (mandibular or maxillary)</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— supply of retainer and supervision of retention (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">347.15</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75050</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Retention, fixed or removable, 2</span><span style="font-size:10pt">‑</span><span style="font-size:10pt">arch (mandibular and maxillary)</span><span style="font-size:10pt"> </span><span style="font-size:10pt">— supply of retainers and supervision of retention (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">670.15</span></p></td></tr><tr><td style="width:9.16%; border-top:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">75051</span></p></td><td style="width:80.26%; border-top:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; line-height:12pt"><span style="font-size:10pt">Jaw growth guidance using removable or functional appliances, including supply of appliances and all adjustments to appliances (AO)</span></p></td><td style="width:10.58%; border-top:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.35pt; padding-left:5.35pt; vertical-align:top; background-color:#ffffff"><p style="margin-top:3pt; margin-bottom:3pt; text-align:right; line-height:12pt"><span style="font-size:10pt">1,028.70</span></p></td></tr></tbody></table>