alliance midmed 2020 rates€¦ · dental practice (54) maxillo-facial & oral surgery (62)...
TRANSCRIPT
*-
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8025 HANDLING FEE - DIRECT
MATERIALS (26% OF MATERIAL
COST TO A MAXIMUM OF R26.00)
43.30R 43.30R 43.30R 43.30R - 43.30R - -
8101 ORAL EXAMINATION 240.00R 240.00R 240.00R 240.00R - 240.00R 124.90R -8102 COMPREHENSIVE ORAL
EXAMINATION
387.70R 387.70R 387.70R 387.70R - 387.70R 201.70R -
8104 LIMITED ORAL EXAMINATION 116.40R 116.40R 116.40R 116.40R - 116.40R 97.30R -8106 SPECIAL REPORT 246.50R 246.50R 246.50R 246.50R - 246.50R - -8107 INTRAORAL RADIOGRAPH -
PERIAPICAL
97.20R 97.20R 97.20R 97.20R - 97.20R 93.70R 93.70R
8108 INTRAORAL RADIOGRAPHS -
COMPLETE SERIES
752.20R 752.20R 752.20R 752.20R - 752.20R 721.70R 721.70R
8109 INFECTION CONTROL/BARRIER
TECHNIQUES
21.60R 21.60R 21.60R 21.60R - 21.60R 21.60R 21.60R
8110 STERILIZED INSTRUMENTATION 55.80R 55.80R 55.80R 55.80R - 55.80R 55.70R 55.40R 8112 INTRAORAL RADIOGRAPH -
BITEWING
97.20R 97.20R 97.20R 97.20R - 97.20R 93.70R -
8113 INTRAORAL RADIOGRAPH -
OCCLUSAL
167.40R 167.40R 167.40R 167.40R - 167.40R - -
8114 EXTRAORAL RADIOGRAPH - HAND-
WRIST
388.50R 388.50R 388.50R 388.50R - 388.50R - -
8115 EXTRAORAL RADIOGRAPH -
PANORAMIC
388.50R 388.50R 388.50R 388.50R - 388.50R - -
8116 EXTRAORAL RADIOGRAPH -
CEPHALOMETRIC
388.50R 388.50R 388.50R 388.50R - 388.50R - -
DENIS shall be entitled to update the tariff schedule from time to time.
The tariffs listed do not consider scheme exclusions and scope of practice and is by no means a commitment of funding.
Benefit entitlement is governed by the relevant scheme option and rules as well as risk management interventions and protocols.
If the clinical code requires managed care intervention, all associated lab codes will be included in the authorisation process. Pre-authorisation is required for the dental code to attract benefitTariff amount not applicable
Alliance Midmed 2020 Rates
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8117 DIAGNOSTIC MODELS 104.40R 104.40R 104.40R 104.40R - 104.40R - -8118 EXTRAORAL RADIOGRAPH -
SKULL/FACIAL BONE
388.50R 388.50R 388.50R 388.50R - 388.50R - -
8119 DIAGNOSTIC MODELS MOUNTED 262.60R 262.60R 262.60R 262.60R - 262.60R - -
8120 TREATMENT PLAN COMPLETED - - - - - - - -8121 ORAL AND/OR FACIAL IMAGE
(DIGITAL/CONVENTIONAL)
104.40R 104.40R 104.40R 104.40R - 104.40R - 100.50R
8123 CARIES SUSCEPTIBILITY TESTS (BY
ARRANGEMENT)
- - - - - - - -
8124 PULP TESTS 28.70R - - - - - - -8129 OFFICE/HOSPITAL VISIT – AFTER
REGULARLY SCHEDULED HOURS
361.60R 361.60R - 361.60R - 361.60R 299.80R -
8131 EMERGENCY DENTAL TREATMENT 147.40R 147.40R 147.40R 147.40R - 300.50R 124.90R 125.00R
8132 PULP REMOVAL (PULPECTOMY) 241.10R 241.10R - - - 320.50R - -8133 RECEMENT INLAY, ONLAY, CROWN
OR VENEER
147.40R 147.40R - - - 187.10R - -
8135 REMOVE INLAY, ONLAY OR CROWN 293.30R 293.30R - - - 293.30R - -
8136 ACCESS THROUGH A PROSTHETIC
CROWN OR INLAY TO FACILITATE
ROOT CANAL TREATMENT
131.30R 131.30R - 131.30R - 131.30R - -
8137 EMERGENCY CROWN (CHAIR-SIDE) 505.50R 505.50R - - - 505.50R - -
8138 REMOVE RETENTION POST
(PREFABRICATED OR CAST)
192.50R 192.50R - - - 192.50R - -
8139 APPOINTMENT NOT KEPT /30MIN - - - - - - - -
8140 HOUSE/EXTENDED CARE
FACILITY/HOSPITAL CALL
* 239.30R 239.30R - 239.30R - 239.30R 198.30R -
8141 INHALATION SEDATION - FIRST 15
MINUTES OR PART THEREOF
108.00R 108.00R - 108.00R - 108.00R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8143 INHALATION SEDATION - EACH
ADDNL 15 MINUTES
55.80R 55.80R - 55.80R - 55.80R - -
8144 INTRAVENOUS SEDATION * 64.80R 64.80R - 64.80R - 64.80R - -8145 LOCAL ANAESTHETIC - PER VISIT 93.70R 93.70R 93.70R 93.70R - 93.70R 21.20R 21.30R 8146 RESIN BONDING FOR
RESTORATIONS
- - - - - - - -
8147 MONITORING EQUIPMENT FOR
INTRAVENOUS SEDATION
230.30R 230.30R - 230.30R - 230.30R - -
8151 ORAL HYGIENE INSTRUCTION 147.40R - - 295.10R - 295.10R 98.10R 98.10R 8153 ORAL HYGIENE INSTRUCTION -
EACH ADDITIONAL VISIT
108.00R - - 142.00R - 142.00R 71.80R 71.80R
8154 ORAL EXAMINATION - ORAL
HYGIENIST
- - - - - - - 124.90R
8155 POLISHING - COMPLETE DENTITION 147.40R 147.40R - 203.20R - 147.40R 120.00R 119.10R
8157 RE-BURNISHING AND POLISHING
OF RESTORATIONS - COMPLETE
DENTITION
147.40R - - - - - - -
8158 ENAMEL MICROABRASION 134.90R - - - - - - -8159 PROPHYLAXIS - COMPLETE
DENTITION
289.70R 289.70R - 408.50R - 289.70R 218.50R 218.40R
8160 REMOVAL OF GROSS CALCULUS - - - - - - - -8161 TOPICAL APPLICATION OF
FLUORIDE - CHILD
147.40R 147.40R - 147.40R - 147.40R 120.00R 119.90R
8162 TOPICAL APPLICATION OF
FLUORIDE - ADULT
147.40R - - 147.40R - 147.40R 120.00R 120.00R
8163 DENTAL SEALANT 97.20R 97.20R - 97.20R - 97.20R 88.80R 88.80R 8164 LIMITED ORAL EXAMINATION -
ORAL HYGIENIST
- - - - - - - 97.30R
8165 SEDATIVE FILLING 147.40R 147.40R - 147.40R - 147.40R 124.90R 125.00R 8166 APPLICATION OF DESENSITISING
RESIN, PER TOOTH
97.20R 97.20R - 97.20R - 97.20R 82.50R 82.60R
8167 APPLICATION OF DESENSITISING
MEDICAMENT, PER VISIT
113.40R 113.40R - 113.40R - 113.40R 96.10R 96.00R
8169 OCCLUSAL GUARD 566.60R 566.60R 566.60R 566.60R - 566.60R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8171 MOUTH PROTECTOR 171.50R 171.50R 171.50R 171.50R - 171.50R - 128.60R 8172 COST OF ORTHOTIC APPLIANCE * - - - - - - - -8173 SPACE MAINTAINER - FIXED, PER
ABUTMENT
273.60R 273.60R 273.60R 273.60R - 273.60R - -
8175 SPACE MAINTAINER - REMOVABLE 352.70R 352.70R 352.70R 352.70R - 352.70R - -
8176 PERIODONTAL SCREENING 202.20R 190.70R - 202.20R - 202.20R - 146.60R 8177 ORAL HYGIENE INSTRUCTION
(PERIODONTALLY COMPROMISED
PATIENT)
223.20R - - - - - - -
8178 ORAL HYGIENE INSTRUCTION -
EACH ADDITIONAL VISIT
(PERIODONTALLY COMPROMISED
PATIENT)
120.50R - - - - - - -
8179 POLISHING - COMPLETE DENTITION
(PERIODONTALLY COMPROMISED
PATIENT)
169.20R 169.20R - 169.20R - 169.20R - 122.70R
8180 PROPHYLAXIS - COMPLETE
DENTITION (PERIODONTALLY
COMPROMISED PATIENT)
* 314.80R 314.80R - 314.80R - 169.20R - 176.30R
8183 THERAPEUTIC DRUG INJECTION 64.80R - - - - - - -8189 RE-EXAMINATION - EXISTING
CONDITION
116.40R - - - - - 97.30R 97.30R
8190 CONSULTATION - SECOND OPINION
OR ADVICE
240.00R 240.00R 240.00R 240.00R - 240.00R - -
8192 SUTURE - MINOR 726.80R 726.80R - 726.80R - 726.80R - -8194 CBCT CAPTURE AND
INTERPRETATION WITH LIMITED
FIELD OF VIEW - LESS THAN ONE
WHOLE JAW
388.50R 388.50R 388.50R 388.50R - 388.50R - -
8195 CBCT CAPTURE AND
INTERPRETATION WITH LIMITED
FIELD OF VIEW OF ONE FULL ARCH -
MANDIBLE
388.50R 388.50R 388.50R 388.50R - 388.50R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8196 CBCT CAPTURE AND
INTERPRETATION WITH LIMITED
FIELD OF VIEW OF ONE FULL ARCH -
MAXILLA WITHOUT ORBITS
AND/OR CRANIUM
388.50R 388.50R 388.50R 388.50R - 388.50R - -
8197 CBCT CAPTURE AND
INTERPRETATION WITH LIMITED
FIELD OF VIEW OF BOTH DENTAL
ARCHES - WITHOUT ORBITS
AND/OR CRANIUM
388.50R 388.50R 388.50R 388.50R - 388.50R - -
8198 CBCT CAPTURE AND
INTERPRETATION FOR TMJ SERIES
INCLUDING TWO OR MORE
EXPOSURES
388.50R 388.50R 388.50R 388.50R - 388.50R - -
8199 CBCT CAPTURE AND
INTERPRETATION WITH LIMITED
FIELD OF VIEW OF ONE FULL ARCH -
MAXILLA WITH ORBITS AND/OR
CRANIUM
388.50R 388.50R 388.50R 388.50R - 388.50R - -
8200 CBCT CAPTURE AND
INTERPRETATION WITH FIELD OF
VIEW OF BOTH DENTAL ARCHES -
WITH ORBITS AND/OR CRANIUM
388.50R 388.50R 388.50R 388.50R - 388.50R - -
8201 EXTRACTION - TOOTH OR EXPOSED
TOOTH ROOTS (FIRST PER
QUADRANT)
147.40R 221.10R 147.40R 147.40R - 147.40R 139.90R -
8202 EXTRACTION - EACH ADDITIONAL
TOOTH OR EXPOSED TOOTH ROOTS
59.40R 89.10R 59.40R 59.40R - 59.40R 54.00R -
8213 SURGICAL REMOVAL OF RESIDUAL
ROOTS, FIRST TOOTH PER
QUADRANT
637.00R 637.00R - 637.00R - 637.00R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8214 SURGICAL REMOVAL OF RESIDUAL
ROOTS, SECOND AND SUBSEQUENT
TEETH'S ROOTS
491.10R 491.10R - 491.10R - 491.10R - -
8220 COST OF SUTURE MATERIAL 231.10R 231.10R - 231.10R - 231.10R 231.10R -8228 ART RESTORATIONS - - - - - - - 255.90R 8231 COMPLETE DENTURES - MAXILLARY
AND MANDIBULAR
* 2 378.50R - - 2 378.50R - 4 965.80R - -
8232 COMPLETE DENTURE - MAXILLARY
OR MANDIBULAR
* 1 466.30R - - 1 466.30R - 3 474.30R - -
8233 PARTIAL DENTURE - RESIN BASE -
ONE TOOTH
* 681.80R - - 681.80R - 681.80R - -
8234 PARTIAL DENTURE - RESIN BASE -
TWO TEETH
* 681.80R - - 681.80R - 681.80R - -
8235 PARTIAL DENTURE - RESIN BASE -
THREE TEETH
* 1 020.10R - - 1 020.10R - 1 020.10R - -
8236 PARTIAL DENTURE - RESIN BASE -
FOUR TEETH
* 1 020.10R - - 1 020.10R - 1 020.10R - -
8237 PARTIAL DENTURE - RESIN BASE -
FIVE TEETH
* 1 020.10R - - 1 020.10R - 1 020.10R - -
8238 PARTIAL DENTURE - RESIN BASE -
SIX TEETH
* 1 353.10R - - 1 353.10R - 1 353.10R - -
8239 PARTIAL DENTURE - RESIN BASE -
SEVEN TEETH
* 1 353.10R - - 1 353.10R - 1 353.10R - -
8240 PARTIAL DENTURE - RESIN BASE -
EIGHT TEETH
* 1 353.10R - - 1 353.10R - 1 353.10R - -
8241 PARTIAL DENTURE - RESIN BASE -
NINE OR MORE TEETH
* 1 353.10R - - 1 353.10R - 1 353.10R - -
8244 IMMEDIATE DENTURE - MAXILLARY * 1 466.30R - - 1 466.30R - 2 199.50R - -
8245 IMMEDIATE DENTURE -
MANDIBULAR
* 1 466.30R - - 1 466.30R - 2 199.50R - -
8251 CLASP OR REST - CAST GOLD 134.90R - - - - - - -8253 CLASP OR REST - WROUGHT GOLD 134.90R - - - - - - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8255 CLASP OR REST - STAINLESS STEEL 142.00R - - - - - - -
8257 BAR - LINGUAL OR PALATAL 167.40R - - - - - - -8259 REBASE COMPLETE OR PARTIAL
DENTURE (LABORATORY)
555.90R - - 555.90R - 802.40R - -
8261 REMODEL COMPLETE OR PARTIAL
DENTURE
892.40R - - 892.40R - 892.40R - -
8263 RELINE COMPLETE OR PARTIAL
DENTURE (CHAIR-SIDE)
352.70R - - 352.70R - 440.70R - -
8265 TISSUES CONDITIONING PER ARCH
(INCLUDING SOFT SELF-CURE
RELINE)
230.30R 230.30R - 230.30R - 295.10R - 167.10R
8267 RELINE COMPLETE OR PARTIAL
DENTURE (LABORATORY)
811.60R - - 811.60R - 811.60R - -
8269 REPAIR DENTURE OR OTHER INTRA-
ORAL APPLIANCE
187.10R - - - - 201.40R - -
8270 ADD CLASP TO EXISTING PARTIAL
DENTURE
134.90R - - - - - - -
8271 ADD TOOTH TO EXISTING PARTIAL
DENTURE
134.90R - - - - - - -
8273 IMPRESSION TO REPAIR OR
MODIFY A DENTURE OR OTHER
INTRA-ORAL APPLIANCE
108.00R - - 108.00R - 108.00R - -
8275 ADJUST COMPLETE OR PARTIAL
DENTURE
108.00R - - 108.00R - 108.00R - -
8277 INLAY IN DENTURE 440.10R - - - - 867.70R - -8281 PARTIAL DENTURE - CAST METAL
FRAMEWORK ONLY
* 1 590.60R - - 1 590.60R - 1 590.60R - -
8301 PULP CAP - DIRECT 196.00R - - - - - - -8303 PULP CAP - INDIRECT 196.00R - - - - - 177.40R -8304 RUBBER DAM PER ARCH 115.20R 115.20R - 115.20R - 115.20R - -8306 COST OF MTA - - - - - - - -8307 PULP AMPUTATION (PULPOTOMY) 192.50R 192.50R - 192.50R - 192.50R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8310 SUPPLY OF BLEACHING MATERIALS - - - - - - - -
8325 INTERNAL BLEACHING - PER TOOTH 349.10R - - - - 523.70R - -
8327 INTERNAL BLEACHING - EACH
ADDITIONAL VISIT
167.40R - - - - 251.10R - -
8328 ROOT CANAL OBTURATION -
ANTERIORS AND PREMOLARS -
EACH ADDITIONAL CANAL
273.60R 273.60R - - - 363.80R - -
8329 ROOT CANAL THERAPY -
ANTERIORS AND PREMOLARS -
EACH ADDITIONAL CANAL
341.90R 341.90R - - - 454.70R - -
8330 REMOVAL OF ROOT CANAL
OBSTRUCTION
192.50R 192.50R - 192.50R - 192.50R - -
8332 ROOT CANAL PREPARATORY VISIT -
SINGLE CANAL TOOTH
147.40R 147.40R - - - 196.00R - -
8333 ROOT CANAL PREPARATORY VISIT -
MULTI CANAL TOOTH
206.80R 206.80R - - - 206.80R - -
8334 RE-TREATMENT OF PREVIOUSLY
COMPLETED ROOT CANAL
THERAPY, PER CANAL
217.80R 217.80R - 217.80R - 262.60R - -
8335 ROOT CANAL OBTURATION -
ANTERIORS AND PREMOLARS -
FIRST CANAL
669.30R 669.30R - - - 890.10R - -
8336 ROOT CANAL OBTURATION -
POSTERIORS - FIRST CANAL
921.10R 921.10R - - - 1 224.90R - -
8337 ROOT CANAL OBTURATION -
POSTERIORS - EACH ADDITIONAL
CANAL
273.60R 273.60R - - - 363.80R - -
8338 ROOT CANAL THERAPY -
ANTERIORS AND PREMOLARS -
FIRST CANAL
1 023.70R 1 023.70R - - - 1 361.60R - -
8339 ROOT CANAL THERAPY -
POSTERIORS - FIRST CANAL
1 406.80R 1 406.80R - - - 1 870.90R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8340 ROOT CANAL THERAPY -
POSTERIORS - EACH ADDITIONAL
CANAL
341.90R 341.90R - - - 454.70R - -
8341 AMALGAM - ONE SURFACE 293.30R 293.30R - 293.30R - 293.30R 256.00R -8342 AMALGAM - TWO SURFACES 361.60R 361.60R - 361.60R - 361.60R 315.60R -8343 AMALGAM - THREE SURFACES 440.70R 440.70R - 440.70R - 440.70R 384.70R -8344 AMALGAM - FOUR OR MORE
SURFACES
491.10R 491.10R - 491.10R - 491.10R 428.50R -
8345 PREFABRICATED POST RETENTION,
PER POST (IN ADDITION TO
RESTORATION)
289.70R 289.70R - 289.70R - 289.70R - -
8347 PIN RETENTION - FIRST PIN (IN
ADDITION TO RESTORATION)
145.60R 145.60R - 145.60R - 145.60R - -
8348 PIN RETENTION - EACH
ADDITIONAL PIN (IN ADDITION TO
RESTORATION)
134.90R 134.90R - 134.90R - 134.90R - -
8349 CARVE RESTORATION TO
ACCOMMODATE EXISTING
REMOVABLE PROSTHESIS
59.40R - - - - - - -
8350 RESIN CROWN - ANTERIOR
PRIMARY TOOTH (DIRECT)
639.80R 639.80R - 639.80R - 639.80R 558.10R -
8351 RESIN - ONE SURFACE, ANTERIOR 322.00R 322.00R - 322.00R - 322.00R 309.70R -
8352 RESIN - TWO SURFACES, ANTERIOR 404.90R 404.90R - 404.90R - 404.90R 389.30R -
8353 RESIN - THREE SURFACES,
ANTERIOR
484.00R 484.00R - 484.00R - 484.00R 465.20R -
8354 RESIN - FOUR OR MORE SURFACES,
ANTERIOR
539.80R 539.80R - 539.80R - 539.80R 519.20R -
8355 VENEER - RESIN (CHAIR-SIDE) 511.10R 511.10R - 511.10R - 511.10R - -8357 PREFABRICATED METAL CROWN 300.50R 300.50R - 300.50R - 300.50R - -8361 INLAY - METAL - ONE SURFACE 447.90R - - - - 883.50R - -8362 INLAY/ONLAY - METAL - TWO
SURFACES
654.90R - - - - 1 280.90R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8363 INLAY/ONLAY - METAL - THREE
SURFACES
1 092.10R - - - - 1 986.30R - -
8364 INLAY/ONLAY - METAL - FOUR OR
MORE SURFACES
1 320.60R - - - - 1 986.30R - -
8366 PIN RETENTION AS PART OF CAST
RESTORATION (ANY NUMBER OF
PINS)
217.80R - - - - 295.10R - -
8367 RESIN - ONE SURFACE, POSTERIOR 349.10R 349.10R - 349.10R - 349.10R 335.80R -
8368 RESIN - TWO SURFACES,
POSTERIOR
431.80R 431.80R - 431.80R - 431.80R 415.30R -
8369 RESIN - THREE SURFACES,
POSTERIOR
521.80R 521.80R - 521.80R - 521.80R 501.70R -
8370 RESIN - FOUR OR MORE SURFACES,
POSTERIOR
561.30R 561.30R - 561.30R - 561.30R 539.60R -
8371 INLAY - PORCELAIN - ONE SURFACE 539.80R - - - - 1 067.00R - -
8372 INLAY/ONLAY - PORCELAIN - TWO
SURFACES
797.00R - - - - 1 536.60R - -
8373 INLAY/ONLAY - PORCELAIN - THREE
SURFACES
1 313.40R - - - - 2 387.60R - -
8374 INLAY/ONLAY - PORCELAIN - FOUR
OR MORE SURFACES
1 590.60R - - - - 2 387.60R - -
8375 PREFABRICATED RESIN CROWN 300.50R 300.50R - 300.50R - 300.50R - -8376 CORE BUILD-UP WITH
PREFABRICATED POSTS
802.40R - - - - 802.40R - -
8379 COST OF PREFABRICATED POSTS 111.70R - - - - 111.70R - -8381 INLAY - RESIN - ONE SURFACE 539.80R - - - - 1 067.00R - -8382 INLAY/ONLAY - RESIN - TWO
SURFACES
797.00R - - - - 1 536.60R - -
8383 INLAY/ONLAY - RESIN - THREE
SURFACES
1 313.40R - - - - 2 387.60R - -
8384 INLAY/ONLAY - RESIN - FOUR OR
MORE SURFACES
1 590.60R - - - - 2 387.60R - -
8391 CAST CORE WITH SINGLE POST * 338.30R - - - - 338.30R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8392 CAST POST (EACH ADDITIONAL) 201.40R - - - - 201.40R - -8397 CAST CORE WITH PINS (ANY
NUMBER OF PINS)
* 539.80R - - - - 701.80R - -
8398 CORE BUILD-UP WITH PINS 654.90R - - - - 654.90R - -8401 CROWN - FULL CAST METAL * 1 684.00R - - - - 2 479.20R - -8403 CROWN - 3/4 CAST METAL * 1 684.00R - - - - 2 479.20R - -8404 CROWN - 3/4 PORCELAIN/CERAMIC * 1 590.40R - - - - 2 387.60R - -
8405 CROWN - RESIN LABORATORY * 1 590.40R - - - - 2 387.60R - -8407 CROWN - RESIN WITH METAL * 1 684.00R - - - - 2 479.20R - -8409 CROWN - PORCELAIN/CERAMIC * 1 684.00R - - - - 2 479.20R - -8410 PROVISIONAL CROWN 327.30R - - 327.30R - 491.10R - -8411 CROWN - PORCELAIN VENEERED
TO METAL
* 1 684.00R - - - - 2 479.20R - -
8413 REPAIR CROWN (PERMANENT OR
PROVISIONAL)
327.30R 327.30R - - - 327.30R - -
8414 ADDITIONAL FEE FOR PROVISION
OF CROWN WITHIN AN EXISTING
CLASP OR REST
97.20R - - - - 97.20R - -
8415 PONTIC - CERAMIC * 1 374.60R - - - - 1 374.60R - -8416 PONTIC - CAST METAL * 1 092.10R - - - - 1 092.20R - -8417 PONTIC - RESIN WITH METAL * 1 374.60R - - - - 1 374.60R - -8418 PONTIC - PORCELAIN VENEERED TO
METAL
* 1 374.60R - - - - 1 374.60R - -
8419 PROVISIONAL PONTIC 327.30R - - - - 491.10R - -8432 INLAY/ONLAY RETAINER - METAL -
TWO SURFACES
* 654.90R - - - - 1 280.90R - -
8433 INLAY/ONLAY RETAINER - METAL -
THREE SURFACES
* 1 092.10R - - - - 1 986.30R - -
8434 INLAY/ONLAY RETAINER - METAL -
FOUR OR MORE SURFACES
* 1 320.60R - - - - 1 986.30R - -
8436 INLAY/ONLAY RETAINER -
PORCELAIN - TWO SURFACES
* 797.00R - - - - 1 536.60R - -
8437 INLAY/ONLAY RETAINER -
PORCELAIN - THREE SURFACES
* 1 313.40R - - - - 2 387.60R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8438 INLAY/ONLAY RETAINER -
PORCELAIN - FOUR OR MORE
SURFACES
* 1 590.60R - - - - 2 387.60R - -
8441 CROWN RETAINER - FULL CAST
METAL
* 1 684.00R - - - - 2 479.20R - -
8442 CROWN RETAINER - 3/4 CAST
METAL
* 1 684.00R - - - - 2 479.20R - -
8443 CROWN RETAINER - CERAMIC * 1 684.00R - - - - 2 479.20R - -8444 CROWN RETAINER - 3/4 CERAMIC * 1 684.00R - - - - 2 479.20R - -
8445 CROWN RETAINER - PORCELAIN
VENEERED TO METAL
* 1 684.00R - - - - 2 479.20R - -
8446 CROWN RETAINER - RESIN WITH
METAL
* 1 684.00R - - - - 2 479.20R - -
8447 PROVISIONAL CROWN RETAINER 327.30R - - - - 491.10R - -8499 GENERAL ANAESTHETIC - - - - - - - -8501 CONSULTATION - PROSTHODONTIS - - - - - 305.90R - -
8503 OCCLUSION ANALYSIS MOUNTED 327.30R - - - - 491.10R - -
8505 PANTOGRAPHIC RECORDING 475.00R - - - - 712.50R - -8506 DETAILED CONSULTATION -
PROSTHODONTIST
- - - - - 800.60R - -
8507 COMPREHENSIVE CONSULTATION -
PROSTHODONTIST
- - - - - 491.10R - -
8508 ELECTROGNATHOGRAPHIC
RECORDING
508.50R - - - - 762.90R - -
8509 ELECTROGNATHOGRAPHIC
RECORDING WITH COMPUTER
ANALYSIS
844.30R - - - - 1 266.60R - -
8514 RECEMENT BRIDGE 147.40R 147.40R - - - 187.10R - -8516 REMOVE BRIDGE 293.30R 293.30R - - - 293.30R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8517 REIMPLANTATION OF AVULSED
TOOTH (INCLUDE STABILISATION)
340.60R 340.60R - 340.60R - 511.10R - -
8518 REPAIR BRIDGE 327.30R 327.30R - - - 327.30R - -8533 IMPLANT SUPPORTED REMOVABLE
COMPLETE OVERDENTURE
* 2 643.50R - - - - 3 965.40R - -
8534 IMPLANT SUPPORTED REMOVABLE
PARTIAL OVERDENTURE
* 2 114.80R - - - - 3 172.30R - -
8536 CROWN-IMPLANT/ABUTMENT
SUPPORTED CROWN -
PORCELAIN/CERAMIC
* 2 185.90R - - - - 2 891.30R - -
8537 CROWN-IMPLANT/ABUTMENT
SUPPORTED CROWN - PORCELAIN
WITH METAL
* 2 185.90R - - - - 2 891.30R - -
8538 CROWN-IMPLANT/ABUTMENT
SUPPORTED CROWN - CAST METAL
* 2 185.90R - - - - 2 891.30R - -
8546 IMPLANT SUPPORTED CROWN
RETAINER - CERAMIC
* 2 185.90R - - - - 2 891.30R - -
8547 IMPLANT SUPPORTED CROWN
RETAINER - PORCELAIN VENEERED
TO METAL
* 2 185.90R - - - - 2 891.30R - -
8548 CROWN RETAINER -
IMPLANT/ABUTMENT SUPPORTED -
CAST METAL
* 2 185.90R - - - - 2 891.30R - -
8551 OCCLUSAL ADJUSTMENT - MAJOR 933.10R - 1 399.70R - - 1 399.70R - -
8552 VENEER - PORCELAIN
(LABORATORY)
1 131.00R - - - - 1 696.60R - -
8553 OCCLUSAL ADJUSTMENT - MINOR 325.50R 446.10R 446.10R 446.10R - 446.10R - -
8554 VENEER - RESIN (LABORATORY) 1 131.00R - - - - 1 696.60R - -8560 COST OF CERAMIC BLOCK * 661.40R - - - - 661.40R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8561 GOLD FOIL CLASS I OR IV 854.00R - - - - 1 280.90R - -8563 GOLD FOIL CLASS V 999.10R - - - - 1 498.70R - -8565 GOLD FOIL CLASS III 1 256.90R - - - - 1 885.50R - -8570 FABRICATION OF COMPUTER
GENERATED CERAMIC
RESTORATION
* 1 604.60R - - - - 1 604.60R - -
8578 PREFABRICATED ABUTMENT 273.60R - - - - 410.30R - -8579 CUSTOM ABUTMENT 1 247.40R - - - - 1 871.10R - -8580 CUSTOMISED PREFABRICATED
ABUTMENT
* - - - - - - - -
8581 CAST CORE WITH SINGLE POST * - - - - - 500.10R - -8582 CAST CORE WITH DOUBLE POST * - - - - - 712.50R - -8583 CAST CORE WITH TRIPLE POST * - - - - - 883.50R - -8584 CONNECTOR BAR - IMPLANT
SUPPORTED
* - - - - - 3 965.40R - -
8585 CONNECTOR BAR - - - - - 3 965.40R - -8586 STRESS BREAKER - - - - - 1 479.00R - -8587 COPING METAL 219.60R - - - - 410.30R - -8590 IMPLANT MAINTENANCE
PROCEDURES - PER IMPLANT
121.10R - - - - 181.70R - -
8592 CROWN - IMPLANT/ABUTMENT
SUPPORTED
* 2 185.40R - - - - 2 891.30R - -
8594 REPAIR OF IMPLANT SUPPORTED
PROSTHESIS
134.40R - - - - 201.40R - -
8595 REPAIR OF IMPLANT ABUTMENT 134.40R - - - - 201.40R - -8597 LOCKS AND MILLED RESTS 134.40R - - - - 201.40R - -8599 PRECISION ATTACHMENT
(REMOVABLE DENTURE)
327.30R - - - - 491.10R - -
8600 COST OF IMPLANT COMPONENTS * - - - - - - - -
8611 PONTIC - SANITARY * - - - - - 1 498.70R - -8613 PONTIC - POSTERIOR * - - - - - 1 833.50R - -8615 PONTIC - ANTERIOR/PREMOLAR * - - - - - 1 980.90R - -8617 RETAINER CAST METAL
(MARYLAND TYPE RETAINER)
* 654.90R - - - - 1 280.90R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8631 ROOT CANAL THERAPY - FIRST
CANAL SPECIALIST
PROSTHODONTIST
- - - - - 1 738.00R - -
8633 ROOT CANAL THERAPY - EACH
ADDITIONAL CANAL SPECIALIST
PROSTHODONTIST
- - - - - 437.10R - -
8635 APEXIFICATION/APEXOGENESIS/RE
CALCIFICATION – PER VISIT
196.00R 196.00R - 196.00R - 260.70R - -
8640 REMOVAL OF FRACTURED ROOT
CANAL INSTRUMENT
* 511.00R - - - - 511.10R - -
8643 COMPLETE DENTURES - MAXILLARY
AND MANDIBULAR. ONLY FOR
PROSTHODONTISTS
* - - - - - 6 444.60R - -
8645 COMPLETE DENTURES - MAXILLARY
OR MANDIBULAR. ONLY FOR
PROSTHODONTISTS
* - - - - - 7 927.20R - -
8649 IMMEDIATE DENTURE -
MAXILLARY. ONLY FOR
PROSTHODONTIST
* - - - - - 3 965.40R - -
8651 IMMEDIATE DENTURE -
MANDIBULAR. ONLY FOR
PROSTHODONTIST
* - - - - - 4 460.10R - -
8652 OVERDENTURE - COMPLETE * 2 643.50R - - - - 3 965.40R - -8653 OVERDENTURE - PARTIAL * 2 114.80R - - - - 3 172.30R - -8654 IMPLANT SUPPORTED FIXED-
DETACHABLE COMPLETE
OVERDENTURE
* 2 973.40R - - - - 4 460.10R - -
8655 IMPLANT SUPPORTED FIXED-
DETACHABLE PARTIAL
OVERDENTURE
* 2 378.60R - - - - 3 056.30R - -
8657 REPLACEMENT OF PRECISION
ATTACHMENT
187.10R - - - - 201.40R - -
8658 INTERIM COMPLETE DENTURE 1 466.20R - - - - 2 199.50R - -8659 INTERIM PARTIAL DENTURE 1 172.90R - - - - 1 759.50R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8660 ADDITIONAL FEE TO IMPLANT
SUPPORTED FIXED-DETACHABLE
DENTURE - PER IMPLANT
410.30R - - - - 410.30R - -
8661 DIAGNOSTIC DENTURES
(INCLUDING TISSUE
CONDITIONING)
- - - - - - - -
8662 ADJUST COMPLETE OR PARTIAL
DENTURES (REMOUNTING)
381.60R - - - - 572.30R - -
8663 METAL BASE TO COMPLETE
DENTURE
796.50R - - - - 1 194.70R - -
8664 REMOUNT CROWN OR BRIDGE FOR
ADJUSTMENT
381.60R - - - - 597.90R - -
8667 SOFT BASE TO DENTURE (HEAT
CURED)
796.50R - - - - 1 194.70R - -
8671 PARTIAL DENTURE - CAST METAL
FRAMEWORK WITH RESIN
DENTURE BASE
* - - - - - 3 965.40R - -
8672 ALTERED CAST TECHNIQUE (IN
ADDITION TO PARTIAL DENTURE)
102.10R - - 102.10R - 153.00R - -
8674 ADDITIVE PARTIAL DENTURE 1 199.50R - - - - 1 799.20R - -8701 CONSULTATION - PERIODONTIST - - - 305.90R - - - -8703 CONSULTATION - PERIODONTIST
(DETAILED)
- - - 800.60R - - - -
8705 RE-EXAMINATION - PERIODONTIST - - - 239.30R - - - -
8707 PERIODONTAL SCREENING -
PERIODONTIST
- - - 239.30R - - - -
8723 PROVISIONAL SPLINTING -
EXTRACORONAL (WIRE) - PER
SEXTANT
273.60R 273.60R - 410.30R - 410.30R - 273.60R
8725 PROVISIONAL SPLINTING -
EXTRACORONAL (WIRE PLUS
RESIN) - PER SEXTANT
397.00R 397.00R - 595.60R - 595.60R - 397.00R
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8727 PROVISIONAL SPLINTING -
INTRACORONAL - PER TOOTH
124.60R 124.60R - 187.10R - 187.10R - -
8731 INCISION & DRAINAGE OF ABSCESS -
INTRA-ORAL
* 235.20R 235.20R - 352.70R - - - -
8737 ROOT PLANING - FOUR OR MORE
TEETH PER QUADRANT
* 590.20R - - 800.60R - 590.20R - 383.60R
8739 ROOT PLANING - ONE TO THREE
TEETH PER QUADRANT
* 469.60R - - 638.80R - 469.50R - 341.90R
8741 GINGIVECTOMY/GINGIVOPLASTY -
FOUR OR MORE TEETH PER
QUADRANT
770.10R - - 1 056.20R - - - -
8743 GINGIVECTOMY OR
GINGIVOPLASTY - ONE TO THREE
TEETH PER QUADRANT
615.30R - - 838.40R - - - -
8749 FLAP PROCEDURE, ROOT PLANING
AND ONE TO THREE SURGICAL
SERVICES - PER QUADRANT
1 598.80R - - 2 398.30R - - - -
8751 FLAP PROCEDURE, ROOT PLANING
AND ONE TO THREE SURGICAL
SERVICES - PER SEXTANT
1 324.20R - - 1 986.30R - - - -
8753 FLAP PROCEDURE, ROOT PLANING
AND FOUR OR MORE SURGICAL
SERVICES - PER QUADRANT
1 981.70R - - 2 972.40R - - - -
8755 FLAP PROCEDURE, ROOT PLANING
AND FOUR OR MORE SURGICAL
SERVICES - PER SEXTANT
1 606.00R - - 2 409.10R - - - -
8756 CLINICAL CROWN LENGTHENING
(ISOLATED PROCEDURE)
* 973.80R - - 1 460.90R - - - -
8759 PEDICLE FLAPPED GRAFT
(ISOLATED PROCEDURE)
731.70R - - 1 097.40R - - - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8761 MASTICATORY MUCOSAL
AUTOGRAFT - ONE TO FOUR TEETH
(ISOLATED PROCEDURE)
795.20R 1 192.90R - 1 192.90R - - - -
8762 MASTICATORY MUCOSAL
AUTOGRAFT - FOUR OR MORE
TEETH (ISOLATED PROCEDURE)
1 194.70R 1 792.00R - 1 792.00R - - - -
8763 WEDGE RESECTION (ISOLATED
PROCEDURE)
* 467.80R 467.80R - 701.80R - - - -
8765 HEMISECTION OF A TOOTH,
RESECTION OF A ROOT OR TUNNEL
PREPARATION (ISOLATED
PROCEDURE)
642.90R - - 964.40R - 964.40R - -
8766 BONE REGENERATION/REPAIR
PROCEDURE - AS PART OF A FLAP
OPERATION
382.60R - - 574.10R - - - -
8767 BONE REGENERATION/REPAIR
PROCEDURE - AT A SINGLE SITE
992.00R 1 488.00R - 1 488.00R - - - -
8768 UNLISTED PERIODONTAL
PROCEDURE
467.80R - - 701.80R - - - -
8769 MEMBRANE REMOVAL (USED FOR
GUIDED TISSUE REGENERATION)
467.80R 701.80R - 701.80R - - - -
8770 COST OF BONE
REGENERATIVE/REPAIR MATERIAL
- - - - - - - -
8772 SUBMUCOSAL CONNECTIVE TISSUE
AUTOGRAFT (ISOLATED
PROCEDURE)
803.60R 1 205.40R - 1 205.40R - - - -
8773 COST OF INTRAPOCKET
CHEMOTHERAPEUTIC AGENT
- - - - - - - -
8781 CONSULTATION - ORAL MEDICINE
(SIMPLE)
- - - - - - - -
8782 CONSULTATION - ORAL MEDICINE
(COMPLEX)
- - - - - - - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8783 CONSULTATION - ORAL MEDICINE
(SUBSEQUENT)
- - - - - - - -
8787 UNLISTED ORAL MEDICINE
PROCEDURE
167.90R - - 251.80R - - - -
8801 CONSULTATION - ORTHODONTIST - - 305.90R - - - - -
8803 CONSULTATION - ORTHODONTIS
(SUBSEQUENT, RETENTION AND
POST TREATMENT)
- - 178.10R - - - - -
8811 TRACING AND ANALYSIS OF EXTRA-
ORAL FILM
45.10R 45.10R 45.10R 45.10R - 45.10R - -
8837 DIAGNOSIS AND TREATMENT
PLANNING - ORTHODONTIST
- - 142.00R - - - - -
8839 DIAGNOSTIC SETUP 200.40R 200.40R 300.50R - - - - -8840 TREATMENT PLANNING FOR
ORTHOGNATHIC SURGERY - ALL
690.80R 1 036.30R 1 036.30R - - - - -
8841 ORTHO TX - FIXED LINGUAL
APPLIANCE - ONE ARCH
* - - - - - - - -
8842 ORTHO TX - FIXED LINGUAL
APPLIANCE - ONE ARCH, MODEATE
* - - - - - - - -
8843 ORTHO TX - FIXED LINGUAL
APPLIANCE - ONE ARCH, SEVERE
* - - - - - - - -
8846 REPAIR ORTHODONTIC APPLIANCE -
REMOVABLE
135.40R - 203.20R - - - - -
8847 REPLACE ORTHODONTIC
APPLIANCE - REMOVABLE
467.80R - 701.80R - - - - -
8848 REPAIR ORTHODONTIC APPLIANCE -
FIXED
200.40R - 300.50R - - - - -
8849 RETAINER (ORTHODONTIC) 467.80R - 701.80R - - - - -8850 TREATMENT OF MPDS - FIRST VISIT 225.50R 225.50R 338.30R 225.50R - 338.30R - -
8851 TREATMENT OF MPDS -
SUBSEQUENT VISIT
118.70R 118.70R 178.10R 118.70R - 178.10R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8852 OCCLUSAL ORTHOTIC APPLIANCE 566.60R 746.60R 746.60R 746.60R - 746.60R - -
8855 CONSULTATION - CLEFT PALATE
THERAPY (HOUSE OR HOSPITAL)
273.60R - 410.30R - - 410.30R - -
8856 CONSULTATION - CLEFT PALATE
(SUBSEQUENT)
134.40R - 201.40R - - 201.40R - -
8857 CONSULTATION - CLEFT PALATE
(MAXIMUM)
934.40R - 1 401.50R - - 1 401.50R - -
8858 ORTHO TX - FUNCTIONAL
APPLIANCE
* - - - - - - - -
8861 ORTHO TX - PARTIAL FIXED
APPLIANCE - MINOR
* - - - - - - - -
8862 ORTHO TX - REMOVABLE
APPLIANCE
* - - - - - - - -
8863 ORTHO TX - EACH ADDITIONAL
REMOVABLE APPLIANCE
* - - - - - - - -
8865 ORTHO TX - PARTIAL FIXED
APPLIANCE - ONE ARCH
* - - - - - - - -
8866 ORTHO TX - PARTIAL FIXED
APPLIANCE - BOTH ARCHES
* - - - - - - - -
8867 ORTHO TX - FIXED APPLIANCE -
ONE ARCH
* - - - - - - - -
8868 ORTHO TX - FIXED APPLIANCE -
ONE ARCH, MODEATE
* - - - - - - - -
8869 ORTHO TX - FIXED APPLIANCE -
ONE ARCH, SEVERE
* - - - - - - - -
8873 ORTHO TX - FIXED APPLIANCE -
BOTH ARCHES, CLASS 1 MILD
* - - - - - - - -
8874 ORTHO TX - FIXED LINGUAL
APPLIANCE - BOTH ARCHES, CLASS
1 MILD
* - - - - - - - -
8875 ORTHO TX - FIXED APPLIANCE -
BOTH ARCHES, CLASS 1 MODERATE
* - - - - - - - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8876 ORTHO TX - FIXED LINGUAL
APPLIANCE - BOTH ARCHES, CLASS
1 MODERATE
* - - - - - - - -
8877 ORTHO TX - FIXED APPLIANCE -
BOTH ARCHES, CLASS 1 SEVERE
* - - - - - - - -
8878 ORTHO TX - FIXED LINGUAL
APPLIANCE - BOTH ARCHES, CLASS
1 SEVERE
* - - - - - - - -
8879 ORTHO TX - FIXED APPLIANCE -
BOTH ARCHES, CLASS 1 SEVERE W/
COMPLICATIONS
* - - - - - - - -
8880 ORTHO TX - FIXED LINGUAL
APPLIANCE - BOTH ARCHES, CLASS
1 SEVERE W/ COMPLICATIONS
* - - - - - - - -
8881 ORTHO TX - FIXED APPLIANCE -
BOTH ARCHES, CLASS 2/3 MILD
* - - - - - - - -
8882 ORTHO TX - FIXED LINGUAL
APPLIANCE - BOTH ARCHES, CLASS
2/3 MILD
* - - - - - - - -
8883 ORTHO TX - FIXED APPLIANCE -
BOTH ARCHES, CLASS 2/3
MODERATE
* - - - - - - - -
8884 ORTHO TX - FIXED LINGUAL
APPLIANCE - BOTH ARCHES, CLASS
2/3 MODERATE
* - - - - - - - -
8885 ORTHO TX - FIXED APPLIANCE -
BOTH ARCHES, CLASS 2/3 SEVERE
* - - - - - - - -
8886 ORTHO TX - FIXED LINGUAL
APPLIANCE - BOTH ARCHES, CLASS
2/3 SEVERE
* - - - - - - - -
8887 ORTHO TX - FIXED APPLIANCE -
BOTH ARCHES, CLASS 2/3 SEVERE
W/ COMPLICATIONS
* - - - - - - - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8888 ORTHO TX - FIXED LINGUAL
APPLIANCE - BOTH ARCHES, CLASS
2/3 SEVERE W/ COMPLICATIONS
* - - - - - - - -
8890 MONTHLY INSTALMENT ORTHO TX * - - - - - - - -
8891 ORTHODONTIC TRANSFER * - - - - - - - -8892 ORTHODONTIC RE-TREATMENT * - - - - - - - -8901 CONSULTATION - MFOS - 305.90R - - - - - -8902 CONSULTATION - MFOS (DETAILED) - 800.60R - - - - - -
8903 HOUSE/HOSP/NURSING HOME
CONSULTATION - MFOS
- 268.00R - - - - - -
8904 HOUSE/HOSP/NURSING HOME
CONSULTATION (SUBSEQUENT) -
MFOS
- 178.10R - - - - - -
8905 AFTER REGULARLY HOURS
CONSULTATION - MFOS
- 392.40R - - - - - -
8907 HOUSE/HOSP/NURSING HOME
CONSULTATION (MAXIMUM PER
WEEK) - MFOS
- 446.10R - - - - - -
8908 SURGICAL REMOVAL OF ROOTS
FROM MAXILLARY ANTRUM
1 947.90R 2 922.00R - - - - - -
8909 ORAL ANTRAL FISTULA CLOSURE 1 493.40R 2 239.90R - - - - - -8911 CALDWELL-LUC PROCEDURE 584.30R 876.30R - - - - - -8917 BIOPSY OF ORAL TISSUE - SOFT 372.40R 496.50R - 496.50R - - - -8919 BIOPSY OF BONE - NEEDLE * 573.30R 859.90R - - - - - -8921 BIOPSY – EXTRA-ORAL BONE/SOFT
TISSUE
* 938.00R 1 406.80R - - - - - -
8931 TREATMENT OF POST-EXTRACTION
HAEMORRHAGE
108.00R 647.80R - 108.00R - 108.00R 91.20R -
8933 TREATMENT OF HAEMORRHAGE
(BLOOD DYSCRACIAS)
1 493.40R 2 239.90R - 1 493.40R - 1 493.40R - -
8935 TREATMENT OF SEPTIC SOCKET 108.00R 169.20R - 108.00R - 108.00R 91.20R -8937 SURGICAL REMOVAL OF TOOTH 637.00R 859.90R - 637.00R - - - -
Trf
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*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8941 SURGICAL REMOVAL OF IMPACTED
TOOTH - FIRST TOOTH
1 056.20R 1 388.90R - 1 056.20R - - - -
8943 SURGICAL REMOVAL OF IMPACTED
TOOTH - SECOND TOOTH
566.60R 748.30R - 566.60R - - - -
8945 SURGICAL REMOVAL OF IMPACTED
TOOTH - THIRD AND SUBSEQUENT
TEETH
322.00R 424.60R - 322.00R - - - -
8953 SURGICAL REMOVAL OF RESIDUAL
ROOTS, FIRST TOOTH - PER TOOTH
* 637.00R 859.90R - 860.00R - - - -
8957 ALVEOLOTOMY OR
ALVEOLECTOMY (INCLUDING
EXTRACTIONS)
782.10R 1 173.20R - 782.10R - - - -
8958 EMERGENCY TRACHEOTOMY * - - - - - - - -8959 PHARYNGOSTOMY * - - - - - - - -8961 TOOTH TRANSPLANTATION 1 282.20R 1 923.30R - - - - - -8962 HARVEST ILIAC CREST GRAFT 472.70R 581.00R - - - - - -8963 HARVEST RIB GRAFT 542.30R 813.30R - - - - - -8964 HARVEST CRANIUM GRAFT 424.60R 637.00R - - - - - -8965 PERIPHERAL NEURECTOMY 1 282.20R 1 923.30R - - - - - -8966 REPAIR OF ORONASAL FISTULA
(LOCAL FLAPS)
* - - - - - - - -
8967 SURGICAL REMOVAL OF JAW CYST -
INTRA-ORAL APPROACH
1 781.30R 2 671.90R - - - - - -
8969 SURGICAL REMOVAL OF JAW CYST -
EXTRA-ORAL APPROACH
2 853.40R 4 280.20R - - - - - -
8971 EXCISION OF TUMOUR OF THE
SOFT TISSUE
573.30R 859.90R - 859.90R - - - -
8973 SURGICAL EXCISION OF TUMOURS
OF THE JAW
2 853.40R 4 280.20R - - - - - -
8975 HEMIRESECTION OF JAW
EXCLUDING CONDYL
* - - - - - - - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
8977 SURGICAL REPAIR OF MAXILLA OR
MANDIBLE - MAJOR
* 2 995.20R 4 492.60R - - - - - -
8979 HARVESTING OF AUTOGENOUS
GRAFTS (INTRA-ORAL)
247.00R 370.60R - 370.60R - - - -
8981 SURGICAL EXPOSURE OF IMPACTED
OR UNERUPTED TEETH TO AID
ERUPTION
1 176.80R 1 603.20R - 1 603.20R - - - -
8983 CORTICOTOMY - FIRST TOOTH 851.50R 1 277.40R - - - - - -8984 CORTICOTOMY - EACH ADDITIONAL
TOOTH
431.80R 647.80R - - - - - -
8985 FRENULECTOMY/FRENULOTOMY 782.10R 1 173.20R - 1 173.20R - - - -8987 REDUCTION OF MYLOHYOID
RIDGES - PER SIDE
1 282.20R 1 923.30R - - - - - -
8989 REMOVAL TORUS MANDIBULARIS 1 282.20R 1 923.30R - - - - - -
8991 REMOVAL OF TORUS PALATINUS 1 282.20R 1 923.30R - - - - - -8993 SURGICAL REDUCTION OF
OSSEOUS TUBEROSITY - PER SIDE
573.30R 859.90R - - - - - -
8995 GINGIVECTOMY - PER JAW 1 140.70R 1 711.20R - - - - - -8997 SULCOPLASTY / VESTIBULOPLASTY 2 939.90R 4 410.00R - 4 410.00R - - - -
9003 REPOSITION MENTAL FORAMEN
AND NERVE - PER SIDE
1 781.30R 2 671.90R - - - - - -
9004 LATERALIZATION OF INFERIOR
DENTAL NERVE
2 870.30R 4 305.50R - - - - - -
9005 ALVEOLAR RIDGE AUGMENTATION -
TOTAL (BY BONE GRAFT)
2 997.50R 4 496.20R - 4 496.20R - - - -
9007 ALVEOLAR RIDGE AUGMENTATION -
TOTAL (BY ALLOPLASTIC MATERIAL)
1 886.70R 2 830.10R - - - - - -
9008 ALVEOLAR RIDGE AUGMENTATION -
ONE TO TWO TOOTH SITES
583.30R 1 067.00R - 1 067.00R - - - -
Trf
CodeTariffDescription
*Pre-
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required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9009 ALVEOLAR RIDGE AUGMENTATION -
THREE ACROSS 3 OR MORE TOOTH
SITES
1 296.60R 1 944.80R - 1 944.80R - - - -
9010 SINUS LIFT PROCEDURE 1 947.90R 2 922.00R - 2 922.00R - - - -9011 INCISION & DRAINAGE OF ABSCESS -
INTRA-ORAL (PYOGENIC)
364.70R 546.90R - - - - 172.30R -
9013 INCISION & DRAINAGE OF ABSCESS -
EXTRA-ORAL (PYOGENIC)
* - - - - - - - -
9015 APICECTOMY/PERIRADICULAR
SURGERY - ANTERIORS (INCLUDING
RETROGRADE FILLING)
726.80R 964.40R - 964.40R - 964.40R - -
9016 APICECTOMY/PERIRADICULAR
SURGERY - MOLARS (INCLUDING
RETROGRADE FILLING)
1 282.20R 1 923.30R - 1 923.30R - 1 923.30R - -
9017 DECORTICATION, SAUCERISATION
AND SEQUESTRECTOMY
* - - - - - - - -
9019 SEQUESTRECTOMY - INTRA ORAL
PER SEXTANT AND OR RAMUS
573.30R 859.90R - - - - - -
9021 SUTURE - RECONSTRUCTION,
MINOR (EXCLUDES CLOSURE OF
SURGICAL INCISIONS)
726.80R 964.40R - - - - - -
9023 SUTURE - RECONSTRUCTION,
MAJOR (EXCLUDES CLOSURE OF
SURGICAL INCISIONS)
1 353.10R 2 029.50R - - - - - -
9024 DENTO-ALVEOLAR FRACTURE - PER
SEXTANT
642.90R 964.40R - - - - - -
9025 MANDIBLE FRACTURE - CLOSED
REDUCTION
* - - - - - - - -
Trf
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authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9027 MANDIBLE FRACTURE -
COMPOUND, WITH EYELET WIRING
* - - - - - - - -
9029 MANDIBLE FRACTURE - SPLINTS * - - - - - - - -9031 MANDIBLE FRACTURE - OPEN
REDUCTION
* - - - - - - - -
9032 REDUCTION OF MASSETER MUSCLE
AND BONE - EXTRA-ORAL
APPROACH
* - - - - - - - -
9033 OPEN TREATMENT OF CONDYLAR
FRACTURE
* - - - - - - - -
9035 MAXILLA FRACTURE - LE FORT I OR
GUERIN
* - - - - - - - -
9036 OPEN TREATMENT OF MAXILLARY
FRACTURE - LE FORT I
* - - - - - - - -
9037 MAXILLA FRACTURE - LE FORT II OR
MIDDLE THIRD FACE
* - - - - - - - -
9038 OPEN TREATMENT OF MAXILLARY
FRACTURE - LE FORT II MIDDLE
THIRD OF FACE
* - - - - - - - -
9039 MAXILLA FRACTURE - LE FORT III
OR CRANIOFACIAL DISJUNCTION
* - - - - - - - -
9041 ZYGOMATIC ARCH FRACTURE -
CLOSED REDUCTION
* - - - - - - - -
9043 ZYGOMATIC ARCH FRACTURE -
OPEN REDUCTION
* - - - - - - - -
9045 ZYGOMATIC ARCH FRACTURE -
OPEN REDUCTION (REQUIRING
OSTEOSYNTHESIS AND/OR
GRAFTING)
* - - - - - - - -
9046 PLACEMENT OF ZYGOMATICUS
FIXTURE, PER FIXTURE
* - - - - - - - -
9047 OSTEOTOMY - OPEN WITH
STABILISATION
* - - - - - - - -
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CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9048 SURGICAL REMOVAL OF INTERNAL
FIXATION DEVICES, PER SITE
* - - - - - - - -
9049 OSTEOTOMY - MANDIBLE BODY,
ANTERIOR SEGMENTAL
* - - - - - - - -
9050 OSTEOTOMY - TOTAL SUBAPICAL * - - - - - - - -9051 GENIOPLASTY * - - - - - - - -9052 MIDFACIAL EXPOSURE * - - - - - - - -9053 CORONOIDECTOMY (INTRA-ORAL
APPROACH)
* - - - - - - - -
9055 OSTEOTOMY - SEGMENTED,
POSTERIOR
* - - - - - - - -
9057 OSTEOTOMY - SEGMENTED,
ANTERIOR
* - - - - - - - -
9059 RECONSTRUCT MAXILLA - LE FORT I
OSTEOTOMY, ONE PIECE
* - - - - - - - -
9060 RECONSTRUCT MAXILLA - LE FORT I
OSTEOTOMY W/ REPOSITIONING
AND GRAFT
* - - - - - - - -
9061 PALATAL OSTEOTOMY * - - - - - - - -9062 RECONSTRUCT MAXILLA - LE FORT I
OSTEOTOMY, MULTIPLE
SEGMENTS
* - - - - - - - -
9063 RECONSTRUCT MAXILLA - LE FORT
2 OSTEOTOMY (FACIAL AND POST-
TRAUMATIC DEFORMITIES)
* - - - - - - - -
9065 RECONSTRUCT MAXILLA - LE FORT
3 OSTEOTOMY (SEVERE
CONGENITAL DEFORMITIES)
* - - - - - - - -
9066 SURGICAL EXPANSION -
MAXILLIARY OR MANDIBULAR
* - - - - - - - -
9067 DISTRACTION OSTEOGENESIS -
ACROSS ONE TO TWO TOOTH SITES
* - - - - - - - -
Trf
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*Pre-
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required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9068 DISTRACTION OSTEOGENESIS -
ACROSS THREE TO FIVE TOOTH
SITES
* - - - - - - - -
9069 GLOSSECTOMY - PARTIAL * - - - - - - - -9070 DISTRACTION OSTEOGENESIS -
FULL ARCH
* - - - - - - - -
9071 GENIOHYOIDOTOMY * - - - - - - - -9072 CLOSE SECONDARY ORO-NASAL
FISTULA W/ BONE GRAFTING
(COMPLETE PROCEDURE)
* - - - - - - - -
9074 TMJ ARTHROSCOPY DIAGNOSTIC * - - - - - - - -9075 CONDYLECTOMY,
CORONOIDECTOMY OR BOTH
* - - - - - - - -
9076 TMJ ARTROCENTESIS * - - - - - - - -9077 TMJ INTRA-ARTICULAR INJECTION * - - - - - - - -
9079 TRIGGER POINT INJECTION * - - - - - - - -9081 CONDYLECTOMY
(WARD/KOSTECKA)
* - - - - - - - -
9083 TMJ SRTHROPLASTY * - - - - - - - -9085 REDUCTION OF TMJ DISLOC W/O
ANAESTHETIC
* - - - - - - - -
9087 REDUCTION OF TMJ DISLOC W/
ANAESTHETIC
* - - - - - - - -
9089 REDUCTION OF TMJ DISLOC W/
ANAESTHETIC AND
IMMOBOBILISATION
* - - - - - - - -
9091 REDUCTION OF TMJ DISLOCATION -
OPEN REDUCTION
* - - - - - - - -
9092 JOINT RECONSTRUCTION * - - - - - - - -9093 REMOVAL OF SALIVARY STONE
(SIALOLITHOTOMY)
642.90R 964.40R - - - - - -
9095 EXCISION OF SUBLINGLUAL
SALIVARY GLAND
* - - - - - - - -
Trf
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*Pre-
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required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9096 EXCISION OF SALIVARY GLAND -
EXTRA ORAL APPROACH
* - - - - - - - -
9099 UNLISTED DENTAL PROCEDURE OR
SERVICE (BY REPORT)
* - - - - - - - -
9101 OBTURATOR PROSTHESIS,
SURGICAL - MODIFIED DENTURE
* - - - - - - - -
9102 OBTURATOR PROSTHESIS,
SURGICAL - CONTINUOUS BASE
* - - - - - - - -
9103 OBTURATOR PROSTHESIS,
SURGICAL - SPLIT BASE
* - - - - - - - -
9104 OBTURATOR PROSTHESIS, INTERIM
- ON EXISTING DENTURE
* - - - - - - - -
9105 OBTURATOR PROSTHESIS, INTERIM
- ON NEW DENTURE
* - - - - - - - -
9106 OBTURATOR PROSTHESIS,
DEFINITIVE - OPEN/HOLLOW BOX
* - - - - - - - -
9107 OBTURATOR PROSTHESIS,
DEFINITIVE - SILICONE GLOVE
* - - - - - - - -
9108 MANDIBULAR RESECTION
PROSTHESIS W/ GUIDE FLANGE
* - - - - - - - -
9109 MANDIBULAR RESECTION
PROSTHESIS W/O GUIDE FLANGE
* - - - - - - - -
9110 MANDIBULAR RESECTION
PROSTHESIS, PALATAL
AUGMENTATION
* - - - - - - - -
9111 GLOSSAL RESECTION PROSTHESIS -
SIMPLE
* - - - - - - - -
9112 GLOSSAL RESECTION PROSTHESIS -
COMPLEX
* - - - - - - - -
9113 RADIATION CARRIER - SIMPLE * - - - - - - - -9114 RADIATION CARRIER - COMPLEX * - - - - - - - -9115 RADIATION SHIELD - SIMPLE * - - - - - - - -
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*Pre-
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required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9116 RADIATION SHIELD - COMPLEX * - - - - - - - -9117 RADIATION CONE LOCATOR * - - - - - - - -9118 CHEMOTHERAPEUTIC AGENT
CARRIER
* - - - - - - - -
9119 FEEDING AID PROSTHESIS,
NEONATAL
* - - - - - - - -
9120 ORTHOPAEDIC APPLIANCE, ACTIVE
PRESURGICAL - MINOR
* - - - - - - - -
9121 ORTHOPAEDIC APPLIANCE, ACTIVE
PRESURGICAL - MODERATE
* - - - - - - - -
9122 ORTHOPAEDIC APPLIANCE, ACTIVE
PRESURGICAL - SEVERE
* - - - - - - - -
9123 ORTHOPAEDIC APPLIANCE, ACTIVE
PRESURGICAL - MODIFICATION
* - - - - - - - -
9125 SPEECH AID/OBTURATOR
PROSTHESIS - PALATAL
ALTERATION
* - - - - - - - -
9126 SPEECH AID/OBTURATOR
PROSTHESIS - VELAR ALTERATION
* - - - - - - - -
9127 SPEECH AID/OBTURATOR
PROSTHESIS - PHARYNGEAL
ALTERATION
* - - - - - - - -
9128 SPEECH AID/OBTURATOR
PROSTHESIS - MODIFICATION
* - - - - - - - -
9129 SPEECH AID/OBTURATOR
PROSTHESIS - SURGICAL
* - - - - - - - -
9130 SPEECH AID APPLIANCE - PALATAL
LIFT
* - - - - - - - -
9131 SPEECH AID APPLIANCE - PALATAL
STIMULATING
* - - - - - - - -
9132 SPEECH AID APPLIANCE - BULB * - - - - - - - -
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required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9133 SPEECH AID APPLIANCE -
MODIFICATION
* - - - - - - - -
9134 UNSPECIFIED SPEECH AID
APPLIANCE
* - - - - - - - -
9135 AURICULAR PROSTHESIS - SIMPLE * - - - - - - - -
9136 AURICULAR PROSTHESIS -
COMPLEX
* - - - - - - - -
9137 NASAL PROSTHESIS - SIMPLE * - - - - - - - -9138 NASAL PROSTHESIS - COMPLEX * - - - - - - - -9139 OCULAR PROSTHESIS - INTERIM * - - - - - - - -9140 OCULAR PROSTHESIS - MODIFIED
STOCK APPLIANCE
* - - - - - - - -
9141 OCULAR PROSTHESIS - CUSTOM
APPLIANCE
* - - - - - - - -
9142 ORBITAL PROSTHESIS - SIMPLE * - - - - - - - -9143 ORBITAL PROSTHESIS - COMPLEX * - - - - - - - -
9148 UNSPECIFIED BODY PROSTHESIS -
SIMPLE
* - - - - - - - -
9149 UNSPECIFIED BODY PROSTHESIS -
COMPLEX
* - - - - - - - -
9150 FACIAL PROSTHESIS, SURGICAL -
SIMPLE
* - - - - - - - -
9151 FACIAL PROSTHESIS, SURGICAL -
COMPLEX
* - - - - - - - -
9155 CRANIAL PROSTHESIS * - - - - - - - -9156 CRANIAL IMPLANT PROSTHESIS,
CUSTOM MADE
* - - - - - - - -
9157 FACIAL IMPLANT PROSTHESIS,
CUSTOM MADE - SIMPLE
* - - - - - - - -
9158 FACIAL IMPLANT PROSTHESIS,
CUSTOM MADE - COMPLEX
* - - - - - - - -
9159 OCULAR IMPLANT PROSTHESIS,
CUSTOM MADE
* - - - - - - - -
Trf
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*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9160 BODY IMPLANT PROSTHESIS -
CUSTOM MADE
* - - - - - - - -
9161 SURGICAL SPLINT - SIMPLE * - - - - - - - -9162 SURGICAL SPLINT - COMPLEX * - - - - - - - -9163 SURGICAL TEMPLATE - SIMPLE * - - - - - - - -9164 SURGICAL TEMPLATE - COMPLEX * - - - - - - - -9165 SURGICAL CONFORMER - SIMPLE * - - - - - - - -
9166 SURGICAL CONFORMER - COMPLEX * - - - - - - - -
9167 TRISMUS APPLIANCE (SIMPLE) * - - - - - - - -9168 TRISMUS APPLIANCE (COMPLEX) * - - - - - - - -9169 ORTHOSES APPLIANCE * - - - - - - - -9170 FACIAL PALSY APPLIANCE * - - - - - - - -9171 COMMISSURE SPLINT * - - - - - - - -9172 ORAL RETRACTOR, DYNAMIC - PER
ARM
* - - - - - - - -
9174 UNSPECIFIED BURN APPLIANCE - - - - - - - -9175 THEATRE ATTENDANCE (MAXFAC
PROSTHOD) /HOUR
- - - - - - - -
9180 SURGICAL PLACEMENT OF SUB-
PERIOSTEAL IMPLANT -
PREPARATORY STAGE
* - - - - - - - -
9181 SURGICAL PLACEMENT OF SUB-
PERIOSTEAL IMPLANT -
PLACEMENT STAGE
* - - - - - - - -
9182 SURGICAL PLACEMENT OF
ENDOSTEAL IMPLANT PLATE
* - - - - - - - -
9183 SURGICAL PLACEMENT OF
ENDOSSEUS IMPLANT - FIRST PER
QUADRANT
* - - - - - - - -
9184 SURGICAL PLACEMENT OF
ENDOSSEUS IMPLANT - SECOND
PER QUADRANT
* - - - - - - - -
Trf
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*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9185 SURGICAL PLACEMENT OF
ENDOSSEUS IMPLANT - THIRD AND
SUBSEQUENT PER QUADRANT
* - - - - - - - -
9187 COST OF ENDOSTEAL IMPLANT
BODY
* - - - - - - - -
9188 COST OF PREFABRICATED
ABUTMENT
* - - - - - - - -
9189 COST OF OTHER IMPLANT
COMPNTS
* - - - - - - - -
9190 SURGICAL EXPOSURE OF
ENDOSSEUS IMPLANT - FIRST PER
QUADRANT
* - - - - - - - -
9191 SURGICAL EXPOSURE OF
ENDOSSEUS IMPLANT - SECOND
PER QUADRANT
* - - - - - - - -
9192 SURGICAL EXPOSURE OF
ENDOSSEUS IMPLANT - THIRD AND
SUBSEQUENT PER QUADRANT
* - - - - - - - -
9198 SURGICAL REMOVAL OF IMPLANT * - - - - - - - -
9201 CONSULTATION - ORAL
PATHOLOGIST
- - - - - - - -
9203 HOUSE/HOSP/NURSING HOME
CONSULTATION - ORAL
PATHOLOGIST
- - - - - - - -
9205 CONSULTATION - ORAL
PATHOLOGIST (SUBSEQUENT)
- - - - - - - -
9207 AFTER HOURS VISIT - ORAL
PATHOLOGIST
- - - - - - - -
9220 REPAIR CLEFT HARD PALATE -
UNILATERAL
* - - - - - - - -
9222 REPAIR CLEFT HARD PALATE -
BILATERAL (ONE PROCEDURE)
* - - - - - - - -
Trf
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General
Dental
Practice (54)
Maxillo-Facial &
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(62)
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(64)
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(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9224 REPAIR CLEFT HARD PALATE -
BILATERAL (TWO PROCEDURES)
* - - - - - - - -
9226 REPAIR CLEFT SOFT PALATE - W/O
MUSCLE RECONSTRUCTION
* - - - - - - - -
9228 REPAIR CLEFT SOFT PALATE - W/
MUSCLE RECONSTRUCTION
* - - - - - - - -
9230 REPAIR SUBMUCOSAL CLEFT
AND/OR BIFID UVULA - W/ MUSCLE
RECONSTRUCTION
* - - - - - - - -
9232 VELOPHARYNGEAL
RECONSTRUCTION -
UNCOMPLICATED
* - - - - - - - -
9234 VELOPHARYNGEAL
RECONSTRUCTION - COMPLICATED
* - - - - - - - -
9238 REPAIR ORONASAL FISTULA (ONE
PROCEDURE)
* - - - - - - - -
9240 REPAIR ORONASAL FISTULA (TWO
PROCEDURES)
* - - - - - - - -
9246 SECONDARY PERIOSTEAL FLAPS * - - - - - - - -9248 LIPADHESION * - - - - - - - -9250 REPAIR CLEFT LIP - UNILATERAL
W/O MUSCLE RECONSTRUCTION
* - - - - - - - -
9252 REPAIR CLEFT LIP - UNILATERAL W/
MUSCLE RECONSTRUCTION
* - - - - - - - -
9254 REPAIR CLEFT LIP - BILATERAL W/O
MUSCLE RECONSTRUCTION
* - - - - - - - -
9256 REPAIR CLEFT LIP - BILATERAL W/
MUSCLE RECONSTRUCTION
* - - - - - - - -
9258 REPAIR ANTERIOR NASAL FLOOR * - - - - - - - -9260 REVISION OF SECONDARY CLEFT LIP
DEFORMITY - PARTIAL
* - - - - - - - -
9262 REVISION OF SECONDARY CLEFT LIP
DEFORMITY - TOTAL W/ MUSCLE
RECONSTRUCTION
* - - - - - - - -
Trf
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(92)
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Technicians
(93)
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(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9264 ABBE-FLAP - TWO STAGES * - - - - - - - -9266 RECONSTRUCT COLUMELLA * - - - - - - - -9268 RECONSTRUCT NOSE DUE TO CLEFT
DEFORMITY - PARTIAL
* - - - - - - - -
9270 RECONSTRUCT NOSE DUE TO CLEFT
DEFORMITY - COMPLETE
* - - - - - - - -
9272 PARANASAL AUGMENTATION FOR
NASAL BASE DEVIATION
* - - - - - - - -
9274 REPAIR ANTERIOR TABLE, FRONTAL
SINUS AND/OR SUPRAORBITAL RIM
* - - - - - - - -
9276 REPAIR ANTERIOR AND POSTERIOR
WALL W/ OBTURATION AND/OR
CRANIALISATION OF FRONTAL
SINUS
* - - - - - - - -
9278 REPAIR MEDIAL CANTHAL
LIGAMENT (CANTHOPEXY), PER
SIDE
* - - - - - - - -
9280 OPEN REDUCTION AND FIXATION
OF NASAL FRACTURES
* - - - - - - - -
9282 MANIPULATION AND
IMMOBILISATION OF NASAL
FRACTURE
* - - - - - - - -
9284 MUSCULOFASCIAL FLAP * - - - - - - - -9286 MUSCULOCRANIAL FLAP * - - - - - - - -9288 BUCCAL FAT PAD (MAJOR REPAIR) * - - - - - - - -
9290 MAXILLECTOMY - ALVEOLUS ONLY,
LEVEL I
* - - - - - - - -
9292 MAXILLECTOMY - ALVEOLUS AND
SINUS OR NASAL FLOOR, LEVEL II
* - - - - - - - -
Trf
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General
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Practice (54)
Maxillo-Facial &
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(62)
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(64)
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(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9294 MAXILLECTOMY - ALVEOLUS,
SINUS, NASAL FLOOR AND
ZYGOMA EXCLUDING ORBITAL RIM
LEVEL III
* - - - - - - - -
9296 MAXILLECTOMY - ALVEOLUS,
SINUS, NASAL FLOOR AND
ZYGOMA INCLUDING ORBITAL RIM
LEVEL IV
* - - - - - - - -
9298 MAXILLECTOMY - ALVEOLUS,
SINUS, NASAL FLOOR, ZYGOMA,
ORBITAL RIM AND PTERYGOID
PLATES LEVEL V
* - - - - - - - -
9300 HEMIRESECTION OF JAW
INCLUDING CONDYLE AND
CORONOID PROCESS
* - - - - - - - -
9301 CASTING AND TRIMMING OF
MODEL IN PLASTER
(YELLOW/WHITE), PER MODEL
42.00R 42.00R 42.00R 42.00R 42.00R 42.00R - -
9303 CASTING AND TRIMMING OF
MODEL IN SUPER-HARD STONE
(DIE-STONE) PER MODEL
59.70R 59.70R 59.70R 59.70R 59.70R 59.70R - -
9305 CASTING AND TRIMMING OF
STUDY MODEL, PER MODEL
110.50R 110.50R 110.50R 110.50R 110.50R 110.50R - -
9307 CASTING AND TRIMMING OF
GNATHOSTATIC MODEL, PER
MODEL.
143.70R 143.70R 143.70R 143.70R 143.70R 143.70R - -
9309 NEW TRIMMED BASE TO SUPPLIED
MODEL, PER MODEL
50.80R 50.80R 50.80R 50.80R 50.80R 50.80R - -
9311 TRIMMING OF SUPPLIED MODEL,
PER MODEL
30.90R 30.90R 30.90R 30.90R 30.90R 30.90R - -
9312 GINGIVAL TISSUE MASK PER
IMPLANT
238.70R 238.70R 238.70R 238.70R 238.70R 238.70R - -
9313 DUPLICATING MODEL, PER MODEL 128.20R 128.20R 128.20R 128.20R 128.20R 128.20R - -
9314 REFRACTORY MODEL, PER UNIT 126.00R 126.00R 126.00R 126.00R 126.00R 126.00R - -
Trf
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General
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Practice (54)
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Oral Surgery
(62)
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(64)
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(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9315 MODELS AND DUPLICATE MODELS
(VIRGIN MODEL) FOR CROWN AND
BRIDGE, WORK INCLUSIVE OF ONE
REMOVABLE DIE
174.60R - - 174.60R 174.60R 174.60R - -
9317 SECTIONAL MODELS FOR CROWN
AND BRIDGE, WORK INCLUSIVE OF
ONE REMOVABLE DIE
154.70R - - - 154.70R 154.70R - -
9319 EACH ADDITIONAL REMOVABLE DIE
FOR ITEMS 9315 AND 9317 PER DIE
39.80R - - 39.80R 39.80R 39.80R - -
9320 INDEXED OR MODEL TRAY PER DIE
(NOT MORE THAN 9319)
39.80R - - - 39.80R 39.80R - -
9321 OCCLUSION BLOCK, PER BLOCK 152.50R 152.50R - - 152.50R 152.50R - -9323 OCCLUSION BLOCK ON BASEPLATE,
PER BLOCK
192.30R - - - 192.30R 192.30R - -
9327 INFECTION CONTROL PER
IMPRESSION, DENTURE (WAX OR
ACRYLIC) OR ANY ITEM IN
CONTACT WITH BODY FLUIDS
28.70R 28.70R 28.70R 28.70R 28.70R 28.70R - -
9329 FIT AND SUPPLY OF DISPOSABLE
ARTICULATOR
75.20R - 75.20R - 75.20R 75.20R - -
9330 DELIVERY / COLLECTION FEE PER
COMPLETED PROCEDURE
(MAXIMUM 4)
- - - - - - - -
9331 FULL UPPER AND LOWER
DENTURES
* 2 051.40R 2 051.40R - - 2 051.40R 2 051.40R - -
9333 FULL UPPER OR LOWER DENTURE * 1 200.30R - - - 1 200.30R 1 200.30R - -
9335 SET-UP AND WAXING OF FULL
UPPER AND LOWER DENTURES
707.40R - - - 707.40R 707.40R - -
9337 SET-UP AND WAXING OF FULL
UPPER OR LOWER DENTURE
* 473.10R - - - 473.10R 473.10R - -
Trf
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General
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Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9339 WAXING AND FINISHING OF FULL
UPPER AND LOWER DENTURES
1 257.80R - - - 1 257.80R 1 257.80R - -
9341 WAXING AND FINISHING OF FULL
UPPER OR LOWER DENTURE
* 703.00R - - - 703.00R 703.00R - -
9343 ADDITIONAL FEE FOR DENTURES
ON FULLY ADJUSTABLE
ARTICULATOR AT REQUEST OF
DENTIST
2 002.80R - - - 2 002.80R 2 002.80R - -
9345 ADDITIONAL FEE FOR IMMEDIATE
DENTURES, OR TOOTH SOCKETED
28.70R - - - 28.70R 28.70R - -
9346 ADDITIONAL FEE FOR IMMEDIATE
DENTURES, PER TOOTH NOT
SOCKETED.
15.50R - - 15.50R 15.50R 15.50R - -
9347 ADDITIONAL FEE FOR EACH RETRY
FROM THE THIRD AND UPWARDS
AT AN AGREED QUANTUM OF TIME
TO BE CALCULATED AT HOURLY
RATE
455.40R - - - 455.40R 455.40R - -
9351 SET-UP AND FINISH OF ONE-TOOTH
DENTURE
* 550.40R - - 550.40R 550.40R 550.40R - -
9352 SET-UP AND FINISH OF TWO-
TOOTH DENTURE
* 585.80R - - 585.80R 585.80R 585.80R - -
9353 SET-UP AND FINISH OF THREE-
TOOTH DENTURE
* 627.80R - - 627.80R 627.80R 627.80R - -
9354 SET-UP AND FINISH OF FOUR-
TOOTH DENTURE
* 663.20R - - 663.20R 663.20R 663.20R - -
9355 SET-UP AND FINISH OF FIVE-TOOTH
DENTURE
* 716.20R - - 716.20R 716.20R 716.20R - -
9356 SET-UP AND FINISH OF SIX-TOOTH
DENTURE
* 855.50R - - 855.50R 855.50R 855.50R - -
9357 SET-UP AND FINISH OF SEVEN-
TOOTH DENTURE
* 1 016.90R - - 1 016.90R 1 016.90R 1 016.90R - -
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(64)
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(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9358 SET-UP AND FINISH OF EIGHT-
TOOTH DENTURE
* 1 078.80R - - 1 078.80R 1 078.80R 1 078.80R - -
9359 SET-UP AND FINISH NINE OR MORE
TOOTH DENTURE
* 1 105.30R - - 1 105.30R 1 105.30R 1 105.30R - -
9361 SET-UP AND WAXING OF ONE-
TOOTH DENTURE
* 157.00R - - 157.00R 157.00R 157.00R - -
9362 SET-UP AND WAXING OF TWO-
TOOTH DENTURE
* 190.10R - - 190.10R 190.10R 190.10R - -
9363 SET-UP AND WAXING OF THREE-
TOOTH DENTURE
* 216.60R - - 216.60R 216.60R 216.60R - -
9364 SET-UP AND WAXING OF FOUR-
TOOTH DENTURE
* 252.00R - - 252.00R 252.00R 252.00R - -
9365 SET-UP AND WAXING OF FIVE-
TOOTH DENTURE
* 278.50R - - 278.50R 278.50R 278.50R - -
9366 SET-UP AND WAXING OF SIX-
TOOTH DENTURE
* 329.40R - - 329.40R 329.40R 329.40R - -
9367 SET-UP AND WAXING OF SEVEN-
TOOTH DENTURE
* 362.50R - - 362.50R 362.50R 362.50R - -
9368 SET-UP AND WAXING OF EIGHT-
TOOTH DENTURE
* 389.10R - - 389.10R 389.10R 389.10R - -
9369 SET-UP AND WAXING OF NINE OR
MORE TOOTH DENTURE
* 415.60R - - 415.60R 415.60R 415.60R - -
9371 WAXING AND FINISHING OF ONE-
TOOTH DENTURE
* 431.10R - - 431.10R 431.10R 431.10R - -
9372 WAXING AND FINISHING OF TWO-
TOOTH DENTURE
* 439.90R - - 439.90R 439.90R 439.90R - -
9373 WAXING AND FINISHING OF THREE-
TOOTH DENTURE
* 446.50R - - 446.50R 446.50R 446.50R - -
9374 WAXING AND FINISHING OF FOUR-
TOOTH DENTURE
* 455.40R - - 455.40R 455.40R 455.40R - -
9375 WAXING AND FINISHING OF FIVE-
TOOTH DENTURE
* 473.10R - - 473.10R 473.10R 473.10R - -
9376 WAXING AND FINISHING OF SIX-
TOOTH DENTURE
* 490.70R - - 490.70R 490.70R 490.70R - -
Trf
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General
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(64)
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(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9377 WAXING AND FINISHING OF SEVEN-
TOOTH DENTURE
* 612.30R - - 612.30R 612.30R 612.30R - -
9378 WAXING AND FINISHING OF
EIGHTH-TOOTH DENTURE
* 636.60R - - 636.60R 636.60R 636.60R - -
9379 WAXING AND FINISHING OF NINE
OR MORE TOOTH DENTURE
* 672.00R - - 672.00R 672.00R 672.00R - -
9383 ADDITIONAL FEE FOR FINISHING
DENTURE IN TOOTH COLOUR
MATERIAL, PER TOOTH
106.10R - - 106.10R 106.10R 106.10R - -
9385 ADDITIONAL FEE FOR SUPPLYING
FINISHED DENTURE ON DUPLICATE
MODEL
201.20R - - 201.20R 201.20R 201.20R - -
9391 BASIC CHARGE WHICH INCLUDES
REPAIR OF ONE FRACTURE, OR
ADDITION OF ONE TOOTH, OR
ADDITION OF ONE CLASP
349.30R - 349.30R 349.30R 349.30R 349.30R - -
9393 ADDITIONAL CHARGE FOR EACH
ADDITIONAL FRACTURE, OR
TOOTH, OR CLASP
108.30R - 108.30R 108.30R 108.30R 108.30R - -
9395 ADDITIONAL FEE FOR USING WIRE
STRENGTHENER
123.80R - 123.80R 123.80R 123.80R 123.80R - -
9397 ADDITIONAL FEE FOR USING PRE-
FORMED STRENGTHENER
132.60R - 132.60R 132.60R 132.60R 132.60R - -
9398 ADDITIONAL FEE FOR USING MESH
STRENGTHENER IN REPAIR
PROCEDURE
210.00R - - 210.00R 210.00R 210.00R - -
9401 CLEAR BASE - - - - - - - -9403 DOX GRINDING OF UPPER AND
LOWER DENTURES
196.70R - - 196.70R - 196.70R - -
9405 INLAY TO ARTIFICIAL TOOTH, ONE
SURFACE ONLY, PER INLAY
- - - - - - - -
Trf
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General
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Practice (54)
Maxillo-Facial &
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Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9406 INLAY TO ARTIFICIAL TOOTH,
MULTI-SURFACES E.G. HORSESHOE
OR L-TYPE INLAY, PER INLAY
- - - - 433.30R - - -
9407 HEKA BASE TECHNIQUE PER UPPER
OR LOWER DENTURE
464.20R - - 464.20R 464.20R 464.20R - -
9409 FREGO FRAME 201.20R - - 201.20R 201.20R 201.20R - -9410 BLEACHING TRAY - - - - - - - -9411 TEMPLATE PER UPPER OR LOWER
DENTURE
554.90R - - 554.90R 554.90R 554.90R - -
9413 RELINE/REBASE OF SINGLE
DENTURE
698.50R - - 698.50R 698.50R 698.50R - -
9415 REMODEL OF SINGLE DENTURE 1 074.30R - - 1 074.30R 1 074.30R 1 074.30R - -9417 SOFT BASE RELINE PER DENTURE 1 764.00R - - 1 764.00R 1 764.00R 1 764.00R - -9419 SOFT BASE TO NEW DENTURE, PER
DENTURE
1 764.00R - - 1 764.00R 1 764.00R 1 764.00R - -
9421 GUM TINTING PER DENTURE - - - - - - - -9423 LINGUAL OR PALATAL BAR 263.10R - 263.10R 263.10R 263.10R 263.10R - -9425 CLEANING AND POLISHING OF
EXISTING DENTURE, PER DENTURE
214.40R - - 214.40R 214.40R 214.40R - -
9427 MESH STRENGTHENER 183.50R - - 183.50R 183.50R 183.50R - -9429 THEATRE/ CONSULTATION OUT OF
LABORATORY PER HOUR OR PART
THEREOF
455.40R 455.40R - 455.40R 455.40R 455.40R - -
9431 SPECIAL TRAY, ACRYLIC, EACH 172.40R - - 172.40R 172.40R 172.40R - -9432 SPECIAL TRAY LIGHT CURE, EACH 187.90R - - 187.90R 187.90R 187.90R - -9433 SPECIAL TRAY IN BASE PLATE
MATERIAL, EACH
176.90R - - 176.90R 176.90R 176.90R - -
9435 PROVISION OF SINGLE ARM CLASP,
TO PARTIAL DENTURE
90.60R - - 90.60R 90.60R 90.60R - -
9437 PROVISION OF DOUBLE ARM
CLASP, TO PARTIAL DENTURE
157.00R - - 157.00R 157.00R 157.00R - -
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General
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(64)
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(92)
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Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9439 PROVISION OF SINGLE ARM CLASP
WITH REST, TO PARTIAL DENTURE
203.40R - - 203.40R 203.40R 203.40R - -
9441 PROVISION OF DOUBLE ARM CLASP
WITH REST, TO PARTIAL DENTURE
274.10R - - 274.10R 274.10R 274.10R - -
9443 PROVISION OF PREFORMED ROACH
CLASP, TO PARTIAL DENTURE
117.20R - - 117.20R 117.20R 117.20R - -
9445 PROVISION OF REST ONLY TO
PARTIAL DENTURE
117.20R - - 117.20R 117.20R 117.20R - -
9447 CAST CLASP 411.20R - - 411.20R 411.20R 411.20R - -9448 CASTING AND TRIMMING OF
MODEL FROM IMPRESSION INSIDE
OCCLUSION BLOCK OR WAX TRY IN
75.20R - - 75.20R 75.20R 75.20R - -
9450 FINISHING OF ACRYLIC WORK ON
ANY CHROME COBALT OR GOLD
PROSTHESIS
157.00R 157.00R 157.00R 157.00R 157.00R 157.00R - -
9451 METAL BASE FOR FULL UPPER OR
FULL LOWER DENTURE EACH
- - - - - - - -
9453 BASIC CHARGE - WHICH EXCLUDES
MODELS AND ANY SPECIAL TRAYS
WHICH MAY BE REQUIRED BY THE
DENTIST, BUT INCLUDES
REFRACTORY MODEL
* 1 231.30R - - - 1 231.30R 1 231.30R - -
9455 ADDITIONAL CHARGE FOR EACH
ONE ARM CLASP
50.80R - - - 50.80R 50.80R - -
9457 ADDITIONAL CHARGE FOR EACH
ROACH CLASP
86.20R - - - 86.20R 86.20R - -
9459 ADDITIONAL CHARGE FOR EACH
REST
46.40R - - - 46.40R 46.40R - -
9461 ADDITIONAL CHARGE FOR
CONTINUOUS CLASP, PER TOOTH
50.80R - - - 50.80R 50.80R - -
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General
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(64)
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(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9463 ADDITIONAL CHARGE FOR LINGUAL
BAR, PER TOOTH PASSED
119.40R - - - 119.40R 119.40R - -
9465 ADDITIONAL CHARGE FOR PALATAL
BAR
190.10R - - - 190.10R 190.10R - -
9467 ADDITIONAL CHARGE FOR ONLAY - - - - - - - -
9469 ADDITIONAL CHARGE FOR SADDLE
WITH FINISHING LINE, PER TOOTH
84.00R - - - 84.00R 84.00R - -
9471 ADDITIONAL CHARGE FOR SADDLE
WITHOUT FINISHING LINE, PER
TOOTH
48.60R - - - 48.60R 48.60R - -
9473 ADDITIONAL CHARGE FOR
HORSESHOE SADDLE, PER TOOTH
84.00R - - - 84.00R 84.00R - -
9475 ADDITIONAL CHARGE FOR FITTING
OF TOOTH TO METAL BACKING,
PER TOOTH
57.50R - - - 57.50R 57.50R - -
9479 ADDITIONAL CHARGE FOR FITTING
ONE DISTAL-EXTENSION HINGE
170.20R - - - 170.20R 170.20R - -
9480 ADDITIONAL CHARGE PER MILLED
EDGE PER TOOTH
148.10R - - - 148.10R 148.10R - -
9481 ADDITIONAL CHARGE FOR EACH
SOLDERING JOINT
207.80R - - - 207.80R 207.80R - -
9483 ADDITIONAL CHARGE FOR
SOLDERING RETENTION
252.00R - - - 252.00R 252.00R - -
9485 ADDITIONAL CHARGE FOR EACH
ADDITIONAL RETENTION
SOLDERING JOINT
77.40R - - - 77.40R 77.40R - -
9487 ADDITIONAL CHARGE FOR EACH
WELDING JOINT
254.20R - - - 254.20R 254.20R - -
9489 ADDITIONAL CHARGE FOR FITTING
SWING LOCK
207.80R - - - 207.80R 207.80R - -
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General
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Practice (54)
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(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9491 ADDITIONAL CHARGE FOR EACH
BACKING CAST
203.40R - - - 203.40R 203.40R - -
9493 ADDITIONAL CHARGE FOR EACH
STEELS BACKING OR PONTIC CAST
(PLASTIC WORK TO BE CHARGED IN
ADDITION)
221.10R - - - 221.10R 221.10R - -
9495 BASIC FEE FOR THE REPAIRING OF
OR ADDITION TO ANY APPLIANCE
NECESSITATING THE CASTING OF A
MODEL (9301)
320.50R - - - 320.50R 320.50R - -
9497 BASIC FEE IF A NEW SECTION IS TO
BE FABRICATED AND WHERE ITEM
9495 DOES NOT APPLY (9301)
364.70R - - - 364.70R 364.70R - -
9501 CERAMIC JACKET
CROWN/CEROMER CROWN OR
PONTIC
* 1 399.30R - - - 1 399.30R 1 399.30R - -
9502 CERAMIC METAL SUBSTITUTE
COPING
* 1 129.60R - - - 1 129.60R 1 129.60R - -
9505 CERAMIC BONDED CROWN OR
PONTIC
* 1 848.00R - - 1 743.60R 1 848.00R 1 848.00R - -
9507 POST-SOLDER INVESTED JOINT, PER
JOINT
378.00R - - - 378.00R 378.00R - -
9511 INLAY IN PORCELAIN VENEER
CROWN
- - - - - - - -
9512 CERAMIC, INLAY/ONLAY, BRIDGE
RETAINER
* 1 434.70R - - - 1 434.70R 1 434.70R - -
9513 CERAMIC POST * - - - - - - - -9515 PORCELAIN SHOULDER PER UNIT
(NOT APPLICABLE TO PONTICS)
123.80R - - 123.80R 123.80R 123.80R - -
9520 ADDITIONAL FEE FOR CROWN- &
BRIDGE WORK PERFORMED ON A
MOVABLE CONDYLE ARTICULATOR
PER UNIT
59.70R - - - 59.70R 59.70R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9521 FULL METAL CROWN, MOD, THREE-
QUARTER CROWN
* 1 142.90R - - - 1 142.90R 1 142.90R - -
9524 INDIRECT COMPOSITE RESIN INLAY - - - - - - - -
9525 CLASS IV, MO, DO,
CERVICAL/OCCLUSAL INLAY
* 941.70R - - - 941.70R 941.70R - -
9526 ADDITIONAL FEE FOR ONE PIECE
CASTING OF CROWN OR INLAY ON
POST
287.40R - - - 287.40R 287.40R - -
9531 PIN-LEDGE INLAY - - - - - - - -9533 FULL METAL PONTIC * 844.40R - - - 844.40R 844.40R - -9535 ABUTMENT THIMBLE CAST 791.40R - - - 791.40R 791.40R - -9537 PRECISION LOCK AND REST CAST - - - - - - - -9538 LOCK AND REST CAST - - - - - - - -9539 CASTING OF REST ONLY 320.50R - - - 320.50R 320.50R - -9541 METAL INLAY OR POST, CAST
DIRECT
- - - - 340.40R - - -
9543 GOLD/PRE-SOLDER INVESTED
JOINT
- - - - - - - -
9545 CAST POST WITH THIMBLE,
INDIRECT
* 563.70R - - - 563.70R 563.70R - -
9546 MULTIPLE POST * 932.90R - - - 932.90R 932.90R - -9547 MANUFACTURE CAST POST AND
CORE TO EXISTING CROWN
* 736.10R - - - 736.10R 736.10R - -
9549 C.S.P. ATTACHMENT (STEIGER) - - - - - 2 484.70R - -9550 MILLING MILLED EDGE PER UNIT 791.40R - - - 791.40R 791.40R - -9551 TELESCOPE CROWN - - - - - - - -9553 COMPOSITE/ACRYLIC VENEER
CROWN/PONTIC, INDIRECT
* 1 558.40R - - - 1 558.40R 1 558.40R - -
9557 COMPOSITE/ACRYLIC JACKET
CROWN, INDIRECT
* 1 100.90R - - - 1 100.90R 1 100.90R - -
9559 COMPOSITE/ACRYLIC VENEER POST
CROWN
* 1 540.80R - - - 1 540.80R 1 540.80R - -
9560 INDIRECT COMPOSITE RESIN
VENEER
- - - - - 652.10R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9561 COMPOSITE/ACRYLIC JACKET
CROWN, DIRECT
* 751.60R - - - 751.60R 751.60R - -
9563 TEMPORARY ACRYLIC/COMPOSITE
CROWN PER UNIT
- - - - - - - -
9564 HEAT FORMED TEMPLATE
SUPPLIED TO DENTIST FOR THE
MANUFACTURE OF TEMPORARY
RESTORATIONS
- - - - - - - -
9565 COMPOSITE/ACRYLIC-FACING
REPLACED
625.60R - - - 625.60R 625.60R - -
9566 PORCELAIN/ CEROMER FACING
REPLACED
1 134.00R - - - 1 134.00R 1 134.00R - -
9569 WAXING OF CROWN TO EXISTING
DENTURE
442.10R - - - 442.10R 442.10R - -
9570 ADDITIONAL FEE FOR EACH
REMAKE AT AN AGREED
QUANTUM OF TIME TO BE
CALCULATED AT AN HOURLY RATE
- - - - - - - -
9571 BASIC CHARGE WHICH INCLUDES
ACRYLIC BASE
559.30R 559.30R 559.30R 559.30R 559.30R 559.30R - -
9572 BASIC CHARGE NON ACRYLIC BASE 269.70R - 269.70R - 269.70R - - -
9573 ADDITIONAL CHARGE FOR FITTING
FIRST EXPANSION SCREW
106.10R - 106.10R - 106.10R - - -
9575 ADDITIONAL FEE FOR FITTING
SUBSEQUENT EXPANSION SCREWS
90.60R - 90.60R - 90.60R - - -
9576 ADDITIONAL FEE FOR FULL
ACLUSAL BITE PLATE
313.90R 313.90R 313.90R 313.90R 313.90R 313.90R - -
9577 ADDITIONAL FEE FOR BITE PLATE
ANTERIOR
106.10R 106.10R 106.10R - 106.10R 106.10R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9578 ADDITIONAL FEE FOR BITE PLATE
POSTERIOR
106.10R 106.10R 106.10R - 106.10R 106.10R - -
9579 ADDITIONAL FEE FOR FITTING
TONGUE GUARD
132.60R - 132.60R - 132.60R - - -
9581 ADDITIONAL FEE FOR FLAT OR
INCLINED PLANE
81.80R - 81.80R - 81.80R - - -
9583 ADDITIONAL FEE FOR ADAMS CRIB 97.30R - 97.30R - 97.30R - - -
9585 ADDITIONAL FEE FOR JACKSON
CRIB
101.70R - 101.70R - 101.70R - - -
9587 ADDITIONAL FEE FOR BALL CLASP 115.00R 115.00R 115.00R 115.00R 115.00R - - -
9589 ADDITIONAL FEE FOR SINGLE ARM
CLASP
88.40R - 88.40R - 88.40R - - -
9591 ADDITIONAL FEE FOR DOUBLE ARM
CLASP
154.70R - 154.70R - 154.70R - - -
9593 ADDITIONAL FEE FOR FITTING
SINGLE LOOP FINGER SPRING
72.90R - 72.90R - 72.90R - - -
9595 ADDITIONAL FEE FOR FITTING
DOUBLE LOOP FINGER SPRING
86.20R - 86.20R - 86.20R - - -
9597 ADDITIONAL FEE FOR FITTING
BUCCAL RETRACTION SPRING
64.10R - 64.10R - 64.10R - - -
9599 ADDITIONAL FEE FOR FITTING
APRON SPRING
165.80R - 165.80R - 165.80R - - -
9603 ADDITIONAL FEE FOR FITTING
COFFIN SPRING
159.20R - 159.20R - 159.20R - - -
9605 ADDITIONAL FEE FOR FITTING
QUAD HELIX
176.90R - 176.90R - 176.90R - - -
9607 ADDITIONAL FEE FOR FITTING
FLAPPER OR “T”-SPRING
132.60R - 132.60R - 132.60R - - -
9609 ADDITIONAL FEE FOR FITTING ALL
SPRINGS WITH TUBING, EACH
148.10R - 148.10R - 148.10R - - -
9611 ADDITIONAL FEE FOR FITTING
LABIAL ARCH
84.00R - 84.00R - 84.00R - - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9613 ADDITIONAL FEE FOR FITTING
BUCCAL ARCH
99.50R - 99.50R - 99.50R - - -
9615 ADDITIONAL FEE FOR FITTING
ROBERTS RETRACTOR
185.70R - 185.70R - 185.70R - - -
9617 INVISIBLE RETAINER - - - - - - - -9619 ADDITIONAL FEE FOR FITTING
TWIN WIRE ARCH EXTRA-ORAL
ARCH
232.10R - 232.10R - 232.10R - - -
9620 ADDITIONAL FEE LIP BUMPER 97.30R - 97.30R - 97.30R - - -9621 ADDITIONAL FEE FOR FITTING
EXTRA-ORAL ARCH
221.10R - 221.10R - 221.10R - - -
9622 ADDITIONAL FEE FOR FITTING
SPACE MAINTAINER ARCH
97.30R - 97.30R - 97.30R - - -
9623 ADDITIONAL FEE FOR EACH SPOT-
WELDING JOINT
44.20R - 44.20R - 44.20R - - -
9625 ADDITIONAL FEE FOR EACH
SOLDERING JOINT
70.70R - 70.70R - 70.70R - - -
9627 ADDITIONAL FEE FOR EACH
INVESTED SOLDERING JOINT
196.70R - 196.70R - 196.70R - - -
9629 ADDITIONAL FEE FOR EACH HOOK
FOR ELASTIC TRACTION
64.10R - 64.10R - 64.10R - - -
9631 MOUTH PROTECTOR (GUM
GUARD)
- - - - - - - -
9633 ORAL SCREEN 510.60R 510.60R 510.60R 510.60R 510.60R 510.60R - -9635 ANDRESEN OR NORWEGIAN
APPLIANCE
913.00R 913.00R 913.00R 913.00R 913.00R 913.00R - -
9637 TOOTH POSITIONER 1 052.20R - 1 052.20R 1 052.20R 1 052.20R 1 052.20R - -9639 GUNNING SPLINT 1 401.50R 1 401.50R 1 401.50R 1 401.50R 1 401.50R 1 401.50R - -9641 FRANKEL APPLIANCE 1 352.90R - 1 352.90R - 1 352.90R - - -9643 CHIN CAP 448.70R - 448.70R - 448.70R - - -9645 BIONATOR 915.20R - 915.20R - 915.20R - - -9646 DIAGNOSTIC SET-UP - - - - - - - -9647 SNORING APPLIANCE - - - - - - - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9651 PINCHED OR SWAGED BAND WITH
WELDED ATTACHMENT
(EXCLUDING COST OF
ATTACHMENT)
269.70R - 269.70R - 269.70R - - -
9653 PINCHED OR SWAGED BAND WITH
SOLDERED ATTACHMENT
353.70R - 353.70R - 353.70R - - -
9662 ADDITIONAL FEE FOR EACH
REMAKE AT AN AGREED
QUANTUM OF TIME TO BE
CALCULATED AT AN HOURLY RATE
- - - - - - - -
9700 DIATORICS 1 X 6/8 221.00R 221.00R - 221.00R 221.00R 221.00R - -9702 DIATORICS, ODDS, ANTERIOR 75.30R - - 75.30R 75.30R 75.30R - -9704 DIATORICS, ODDS, POSTERIOR 75.30R - - 75.30R 75.30R 75.30R - -9706 COST OF BLEACHING TRAY
MATERIAL
- - - - - - - -
9720 SOFT BASE MATERIAL PER
DENTURE
800.10R - - 800.10R 800.10R 800.10R - -
9722 ACRYLIC PER DENTURE 90.50R 90.50R 90.50R 90.50R 90.50R 90.50R - -9724 COST OF PRECISION ATTACHMENT,
PER ATTACHMENT
- - - - - - - -
9726 PREFORMED BALL OR ROACH
CLASP
15.50R 15.50R 15.50R 15.50R 15.50R 15.50R - -
9728 COST OF LINGUAL / PALATAL BAR 181.10R - - - 181.10R 181.10R - -9729 COST OF MESH STRENGTHENER 95.00R - - - 95.00R 95.00R - -9730 COST OF PRE-FABRICATED BURN-
OUT COMPONENT, PER
COMPONENT
94.10R - - - 94.10R 94.10R - -
9732 COST OF OTHER ATTACHMENT
COMPONENTS E.G. NYLON CAPS,
SLEEVES ETC
- - - - - - - -
9734 COST OF DOLDER BAR AND CLIPS,
PER GRAM OR PER CLIP
- - - - - - - -
9736 COST OF IMPLANT COMPONENTS * - - - - - - - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9738 COST OF PREFORMED
STRENGTHENER
95.00R - - - 95.00R 95.00R - -
9739 ADDITIONAL CHARGE GOLD
PLATING
- - - - - - - -
9740 COST OF GOLD WIRE, PER GRAM - - - - - - - -9741 COST OF COBALT CHROME
CASTING ALLOY
150.20R - - - 150.20R 150.20R - -
9742 COST OF SPECIALISED COBALT
CHROME CASTING METAL E G
VITALLIUM, TITANIUM
- - - - - - - -
9744 COST OF PRECIOUS CASTING ALLOY - - - - - - - -
9746 COST OF SEMI-PRECIOUS CASTING
ALLOY
- - - - - - - -
9748 COST OF NON-PRECIOUS CASTING
ALLOY
* 170.30R - - 170.30R 170.30R 170.30R - -
9752 COST OF PLATINUM FOIL - - - - - - - -9754 COST OF GOLD SOLDER, PER GRAM - - - - - - - -
9755 ETCHING FOR BONDING (METAL
OR CERAMIC)
- - - - - - - -
9756 COST OF SILVER SOLDER, PER
GRAM
55.40R - - - 55.40R 55.40R - -
9757 CEROMER MATERIAL - PER UNIT * 1 129.80R - - - 1 129.80R 1 129.80R - -9758 FIBER RE-ENFORCED MATERIAL PER
UNIT
367.90R - 367.90R 367.90R 367.90R 367.90R - -
9759 FIBRE POST * - - - - - - - -9760 COMPOSITE RESTORATION
MATERIAL
- - - - - - - -
9761 CERAMIC MATERIAL - - - - - - - -9762 COST OF ANTERIOR ORTHODONTIC
ATTACHMENT, PER ATTACHMENT
33.10R - 33.10R - 33.10R - - -
9763 ORTHODONTIC MATERIAL 33.10R 33.10R 33.10R - 33.10R - - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9764 COST OF POSTERIOR
ORTHODONTIC ATTACHMENT, PER
ATTACHMENT
33.10R - 33.10R - 33.10R - - -
9765 PREFORMED COMPONENTS 17.80R - 17.80R - 17.80R 17.80R - -9766 COST OF EXPANSION SCREW, PER
SCREW
37.50R - 37.50R - 37.50R - - -
9767 SOLDERING MATERIAL 8.83R - 8.83R - 8.83R 8.83R - -9768 COST OF BUCCAL TUBE/TRANSFER
TUBE, PER TUBE
- - - - - - - -
9770 COST OF J-HOOK, PER HOOK 35.20R - 35.20R - 35.20R - - -9772 COST OF LINGUAL BUTTONS, PER
BUTTON
35.20R - 35.20R - 35.20R 35.20R - -
9774 COST OF INVISIBLE RETAINER
MATERIAL
- - - - - - - -
9775 R/A CASE - - - - - - - -9776 COST OF MOUTH PROTECTOR
MATERIAL
- - - - - - - -
9778 COST OF ARCH WIRE 8.83R - 8.83R - 8.83R - - -9779 DUAL LAMINATE MATERIAL - - - - - - - -9780 POSITIONING AND FINISHING OF
COMPLETE (MALE AND FEMALE)
PREFABRICATED BURN-OUT
ATTACHMENT
- - - - - - - -
9782 POSITIONING AND SOLDERING OF
COMPLETE (MALE AND FEMALE)
PRECISION ATTACHMENT
* - - - - - - - -
9783 IMPLANT STENT PER UNIT - - - - - - - -9784 ALIGNMENT OF DOLDER BAR AND
CLIPS
* - - - - - - - -
9786 TRIMMING, WAXING AND
FINISHING OF IMPLANT ABUTMENT
- CROWN AND BRIDGE WORK
ONLY, PER ABUTMENT
316.10R - - 316.10R 316.10R 316.10R - -
Trf
CodeTariffDescription
*Pre-
authorisation
required
General
Dental
Practice (54)
Maxillo-Facial &
Oral Surgery
(62)
Orthodontics
(64)
Periodontics
(92)
Dental
Technicians
(93)
Prostodontics
(94)
Dental
Therapists
(95)
Oral
Hygiene
(113)
9787 WAXING, MILLING AND FINISHING
OF A CUSTOM ABUTMENT
616.70R - - - 616.70R 616.70R - -
9788 IMPLANT SUPERSTRUCTURE
(EDENTULOUS CASES) INCLUDING
PLACING OF PREFORMED PARTS,
PER SECTION CAST
- - - - - - - -
9789 FINISHING OF PROSTHESIS ON
IMPLANT STRUCTURE PER ARCH
1 231.30R - - - 1 231.30R 1 231.30R - -