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FEE SCHEDULEOFDENTAL SERVICESFORDENTISTSANDDENTAL SPECIALISTSEffective 1 July 2022Based on The Australian Schedule of Dental Services and Glossary, 12th Edition1
IMPORTANT INFORMATIONDental Services by Dental Therapists, Dental Hygienists and Oral Health TherapistsDental therapists, dental hygienists and oral health therapists can provide dental services to members of theveteran community if they are: registered with the Dental Board of Australia and comply with approved scope of practice registrationstandards; covered by either their employer’s indemnity insurance or maintain their own insurance as mandated bythe Dental Board of Australia; and qualified and competent to provide the service.Claims for these services are to be submitted by the dentist or dental specialist on their behalf at the currentDVA dental fee.Process for Schedule A – time and quantity restrictionsIf there is a clinically assessed need to provide dental services above the time and/or quantity limits as listed inthe fee schedule, dentists and dental specialists will only be required to seek prior financial authorisation foritems marked with an asterisk (*).Lost or broken denturesFor the replacement of dentures that are lost or broken beyond repair, a statutory declaration from the patientmust be provided and stored for audit purposes.Changes to holders of Repatriation Health Card – For Specific Conditions (White Card) For treatment provided under the Veterans’ Entitlements Act 1986 (VEA) and the Military Rehabilitationand Compensation Act 2004 (MRCA)Where a service is related to the White Card holders accepted condition(s) dental providers are not requiredto contact DVA for prior financial authorisation of the treatment unless otherwise specified in this fee schedule.Providers can contact DVA (see telephone numbers listed below) if they require treatment status for White Cardholders.ComplianceDVA is placing a greater emphasis on the existing compliance model for the provision of all health services.DVA will maintain its commitment to working with service providers to maximise voluntary compliance.Therefore treatment must be based on assessed clinical need. It is important dental providers continue todocument the clinical reasons for treatment provision to DVA entitled persons.DVA has compliance monitoring systems which monitor the servicing and claiming patterns of health careproviders. This information assists DVA to establish internal benchmarks, the current utilisation and projectedfuture delivery of services.Further health-professionals2
ADDRESS AND CONTACT NUMBERS FORTHE DEPARTMENT OF VETERANS’ AFFAIRS (DVA)Further information on dental services may be obtained from DVA. The contact details for health careproviders requiring further information or prior financial authorisation for all States & Territories arelisted below:Phone: 1800 550 457 (Select Option 3, then Option 1)Email:health.approval@dva.gov.auPost:Health Approvals & Home Care SectionDepartment of Veterans’ AffairsGPO Box 9998BRISBANE QLD 4001Prior financial authorisation can only be submitted by email - health.approval@dva.gov.auThe prior approval request form can be found ring-prior-approval.Information for dentists and dental specialists can be found -specialists-and-dental-prosthetistsCLAIMS FOR PAYMENTClaim Enquiries:1300 550 017 (Option 2 Allied Health)For more information about claims for payment visit:www.dva.gov.au/providers/how-claimClaiming Online and DVA WebclaimDVA offers online claiming utilising Medicare Online Claiming. DVA Webclaim is available on theDepartment of Human Services (DHS) Provider Digital Access (PRODA) Service. For moreinformation about the online solutions available: DVA Webclaim\Technical Support enquiries: Phone: 1800 700 199 or email:eBusiness@servicesaustralia.gov.au Billing, banking and claim enquiries: Phone: 1300 550 017 Visit the Services Australia Medicare website fessionals3
Manual ClaimingPlease send all claims for payment to:Veterans’ Affairs Processing (VAP)Department of Human ServicesGPO Box 964ADELAIDE SA 5001Dental Claim FormsDVA provider health care claim forms and vouchers are available via the DVA website or byrequest. Further information: iders4
EXPLANATION OF THE FEE SCHEDULE Schedules A, B and C together form the DVA comprehensive dental schedule. The entitlements aredetailed below. “D” prefix refers to items that may be provided by a General Dental Practitioner. “S” prefix refers to items that may be provided by a Dental Specialist. “FBN” means Fee By Negotiation.Schedule ASchedule BSchedule C Prior financial authorisation is not required for Gold Cardholders (except where specified). Prior financial authorisation is not required for White Cardholders (except where specified) provided the treatmentrelates to the White Card holder’s accepted condition(s). Prior financial authorisation is required for items markedwith an asterisk (*) if treatment is provided above thequantity and/or time limits listed in Schedule A. No Annual Monetary Limit (AML) applies. Prior financial authorisation required for all Gold and WhiteCard holders. No AML applies. Prior financial authorisation is generally not required (seeexceptions below). Prior financial authorisation is generally not required forWhite Card holders (see exceptions below) provided thetreatment is related to the White Card holder’s acceptedcondition(s). Gold and White Card holders are not entitled to receiveunlimited gold crowns. An AML applies for all items listed as Schedule C items.This limit is not cumulative and cannot be used insubsequent years. DVA will pay up to a total of 2667.05 for each calendaryear from 2022 for all services provided from Schedule C. DVA Dental Advisers have no discretion in the applicationof the Schedule C AML.5
Exceptions: The AML does not apply to all ex-POWs and entitled persons with a relevant dental accepteddisability who are receiving dental treatment related to accepted war-caused disabilities ormalignant neoplasia involving oral tissues. Prior financial authorisation is required for treatment plans that include Schedule C items forentitled persons who are exempt from the AML.Provision of dentures for radiation therapy patients:A patient with a history of oral pathology needs to have a consultation with a dentist or specialist6
CATEGORY 000 DIAGNOSTIC SERVICESEXAMINATIONSNote 1: Prior financial authorisation is required for orthodontic, oral medicine and prosthodonticspecialists claiming items 014 and 015.DESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)SPECIALREMARKSSCHEDULEComprehensive oralexaminationD011No57.45Limit of one (1) per providerevery two years afterprevious 011 or 012. Limitapplies to the same provider.APeriodic oralexaminationD012No47.70AS012No47.70Limit of one (1) per providerevery 6 months. Limitapplies to the same provider.Oral examination –limitedD013No29.95AS013No29.95Limit of three (3) per threemonth period.ConsultationS014No69.25See Note 1.AAANot claimable by generaldentistsConsultation - extended(30 mins)S015No113.35Consultation by referralfrom DVAD016Yes112.05S016Yes164.65See Note 1.Limit of one (1) per providerper 12 month period.APayable only whenspecifically requested byDVA. Includes report toDVA.BSubject to GST.7B
EXAMINATIONS (Cont.)DESCRIPTIONITEMPRIORAPPROVALFEE SPECIALREMARKS(EXCL. GST)Consultation byreferral - extended(30 mins or more)S017No224.40Comprehensiveclinical report (notelsewhere included)D018Yes51.35S018Yes51.35SCHEDULEMay only be claimed by oralmedicine and special needsdentistry specialists.AClaimable only whenspecifically requested byDVA. Report must be kepton patient’s file.BBSubject to GST.S6A typed letter ofreferral. This must bea detailed typedreferral.*D019No12.10*S019No12.10Limit of one (1) per providerper 12 month period. A copyof this referral must beretained by provider.AARADIOLOGICAL EXAMINATION AND INTERPRETATIONDESCRIPTIONITEMPRIORAPPROVALFEE SPECIALREMARKS(EXCL. GST)SCHEDULEIntraoral periapical or bitewing radiograph – per exposure.Claim the higher fee for first periapical or bitewing radiograph each day and claim the step-down feefor each subsequent radiograph on the same day.First exposure only*D022No40.40*S022No40.40Each subsequentexposure (on sameday)*D022No33.20*S022No33.20Intraoral radiographocclusal, maxillary ormandibular – perexposureD025No67.15AS025No67.15A8Limit of six (6) per day – oneinitial and five subsequentexposures.For use of radiographs inendodontics refer to Note 9.ASee above.AAA
RADIOLOGICAL EXAMINATION AND INTERPRETATION (Cont.)DESCRIPTIONITEMFEE PRIORAPPROVAL(EXCL. GST)SPECIALREMARKSSCHEDULEExtraoral radiographmaxillary, mandibular –per exposureD031No76.50AS031No76.50ALateral, antero-posterior,postero-anterior orsubmento-vertexradiograph of the skull –per exposureS033No143.60Radiograph oftemporomandibular joint– per exposureS035No110.35Cephalometricradiograph – lateral,antero-posterior,postero-anterior orsubmento-vertex – perexposureS036No162.10Panoramic radiograph –per exposureD037No102.80AS037No102.80AHand-wrist radiographfor skeletal ageassessmentS038No96.20Computed tomographyof the skull or partsthereofD039No162.20S039No162.20Limit of one (1) per 12month period.AALimit of one (1) per 12month period.Age limit applies - 18years or under.AALimit of one (1) per 12month period perprovider.9Limit of one (1) per 12month period.AA
OTHER DIAGNOSTIC SERVICESDESCRIPTIONSaliva screening testITEMPRIORAPPROVALFEE (EXCL. 20AS051No135.20APulp testing – perappointmentD061No-S061No-Diagnostic model –per modelD071No65.95S071No65.95Biopsy of tissueLimit of one (1) per 12month period.SCHEDULEAANo fee payable - part ofexamination.ALimit of two (2) models perappointment (that is, oneupper and one lower).AAAThe preparation of a model,from an impression. Themodel is used forexamination and treatmentplanning procedures.This item should not be usedto describe a working model.Photographic records– , excludingradiographsS081No70.80May only be claimed withitem 881.ATooth-jaw sizeprediction analysis*S082No115.30Age limit applies 18 years orunder.APhotographic records– extraoralDiagnostic wax-upLimit of one (1) per 12month period.Fee to include allphotographs taken, not perphotograph.Limit of one (1) per 12month period.Fee to include allphotographs taken, not perphotograph.For use in complexprosthodontic cases only.Limit of one (1) per 12month period per provider.10AAAABB
CATEGORY 100 PREVENTIVE SERVICESDENTAL PROPHYLAXISDESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)SPECIALREMARKSLimit of one (1) per sixmonth period.SCHEDULERemoval of plaqueand/or stain.D111No58.65AS111No58.65Recontouring andpolishing of preexisting restoration(s)– per appointmentD113No22.20AS113No22.20ARemoval of calculus first appointmentD114No97.85S114No97.85Removal of calculus ng, internal per toothD117No209.35S117No209.35ALimit of one (1) per sixmonth period.ALimit of two (2) per 12month period.AFor non-vital discolouredtooth.Limit of two (2) teeth per 12month period.AAAAREMINERALISING AGENTSDESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)Topical application ofremineralising and/orcariostatic agents, neralising and /orcariostatic agent,application – CHEDULELimit of one (1) per sixmonth period.ALimit of one (1) perappointment.AAA
OTHER PREVENTIVE SERVICESDESCRIPTIONDietary analysis andadviceITEMPRIORAPPROVALFEE (EXCL. 5S141No53.95Where a full appointment ofat least 15 minutes is used.Provision of amouthguard –indirectD151No164.00Subject to GST.S151No164.00AFissure and/or toothsurface ingprocedure - - pertoothD171No55.40S171No55.40Oral hygieneinstructionWhere a full appointment ofat least 15 minutes is used.SCHEDULELimit of one (1) per 12month period.Limit of one (1) per 12month period.Limit of one (1) perappointment.AAAAAAACATEGORY 200 PERIODONTICSDESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)Treatment of acuteperiodontal infection– per appointmentD213No76.05S213No76.05Clinical periodontalanalysis idement - t of periimplant disease – SCHEDULELimit of two (2)appointments per 12 monthperiod.ALimit of one (1) per 12month period.ALimit of 10 per appointment,maximum 20 per 12 monthperiod.ALimit of five (5) perappointment, maximum 10per 12 month period.AAAAA
CATEGORY 200 PERIODONTICS (Cont.)DESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)SPECIALREMARKSSCHEDULEGingivectomy - pertoothD231YesFBNS231YesFBNPeriodontal flapsurgery - per toothD232YesFBNS232YesFBNSurgical treatment ofperi-implant disease per implantS233YesFBNBApplication ofbiologically activematerialS234YesFBNBGingival graft – pertooth or implantS235No577.55Guided tissueregeneration - pertooth or implantS236Yes577.55BGuided tissueregeneration –membrane removalS237No297.15APeriodontal flapsurgery for crownlengthening-per toothD238No412.50AS238No610.50ARoot resection – perrootD241No236.25AS241No295.30AOsseous surgery - pertooth or implantD242YesFBNBS242YesFBNBOsseous graft -pertooth or implantD243YesFBNBS243YesFBNBOsseous graft – blockS2443YesFBNPeriodontal surgeryinvolving one tooth*D245No86.60*S245No172.9513Limit of 10 per appointment, 20per 12 month period.BLimit of 10 per appointment, 20per 12 month period.BLimit of two (2) per 12 monthperiod.BBALimit one (1) per 12 monthperiod.BLimit of one (1) per 12 monthperiod.AA
DESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)SPECIALREMARKSSCHEDULEMaxillary sinusaugmentation –Trans-alveolartechnique – per sinusS246Yes859.80Will only be approved whereapplicable as part of an entiretreatment plan that includesimplants.BMaxillary sinusaugmentation –Lateral wall approach– per sinusS247Yes859.80Will only be approved whereapplicable as part of an entiretreatment plan that includesimplants.BActive Non-surgicalPeriodontal Therapy per quadrantD250No160.95AS250No321.90Limit of four (4) per 12 monthperiod.SupportivePeriodontal Therapy per appointmentD251No172.95S251No300.3514Only claim as per quadrants ofteeth treated.Limit of three (3) per 12 monthperiod.A
CATEGORY 300 ORAL SURGERYEXTRACTIONSNote 2: For items 311, 314, 322, 323 and 324 DVA will pay the higher fee for the first extracted toothfrom each quadrant and pay a step down fee for the second and subsequent extractions from the samequadrant on the same day. Where the teeth are not clearly identified on the D919, DVA will pay thehigher fee for the first extracted tooth and pay the step down fee for the second and subsequentextractions. All items inclusive of local anaesthesia and routine post-operative care.DESCRIPTIONITEMFEE PRIORAPPROVAL (EXCL. GST)SPECIALREMARKSSCHEDULERemoval of a tooth or part(s) thereof1st tooth extractedfrom each quadrantD311No143.25S311No177.95AStep down fee forsecond tooth in samequadrantD311No90.25AS311No115.30ASee Note 2.ASectional removal of a tooth.1st sectional removalfrom each quadrantD314No183.10S314No243.65AStep down fee forsecond tooth in samequadrantD314No120.95AS314No160.80APRIORFEE See Note 2.ASURGICAL EXTRACTIONSDESCRIPTIONITEMAPPROVAL(EXCL. GST)SPECIALREMARKSSCHEDULESurgical removal of a tooth or tooth fragment not requiring removal of bone or tooth division.1st tooth extractedfrom each quadrantD322No232.50S322No309.10AStep down fee forsecond tooth in samequadrantD322No154.70AS322No192.35ASee Note 2.Surgical removal of a tooth or tooth fragment requiring removal of bone.15A
1st tooth extractedfrom each quadrantD323No265.60S323No383.80AStep down fee forsecond tooth in samequadrantD323No190.25AS323No251.85ASee Note 2.ASurgical removal of a tooth or tooth fragment requiring both removal of bone and tooth division.1st tooth extractedfrom each quadrantD324No357.25S324No475.20AStep down fee forsecond tooth in samequadrantD324No235.45AS324No313.50ASee Note 2.ASURGERY FOR PROSTHESESNote 3: Fee exclusive of fee for extraction. Procedures described in this section include insertion ofsutures, normal post-operative care and suture removal.DESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)Alveolectomy - persegmentD331No144.95S331No182.60Ostectomy – per jawS332NoReduction of PECIALREMARKSSee Note 3.SCHEDULEAASee Note 3.ASee Note 3.AA
SURGERY FOR PROSTHESES (Cont.)DESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)SPECIALREMARKSSCHEDULEReduction of flabbyridge - per segmentD338No115.40See Note 3.AS338No164.95Limit of one (1) per 12month period.ARemoval ofhyperplastic tissueD341No184.75See Note 3.AS341No396.00Limit of one (1) per 12month period.ANot for tooth-associated softtissue treatment.Repositioning ofmuscle attachmentS343No445.55See Note 3.AVestibuloplastyS344No472.45See Note 3.ASkin or mucosal graftS345Yes434.25See Note 3.BTREATMENT OF MAXILLO-FACIAL INJURIESNote 4: Procedures described in this section include insertion of sutures, normal post-operative care andsuture removal.DESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)SPECIALREMARKSRepair of skin andsubcutaneous tissueor mucous membraneD351No174.55S351No232.20Fracture of maxilla ormandible – notrequiring fixationS352No203.25See Note 4.AFracture of maxilla ormandible – withwiring of teeth orintra-oral fixationS353No640.55See Note 4.AFracture of maxilla ormandible – withexternal fixationS354No640.55See Note 4.AFracture of zygomaS355No851.65See Note 4.A17See Note 4.SCHEDULEAA
Fracture requiringopen reductionS359No688.15See Note 4.ADISLOCATIONSNote 5: Procedures described in this section include insertion of sutures, normal post-operative care andsuture removal.DESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)SPECIALREMARKSSCHEDULEMandible – relocationfollowing dislocationS361No64.75See Note 5.AMandible – relocationrequiring openoperationS363No187.35See Note 5.AOSTEOTOMIESNote 6: Procedures described in this section include insertion of sutures, normal post-operative careand suture removal.DESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)SPECIALREMARKSSCHEDULEOsteotomy – maxillaS365No1523.65See Note 6.AOsteotomy –mandibleS366No1523.65See Note 6.AGENERAL SURGICALNote 7: Procedures described in this section include insertion of sutures, normal post-operative care andsuture removal.DESCRIPTIONRemoval of tumour,cyst or scar –cutaneous,subcutaneous or inmucous membraneITEMS371PRIORAPPROVALNoFEE (EXCL. GST)224.25SPECIALREMARKSSee Note 7.Limit one (1) perappointment18SCHEDULEA
Removal of tumour,cyst or scar involvingmuscle, bone or otherdeep tissue.S373NoSurgery to salivaryductS375No795.00699.95See Note 7.ASee Note 7.AGENERAL SURGICAL (Cont.)DESCRIPTIONITEMFEE PRIORAPPROVAL (EXCL. GST)SPECIALREMARKSSCHEDULESurgery to salivaryglandS376No237.25See Note 7.ARemoval or repair ofsoft tissue (notelsewhere defined)D377No221.15See Note 7.AS377No294.40Surgical removal offoreign bodyD378No125.15S378No166.30Marsupialisation ofcystS379No429.0519ASee Note 7.AASee Note 7.A
OTHER SURGICAL PROCEDURESNote 8: Procedures described in this section include insertion of sutures, normal post-operative care andsuture removal.DESCRIPTIONITEMFEE PRIORAPPROVAL (EXCL. GST)SPECIALREMARKSSurgical exposure ofunerupted tooth – pertoothD381YesFBNS381Yes379.45Surgical exposureand attachment ofdevice fororthodontic tractionS382Yes430.40Repositioning ofdisplaced tooth/teeth– per toothD384No208.30S384No277.70Surgicalrepositioning ofunerupted tooth – pertoothS385YesSplinting of displacedtooth/teeth – pertoothD386No214.90S386No289.45Replantation andsplinting of a tooth –per toothD387No420.75S387No559.65Transplantation oftooth or tooth budS388Yes642.45See Note 8.BSurgery to isolate andpreserveneurovascular tissueS389No205.20See Note 8.AFrenectomyD391No193.00See Note 80Drainage of abscessSurgery involving themaxillary antrum430.4020See Note 8.SCHEDULEBBSee Note 8.BSee Note 8.AASee Note 8.BSee Note 8.AASee Note 8.AAASee Note 8.AASee Note 8.B
DESCRIPTIONITEMFEE PRIORAPPROVAL (EXCL. GST)SPECIALREMARKSSCHEDULESurgery forosteomylitisS394No561.40See Note 8.ARepair of nerve trunkS395No1127.05See Note 8.A21
CATEGORY 400 ENDODONTICSNote 9: A maximum of four (4) radiographs are payable per tooth, for each course of endodontictreatment. Item fees include all other radiographs.PULP and ROOT CANAL TREATMENTSDESCRIPTIONDirect pulp cappingITEMPRIORAPPROVALFEE (EXCL. GST)*D411No38.10*S411No50.50Incompleteendodontic therapy(tooth not suitable forfurther No83.00*S414No96.20SPECIALREMARKSSee Note 9.SCHEDULEAASee Note 9.AASee Note 9.AAPULP and ROOT CANAL TREATMENTS (Cont.)DESCRIPTIONITEMFEE PRIORAPPROVAL (EXCL. GST)SPECIALREMARKSComplete chemomechanicalpreparation of rootcanal – one canal*D415No233.70*S415No432.65Complete chemomechanicalpreparation of rootcanal – eachadditional canal*D416No111.35*S416No221.15Root canal obturation– one canal*D417No227.70*S417No432.65Root canal obturation– each ion of pulp ordebridement of rootcanal(s) – emergencyor palliativeD419No150.45AS419No180.70AResorbable root canalfilling – primarytooth*D421No130.30See note 9.A*S421No208.30Limit of one (1) per primarytoothA22See Note 9.SCHEDULEAASee Note 9.AASee Note 9.AASee Note 9.A
PERIRADICULAR SURGERYDESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)SPECIALREMARKSSCHEDULEPeriapical curettage –per rootD431No330.05See Note 9.AS431No445.55Item cannot be claimed with432 and 434AApicectomy – perrootD432No330.05See Note 9.AS432No445.55Includes curettage.AExploratoryperiradicular surgeryD433No138.80AS433No173.60Limit of one (1) per 12month period.Apical seal - percanalD434No396.00See Note 9.AS434No577.55Includes apicectomy andperiapical curettage.ASealing of perforationD436No207.80See Note 9.AS436No412.50Limit of one (1) per 12month period.ASurgical treatmentand repair of anexternal rootresorption – per toothD437No288.70See Note 9.AS437No404.15Limit of one (1) per 12month period.AHemisectionD438No265.60See Note 9.AS438No383.8023Not claimable with items431, 432, 434, 436, 437 and438.AA
OTHER ENDODONTIC SERVICESDESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)Exploration and/ornegotiation of acalcified canal – percanal, perappointmentD445No115.30S445No153.80Removal of rootfilling – per canalD451No115.30S451No153.80Removal of cementedroot canal post orpost crownD452No115.30S452No144.15Removal orbypassing 65Additionalappointment forirrigation and/ordressing of the rootcanal system – pertooth*D455No115.30*S455No153.80Obturation ofresorption defect orperforation (nonsurgical)D457NoS457Interim therapeuticroot filling – pertoothSPECIALREMARKSSee Note 9.SCHEDULEAASee Note 9.AASee Note 9.AASee Note 9.AAWithin three months of items415 or 416.Appointment for irrigationonly – cannot be paid withany other item.A115.30See Note 9.ANo153.80Limit of one (1) per tooth.AD458No153.80AS458No172.95No other endodontictreatment on the same toothwithin three months.Limit of three (3) in a 12month period.24AA
CATEGORY 500 RESTORATIVE SERVICESMETALLIC RESTORATIONS - DIRECTDESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)SPECIALREMARKSSCHEDULEMetallic restoration- one surfaceD511No113.75AS511No113.75AMetallic restoration- two surfacesD512No139.40AS512No139.40AMetallic restoration- three surfacesD513No166.40AS513No166.40AMetallic restoration- four surfacesD514No189.70AS514No189.70AMetallic restoration- five surfacesD515No216.55AS515No216.55AADHESIVE RESTORATIONS – ANTERIOR TEETH – DIRECTDESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)SPECIALREMARKSSCHEDULEAdhesive restoration- one surface- anterior toothD521No125.95AS521No125.95AAdhesive restoration- two surfaces- anterior toothD522No152.95AS522No152.95AAdhesive restoration– three surfaces- anterior toothD523No181.15AS523No181.15AAdhesive restoration– four surfaces- anterior toothD524No209.35AS524No209.35AAdhesive restoration– five surfaces- anterior toothD525No246.00AS525No292.45AAdhesive restoration– veneer – anteriortooth – directD526No246.00S526No292.4525Annual limit applies.CC
ADHESIVE RESTORATIONS - POSTERIOR TEETH - DIRECTDESCRIPTIONITEMFEE PRIORAPPROVAL(EXCL. GST)SPECIALREMARKSSCHEDULEAdhesive restoration- one surface- posterior toothD531No134.60AS531No134.60AAdhesive restoration- two surfaces- posterior toothD532No168.95AS532No168.95AAdhesive restoration– three surfaces– posterior toothD533No203.10AS533No203.10AAdhesive restoration– four surfaces– posterior toothD534No228.80AS534No228.80AAdhesive restoration– five surfaces– posterior toothD535No264.25AS535No342.55AAdhesive restoration– veneer – posteriortooth – directD536No246.00S536No292.45Annual limit appliesCCMETALLIC RESTORATIONS - INDIRECTDESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)Metallic restoration– one surfaceD541No593.90S541No593.90Metallic restoration– two surfacesD542No759.00S542No759.00Metallic restoration– three surfacesD543No990.05S543No990.05Metallic restoration- four surfacesD544No1105.60S544No1105.60Metallic restoration- five Annual limit applies.SCHEDULECCAnnual limit applies.CCAnnual limit applies.CCAnnual limit applies.CCAnnual limit applies.CC
TOOTH COLOURED RESTORATIONS - INDIRECTDESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)Tooth-colouredrestoration- one ration- two toration- three storation- four storation- five storation – veneer SAnnual limit applies.SCHEDULECCAnnual limit applies.CCAnnual limit applies.CCAnnual limit applies.CCAnnual limit applies.CCAnnual limit applies.CC
OTHER RESTORATIVE SERVICESDESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)SPECIALREMARKSNot claimable withendodontic items except toration – pertoothD572No53.20S572No53.20Metal bandD574No44.85AS574No44.85APin retention– per pinD575No30.65S575No30.65Cusp capping – percuspD577No33.05S577NoRestoration of anincisal corner – percornerD578Limit of three (3) per threemonth period.AALimit of three (3) per tooth.Limit of six (6) pins payable.AA33.05Limit of two (2) cusps pertooth.No33.05Limit of two (2) per tooth.AS578No33.05Bonding of toothfragmentD579No105.70S579No134.65Crown – metallic –with toothpreparation –preformed*D586No280.45*S586No379.45Crown – metallic –minimal toothpreparation –preformed*D587No166.40*S587No166.40Crown – toothcoloured – preformed*D588No280.45*S588No379.45Removal of enting ofindirect restorationD596No86.40AS596No86.40A28AAALimit of one (1) perappointmentANo other crown item numberto be claimed on the sametooth within six (6) months.ANo other crown item numberto be claimed on the sametooth within six (6) months.ANo other crown item numberto be claimed on the sametooth within six (6) months.AAAAA
OTHER RESTORATIVE SERVICES (Cont.)DESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)SPECIALREMARKSSCHEDULEPost – direct 1st post in a toothStep down fee forsubsequent postsin the same toothD597No163.45S597No211.40Limit of two (2) posts pertooth.AAAD597No96.20S597No115.3029A
CATEGORY 600 CROWN AND BRIDGECROWNSDESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)Full crown- acrylic resin- indirectD611No1007.95S611No1340.70Full crown- non metallic- indirectD613No1465.95S613No1949.75Full crown- veneered- indirectD615No1379.05S615No2151.50Full crown- metallic- indirectD618No1292.25S618No1721.05Core for crownincluding post oration for crown– directD627No144.15S627No192.35Post and root cap nnual limit applies.SCHEDULECCAnnual limit applies.CCAnnual limit applies.CCAnnual limit applies.CCAnnual limit applies.CCAnnual limit applies.CCAnnual limit applies.CCTEMPORARY (PROVISIONAL) CROWN, BRIDGE OR IMPLANTDESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)Provisional crown –per tooth*D631No166.30*S631No166.30Provisional bridge per HEDULENo other crown item numberto be claimed on same toothwithin six (6) months.ANo other crown item numberto be claimed on same toothwithin six (6) months.AAA
Provisional implantcrown abutment – perabutment*D633No166.30*S633No166.30PRIORFEE No other crown item numberto be claimed on same toothwithin 6 months.AABRIDGESDESCRIPTIONITEMAPPROVAL(EXCL. GST)Bridge pontic- direct- per ponticD642No1055.95S642No1418.95Bridge pontic- indirect- per ntD644No254.05S644No461.85Precision or magneticattachmentD645No323.30S645No415.75Retainer for bondedfixture – indirect –per l limit applies.SCHEDULECCAnnual limit applies.CCAnnual limit applies.CCAnnual limit applies.CCAnnual limit applies.CC
CROWN AND BRIDGE REPAIRS AND OTHER SERVICESDESCRIPTIONITEMPRIORAPPROVALFEE (EXCL. GST)SPECIALREMARKSSCHEDULERecementing crownor veneerD651No112.50AS651No128.05ARecementing bridgeor splint – perabutmentD652No109.90AS652No146.25ARebonding of bridgeor splint whereretreatment of bridgesurface is requiredD653No99.95AS653No136.55
An AML applies for all items listed as Schedule C items. This limit is not cumulative and cannot be used in subsequent years. DVA will pay up to a total of 2667.05 for each calendar year from 2022 for all services provided from Schedule C. DVA Dental Advisers have no discretion in the application of the Schedule C AML.
