Dentists And Dental Specialists - Department of Veterans Affairs

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					         FEE SCHEDULE
                                  OF

        DENTAL SERVICES
                                 FOR




                     DENTISTS
                                AND



    DENTAL SPECIALISTS

               EF F ECT I   V E 1 S EP T EMBER     2012

                                                              TH
BASED ON AUSTRALIAN SCHEDULE OF DENTAL SERVICES AND GLOSSARY, 9    EDITION
IMPORTANT INFORMATION
Changes since the Fee Schedule of Dental Services for Dentists and Dental Specialists Effective 1
November 2011 are listed below.

Removal of prior approval
Effective 1 September 2012 prior financial authorisation requirements have been removed from the
following items:
Dentists
D238, D324, D377 & D971
Dental Specialists
S017, S237, S238, S324, S352, S353, S354, S355, S365, S366, S373, S377, S389, S391, S394, S395
& S971.

New processes for Schedule A – time and quantity restrictions, effective 1 September 2012
If there is a clinical assessed need to provide dental services above the time and/or quantity limits as
listed in the fee schedule, dentists and dental specialists will only be required to seek prior financial
authorisation for items marked with an asterisk (*).


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
   Rehabilitation and Compensation Act 2004 (MRCA)

As from 1 September 2012 dental providers will no longer be required to contact DVA for prior
financial authorisation of treatment for White Card holders where the service is related to the White
Card holders accepted condition(s) unless otherwise specified in this fee schedule.

Providers can contact DVA (see telephone numbers listed below) if they require treatment status
for White Card holders.

Compliance
DVA 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 to document the clinical reasons for treatment provision to DVA entitled
persons.

DVA has compliance monitoring systems which monitor the servicing and claiming patterns of
health care providers. This information assists DVA to establish internal benchmarks, the current
utilisation and projected future delivery of services.

Further information
Website: http://www.dva.gov.au/service_providers/dental_allied/dental/Pages/dental.aspx

Or

Medical & Allied Health section on:
Non-metropolitan callers:                      1800 550 457 (Select Option 3, then Option 1)
Metropolitan callers:                          1300 550 457 (Select Option 3, then Option 1)

                                                    2
EXPLANATION OF THE FEE SCHEDULE
   Schedules A, B and C together form the DVA comprehensive dental schedule. The entitlements
    are detailed 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.


                                           Prior financial authorisation not required for Gold or White
                                            Card holders (except where specified).
                                           Prior financial authorisation is required for items marked
        Schedule A                          with an asterisk (*) if treatment is provided above the
                                            quantity and/or time limits listed in Schedule A.
                                           No Annual Monetary Limit (AML) applies.


                                           Prior financial authorisation required for all Gold and White
                                            Card holders.
        Schedule B
                                           No AML applies.

                                           Prior financial authorisation is generally not required (see
                                            exceptions below).
                                           Gold and White Card holders are not entitled to receive
                                            unlimited gold crowns.
                                           An AML applies for all items listed as Schedule C items.
                                            This limit is adjusted on an annual basis and applies to a
        Schedule C                          calendar year. This limit is not cumulative and cannot be
                                            used in subsequent years.
                                           DVA will pay up to a total of $2,400 in the 2012 calendar
                                            year for all services provided from Schedule C.
                                           DVA Dental Advisers have no discretion in the application
                                            of the Schedule C AML.
Exceptions:
   The AML does not apply to all ex-POWs and entitled persons with a relevant dental accepted
    disability who are receiving dental treatment related to accepted war-caused disabilities or
    malignant neoplasia involving oral tissues.
   Prior financial authorisation is required for treatment plans that include Schedule C items for
    entitled 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 specialist.




                                                   3
                           ADDRESS AND CONTACT NUMBERS FOR
                       THE DEPARTMENT OF VETERANS’ AFFAIRS (DVA)

Further information on dental services may be obtained from DVA. The contact numbers for health
care providers requiring further information or prior financial authorisation for all States & Territories
are listed below:

Non-metropolitan callers:                      1800 550 457 (Select Option 3, then Option 1)
Metropolitan callers:                          1300 550 457 (Select Option 3, then Option 1)

DVA fax number for prior financial authorisation: (08) 8290 0422 (for all States & Territories)

Postal address (for all States & Territories): Medical & Allied Health Section
                                               Department of Veterans’ Affairs
                                               GPO Box 9998
                                               ADELAIDE SA 5001

http://www.dva.gov.au/service_providers/dental_allied/Pages/index.aspx.

Department of Human Services (DHS) processes claims for health care providers on behalf of DVA.

Postal address for claims:                     Veterans’ Affairs Processing (VAP)
                                               Department of Human Services
                                               GPO Box 964
                                               ADELAIDE SA 5001

All claim enquiries telephone:                 1300 550 017 (for all States & Territories)


Dental Claim Forms
D919 - Dental Report and Voucher
D986 - Dental Request
D1217 - Claim for Treatment Services
P02098C - Schedule of Dental Services for Dentists and Dental Specialists

Ordering forms online is quick and simple and will ensure prompt delivery. To place your order
online go to:
http://www.dva.gov.au/service_providers/Pages/Forms.aspx or
Tel: 1800 155 355
Fax: 1800 671 670


DVA provider fillable and printable health care claim forms & vouchers are also available on
the DVA website at: http://www.dva.gov.au/service_providers/Pages/Forms.aspx

                                                    4
CATEGORY 000 DIAGNOSTIC SERVICES
EXAMINATIONS

Note 1: Prior financial authorisation is required for orthodontic, oral medicine and prosthodontic
specialists claiming items 014 and 015.

                                                FEE
                                   PRIOR         $                   SPECIAL
     DESCRIPTION          ITEM                                                               SCHEDULE
                                 APPROVAL                            REMARKS
                                            (EXCL. GST)
Comprehensive oral       D011       No          51.65     See Note 1.                            A
examination                                               Limit of one (1) per provider
                                                          every two years after
                                                          previous 011 or 012. Limit
                                                          applies to the same provider.
Periodic oral            D012       No          42.95     See Note 1.                            A
examination                                               Limit of one (1) per provider
                         S012       No          42.95                                            A
                                                          every 6 months. Limit
                                                          applies to the same provider.
Oral examination –       D013       No          27.00     Limit of three (3) per three           A
limited                                                   month period.
                         S013       No          27.00                                            A
Consultation             S014       No          62.25     See Note 1.                            A
                                                          Not claimable by general
                                                          dentists
Consultation -           S015       No         101.90     See Note 1.                            A
extended (30 mins)                                        Limit of one (1) per provider
                                                          per 12 month period.
Consultation by          D016       Yes        100.80     Payable only when                      B
referral                                                  specifically requested by
                         S016       Yes        148.10                                            B
                                                          DVA. Includes report to
                                                          referring practitioner.
                                                          Subject to GST.




                                                  5
EXAMINATIONS (Cont.)
                                                FEE
                                   PRIOR         $                   SPECIAL
     DESCRIPTION          ITEM                                                              SCHEDULE
                                 APPROVAL                            REMARKS
                                            (EXCL. GST)
Consultation by          S017       No         201.75     May only be claimed by oral          A
referral - extended                                       medicine and special needs
(30 mins or more)                                         dentistry specialists.

Comprehensive            D018       Yes        46.15      See Note 1.                           B
clinical report (not                                      Claimable only when
                         S018       Yes        46.15                                            B
elsewhere included)                                       specifically requested by
                                                          DVA. Report must be kept
                                                          on patient’s file.
                                                          Subject to GST.
A typed letter of        *D019      No         10.90      Limit of one (1) per provider        A
referral. This must be                                    per 12 month period. A copy
                         *S019      No         10.90                                           A
a detailed typed                                          of this referral must be
referral.                                                 retained by provider.



RADIOLOGICAL EXAMINATION AND INTERPRETATION
                                                FEE
                                   PRIOR         $                   SPECIAL
     DESCRIPTION          ITEM                                                              SCHEDULE
                                 APPROVAL                            REMARKS
                                            (EXCL. GST)
Intraoral periapical or bitewing radiograph – per exposure.
Claim the higher fee for first periapical or bitewing radiograph each day and claim the step-down fee
for each subsequent radiographs on the same day.
First exposure only      *D022      No         36.30      Limit of six (6) per day – one       A
                                                          initial and five subsequent
                         *S022      No         36.30                                           A
                                                          exposures.
Each subsequent          *D022      No         29.90      Limit of four (4) per tooth          A
exposure (on same                                         undergoing endodontic
                         *S022      No         29.90                                           A
day)                                                      treatment (refer to Note 9).


Intraoral radiograph-    D025       No         60.40                                           A
occlusal, maxillary or   S025       No         60.40                                           A
mandibular – per
exposure




                                                  6
RADIOLOGICAL EXAMINATION AND INTERPRETATION (Cont.)
                                              FEE
                                 PRIOR         $                    SPECIAL
     DESCRIPTION         ITEM                                                            SCHEDULE
                                APPROVAL                            REMARKS
                                           (EXCL. GST)
Extraoral radiograph-    D031     No          68.85                                         A
maxillary,               S031     No          68.85                                         A
mandibular – per
exposure
Lateral, antero-         S033     No         129.20      Limit of one (1) per 12 month      A
posterior, postero-                                      period.
anterior or submento-
vertex radiograph of
the skull – per
exposure
Radiograph of            S035     No          99.25                                         A
temporomandibular
joint – per exposure
Cephalometric            S036     No         145.80      Limit of one (1) per 12            A
radiograph – lateral,                                    month period.
antero-posterior,
postero-anterior or
submento-vertex –
per exposure
Panoramic radiograph     D037     No          92.45                                         A
– per exposure           S037     No          92.45                                         A
Hand-wrist               S038     No          86.50      Age limit applies - 18 years       A
radiograph for                                           or under.
skeletal age                                             Limit of one (1) per 12
assessment                                               month period per provider.
Tomography of the        D039     No         145.90      Limit of one (1) per 12            A
skull or parts thereof                                   month period.
                         S039     No         145.90                                         A




                                                7
OTHER DIAGNOSTIC SERVICES
                                              FEE
                                 PRIOR         $                    SPECIAL
     DESCRIPTION        ITEM                                                             SCHEDULE
                                APPROVAL                            REMARKS
                                           (EXCL. GST)
Saliva screening test   D047      No          39.75      Limit of one (1) per 12            A
                                                         month period.
                        S047      No          39.75                                         A
Biopsy of tissue        D051      No         121.55                                         A
                        S051      No         121.55                                         A
Pulp testing – per      D061      No            -        No fee payable - part of           A
visit                                                    examination.
                        S061      No            -                                           A
Diagnostic model –      D071      No          59.25      The preparation of a model,        A
per model                                                from an impression. The
                        S071      No          59.25                                         A
                                                         model is used for
                                                         examination and treatment
                                                         planning procedures.
                                                         This item should not be used
                                                         to describe a working model.
Photographic records    D072      No          31.90      Limit of one (1) per 12            A
– intraoral                                              month period.
                        S072      No          31.90                                         A
                                                         Fee to include all
                                                         photographs taken, not per
                                                         photograph.
Photographic records    D073      No          31.90      Limit of one (1) per 12            A
– extraoral                                              month period.
                        S073      No          31.90                                         A
                                                         Fee to include all
                                                         photographs taken, not per
                                                         photograph.
Diagnostic wax-up       D074      Yes        156.10      For use in complex                 B
                                                         prosthodontic cases only.
                        S074      Yes        234.15                                         B
Cephalometric           S081      No          63.75      May only be claimed with           A
analysis, excluding                                      item 881.
radiographs
Tooth-jaw size          *S082     No         103.75      Age limit applies 18 years or      A
prediction analysis                                      under.
                                                         Limit of one (1) per 12
                                                         month period per provider.




                                                8
CATEGORY 100 PREVENTIVE SERVICES
DENTAL PROPHYLAXIS
                                               FEE
                                  PRIOR         $                    SPECIAL
     DESCRIPTION          ITEM                                                            SCHEDULE
                                 APPROVAL                            REMARKS
                                            (EXCL. GST)
Removal of plaque         D111     No          52.80      Limit of one (1) per six           A
and/or stain.                                             month period.
                          S111     No          52.80                                         A
Recontouring pre-         D113     No          19.95                                         A
existing restoration(s)   S113     No          19.95                                         A
Removal of calculus -     D114     No          88.05      Limit of one (1) per six           A
first visit                                               month period.
                          S114     No          88.05                                         A
Removal of calculus -     D115     No          57.25      Limit of two (2) per 12            A
subsequent visit                                          month period.
                          S115     No          57.25                                         A
Bleaching, internal -     D117     No         188.25      For non-vital discoloured          A
per tooth                                                 tooth.
                          S117     No         188.25                                         A
                                                          Limit of two (2) teeth per 12
                                                          month period.



REMINERALISING AGENTS
                                               FEE
                                  PRIOR         $                    SPECIAL
     DESCRIPTION          ITEM                                                            SCHEDULE
                                 APPROVAL                            REMARKS
                                            (EXCL. GST)
Topical application of    D121     No          33.90      Limit of one (1) per six           A
remineralising and/or                                     month period.
                          S121     No          33.90                                         A
cariostatic agents, one
treatment
Concentrated              D123     No          26.55      Limit of one (1) per visit.        A
remineralising and /or    S123     No          26.55                                         A
cariostatic agent,
application – single
tooth




                                                 9
OTHER PREVENTIVE SERVICES
                                             FEE
                                PRIOR         $                    SPECIAL
     DESCRIPTION        ITEM                                                             SCHEDULE
                               APPROVAL                            REMARKS
                                          (EXCL. GST)
Dietary advice          D131     No          35.70      Where a full appointment of         A
                                                        at least 15 minutes is used.
                        S131     No          35.70                                          A
                                                        Limit of one (1) per 12
                                                        month period.
Oral hygiene            D141     No          48.55      Where a full appointment of         A
instruction                                             at least 15 minutes is used.
                        S141     No          48.55                                          A
                                                        Limit of one (1) per 12
                                                        month period.
Provision of a          D151     No         147.45      Subject to GST.                     A
mouthguard –            S151     No         147.45                                          A
indirect
Fissure sealing – per   D161     No          45.20                                          A
tooth                   S161     No          45.20                                          A
Desensitizing           D165     No          26.55                                          A
procedure - per visit   S165     No          26.55                                          A
Odontoplasty- per       D171     No          49.85      Limit of two (2) per visit.         A
tooth                   S171     No          49.85                                          A

CATEGORY 200 PERIODONTICS
                                             FEE
                                PRIOR         $                    SPECIAL
     DESCRIPTION        ITEM                                                             SCHEDULE
                               APPROVAL                            REMARKS
                                          (EXCL. GST)
Treatment of acute      D213     No         68.40       Limit of two (2) visits per 12      A
periodontal infection                                   month period.
                        S213     No         68.40                                           A
– per visit
Clinical periodontal    D221     No         51.95       Limit of one (1) per 12             A
analysis and                                            month period.
                        S221     No        138.30                                           A
recording
Root planing and        D222     No         25.55       Limit of 10 per visit,              A
subgingival curettage                                   maximum 20 per 12 month
                        S222     No         35.30                                           A
- per tooth                                             period.
Non-surgical            D225     No        103.75       Limit of one (1) per 12             A
periodontal treatment                                   month period.
                        S225     No        138.30                                           A
where not otherwise
specified – per visit




                                              10
CATEGORY 200 PERIODONTICS (Cont.)
                                              FEE
                                 PRIOR         $                    SPECIAL
     DESCRIPTION        ITEM                                                               SCHEDULE
                                APPROVAL                            REMARKS
                                           (EXCL. GST)
Gingivectomy - per      D231      Yes        FBN         Limit of ten (10) per visit, 20      B
tooth                                                    per 12 month period.
                        S231      Yes        FBN                                              B
Periodontal flap        D232      Yes        FBN         Limit of ten (10) per visit, 20      B
surgery - per tooth                                      per 12 month period.
                        S232      Yes        FBN                                              B
Gingival graft – per    S235      No        519.40       Limit of two (2) per 12              A
tooth or implant                                         month period.
Guided tissue           S236      Yes       519.40                                            B
regeneration - per
tooth or implant
Guided tissue           S237      No        267.15                                            A
regeneration –
membrane removal
Periodontal flap        D238      No        370.95                                            A
surgery for crown       S238      No        549.00                                            A
lengthening-per tooth
Root resection – per    D241      No        212.45                                            A
root                    S241      No        265.55                                            A
Osseous surgery - per   D242      Yes        FBN                                              B
tooth                   S242      Yes        FBN                                              B
Osseous graft -per      D243      Yes        FBN                                              B
tooth or implant        S243      Yes        FBN                                              B
Osseous graft – block   S244      Yes        FBN         Limit one (1) per 12 month           B
                                                         period.
Periodontal surgery     *D245     No         77.90       Limit of one (1) per 12              A
involving one tooth                                      month period.
                        *S245     No        155.60                                            A
or an implant
Course of non-          D281      Yes        FBN         Limit of one (1) per 12              B
surgical periodontal                                     month period.
                        S281      Yes        FBN                                              B
treatment
Continuation/review     *D282     No        155.60       Limit of three (3) per 12            A
of periodontal                                           month period.
                        *S282     No        270.00                                            A
treatment or
maintenance                                              S282 can only be claimed
subsequent to item                                       where item S281 or S282 has
281                                                      been paid in the last 5 years.




                                               11
CATEGORY 300 ORAL SURGERY

EXTRACTIONS

Note 2: For items 311, 314, 322, 323 and 324 DVA will pay the higher fee for the first extracted
tooth from each quadrant and pay a step down fee for the second and subsequent extractions from the
same quadrant on the same day. Where the teeth are not clearly identified on the D919, DVA will
pay the higher fee for the first extracted tooth and pay the step down fee for the second and
subsequent extractions. All items inclusive of local anaesthesia and routine post-operative care.



                                              FEE
                                               $
     DESCRIPTION          ITEM    PRIOR                           SPECIAL                 SCHEDULE
                                 APPROVAL (EXCL. GST)             REMARKS
Removal of a tooth or part(s) thereof
1st tooth extracted      D311       No      128.85      See Note 2.                          A
from each quadrant       S311       No      160.05                                           A
Step down fee for        D311       No       81.20                                           A
second tooth in same     S311       No      103.65                                           A
quadrant
Sectional removal of a tooth.

1st sectional removal    D314       No      164.65      See Note 2.                          A
from each quadrant       S314       No      219.10                                           A

Step down fee for        D314       No      108.75                                           A
second tooth in same     S314       No      144.60                                           A
quadrant




                                                12
SURGICAL EXTRACTIONS
                                                FEE
                                   PRIOR         $                   SPECIAL
     DESCRIPTION          ITEM                                                               SCHEDULE
                                 APPROVAL                            REMARKS
                                            (EXCL. GST)
Surgical removal of a tooth or tooth fragment not requiring removal of bone or tooth division.
1st tooth extracted      D322        No       209.15      See Note 2.                            A
from each quadrant       S322        No       278.00                                             A
Step down fee for        D322        No       139.10                                             A
second tooth in same     S322        No       172.95                                             A
quadrant
Surgical removal of a tooth or tooth fragment requiring removal of bone.

1st tooth extracted      D323        No       238.80      See Note 2.                            A
from each quadrant
                         S323        No       345.15                                             A

Step down fee for        D323        No       171.10                                             A
second tooth in same     S323        No       226.55                                             A
quadrant


Surgical removal of a tooth or tooth fragment requiring both removal of bone and tooth division.
1st tooth extracted      D324        No       321.25      See Note 2.                            A
from each quadrant       S324        No       427.35                                             A
Step down fee for        D324        No       211.80                                             A
second tooth in same     S324        No       281.90                                             A
quadrant


SURGERY FOR PROSTHESES
Note 3: Fee exclusive of fee for extraction. Procedures described in this section include insertion of
sutures, normal post-operative care and suture removal.

                                                FEE
                                   PRIOR         $                   SPECIAL
     DESCRIPTION          ITEM                                                               SCHEDULE
                                 APPROVAL                            REMARKS
                                            (EXCL. GST)
Alveolectomy - per       D331        No       130.30      See Note 3.                            A
segment                  S331        No       164.20                                             A
Ostectomy – per jaw      S332        No       436.10      See Note 3.                            A
Reduction of fibrous     D337        No       183.25      See Note 3.                            A
tuberosity               S337        No       243.70                                             A




                                                  13
SURGERY FOR PROSTHESES (Cont.)
                                                FEE
                                   PRIOR         $                   SPECIAL
     DESCRIPTION          ITEM                                                               SCHEDULE
                                 APPROVAL                            REMARKS
                                            (EXCL. GST)
Reduction of flabby      D338       No        103.85      See Note 3.                           A
ridge - per segment      S338       No        148.35      Limit of one (1) per 12               A
                                                          month period.
Removal of               D341       No        166.15      See Note 3.                           A
hyperplastic tissue      S341       No        356.10      Limit of one (1) per 12               A
                                                          month period.
                                                          Not for tooth-associated soft
                                                          tissue treatment.
Repositioning of         S343       No        400.70      See Note 3.                           A
muscle attachment
Vestibuloplasty          S344       No        424.90      See Note 3.                           A
Skin or mucosal graft    S345       Yes       390.60      See Note 3.                           B

TREATMENT OF MAXILLO-FACIAL INJURIES
Note 4: Procedures described in this section include insertion of sutures, normal post-operative care
and suture removal.

                                                FEE
                                   PRIOR         $                   SPECIAL
     DESCRIPTION          ITEM                                                               SCHEDULE
                                 APPROVAL                            REMARKS
                                            (EXCL. GST)
Repair of skin and       D351       No        156.95      See Note 4.                           A
subcutaneous tissue      S351       No        208.85                                            A
or mucous membrane
Fracture of maxilla or   S352       No        182.70      See Note 4.                           A
mandible – not
requiring splinting
Fracture of maxilla or   S353       No        576.00      See Note 4.                           A
mandible – with
wiring of teeth or
intra-oral fixation
Fracture of maxilla or   S354       No        576.00      See Note 4.                           A
mandible – with
external fixation
Fracture of zygoma       S355       No        765.85      See Note 4.                           A
Fracture requiring       S359       No        618.90      See Note 4.                           A
open reduction



                                                 14
DISLOCATIONS

Note 5: Procedures described in this section include insertion of sutures, normal post-operative care
and suture removal.

                                                FEE
                                   PRIOR         $                   SPECIAL
     DESCRIPTION          ITEM                                                               SCHEDULE
                                 APPROVAL                            REMARKS
                                            (EXCL. GST)
Mandible – relocation    S361       No         58.25      See Note 5.                           A
following dislocation
Mandible – relocation    S363       No        168.50      See Note 5.                           A
requiring open
operation


OSTEOTOMIES

Note 6: Procedures described in this section include insertion of sutures, normal post-operative care
and suture removal.

                                                FEE
                                   PRIOR         $                   SPECIAL
     DESCRIPTION          ITEM                                                               SCHEDULE
                                 APPROVAL                            REMARKS
                                            (EXCL. GST)
Osteotomy – maxilla      S365       No       1370.15      See Note 6.                           A
Osteotomy –              S366       No       1370.15      See Note 6.                           A
mandible



GENERAL SURGICAL

Note 7: Procedures described in this section include insertion of sutures, normal post-operative care
and suture removal.

                                                FEE
                                   PRIOR         $                   SPECIAL
     DESCRIPTION          ITEM                                                               SCHEDULE
                                 APPROVAL                            REMARKS
                                            (EXCL. GST)
Removal of tumour,       S371       No        201.60      See Note 7.                           A
cyst or scar –                                            Limit one (1) per visit
cutaneous,
subcutaneous or in
mucous membrane
Removal of tumour,       S373       No        714.90      See Note 7.                           A
cyst or scar involving
muscle, bone or other
deep tissue.
Surgery to salivary      S375       No        629.45      See Note 7.                           A
duct

                                                 15
GENERAL SURGICAL (Cont.)
                                                FEE
                                                 $
     DESCRIPTION          ITEM    PRIOR                             SPECIAL                  SCHEDULE
                                 APPROVAL (EXCL. GST)               REMARKS
Surgery to salivary      S376       No        213.35     See Note 7.                            A
gland
Removal or repair of     D377       No        198.80     See Note 7.                            A
soft tissue (not         S377       No        264.70                                            A
elsewhere defined)
Surgical removal of      D378       No        112.55     See Note 7.                            A
foreign body             S378       No        149.55                                            A
Marsupialisation of      S379       No        385.80     See Note 7.                            A
cyst




OTHER SURGICAL PROCEDURES

Note 8: Procedures described in this section include insertion of sutures, normal post-operative care
and suture removal.

                                                FEE
                                                 $
     DESCRIPTION          ITEM    PRIOR                             SPECIAL                  SCHEDULE
                                 APPROVAL (EXCL. GST)               REMARKS
Surgical exposure of     D381       Yes        FBN       See Note 8.                            B
unerupted tooth          S381       Yes       341.20                                            B
Surgical exposure        S382       Yes       387.05     See Note 8.                            B
and attachment of
device for
orthodontic traction
Repositioning of         D384       No        187.30     See Note 8.                            A
displaced tooth/teeth    S384       No        249.70                                            A
– per tooth
Surgical                 S385       Yes       387.05     See Note 8.                            B
repositioning of
unerupted tooth
Splinting of displaced   D386       No        193.25     See Note 8.                            A
tooth/teeth – per        S386       No        260.30                                            A
tooth
Replantation and         D387       No        378.35     See Note 8.                            A
splinting of a tooth     S387       No        503.40                                            A


                                                 16
OTHER SURGICAL PROCEDURES (Cont.)

                                               FEE
                                                $
     DESCRIPTION         ITEM     PRIOR                             SPECIAL             SCHEDULE
                                 APPROVAL (EXCL. GST)               REMARKS
Transplantation of       S388      Yes       577.75       See Note 8.                      B
tooth or tooth bud

Surgery to isolate and   S389      No        184.55       See Note 8.                      A
preserve
neurovascular tissue
Frenectomy               D391      No        173.55       See Note 8.                      A
                         S391      No        230.80                                        A
Drainage of abscess      D392      No         95.05       See Note 8.                      A
                         S392      No        121.05                                        A
Surgery involving the    S393      Yes       831.60       See Note 8.                      B
maxillary antrum
Surgery for              S394      No        504.80       See Note 8.                      A
osteomylitis
Repair of nerve trunk    S395      No        1013.55      See Note 8.                      A




CATEGORY 400 ENDODONTICS

Note 9: A maximum of four (4) radiographs are payable per course of endodontic treatment. Item
fees include all other radiographs.

PULP and ROOT CANAL TREATMENTS
                                               FEE
                                  PRIOR         $                   SPECIAL
     DESCRIPTION         ITEM                                                           SCHEDULE
                                 APPROVAL                           REMARKS
                                            (EXCL. GST)
Direct pulp capping      *D411     No         34.20       See Note 9.                      A
                         *S411     No         45.40                                        A
Incomplete               *D412     No        117.15       See Note 9.                      A
endodontic therapy       *S412     No        187.30                                        A
(inoperable or
fractured)
Pulpotomy                *D414     No         74.65       See Note 9.                      A
                         *S414     No         86.50                                        A



                                                17
PULP and ROOT CANAL TREATMENTS (Cont.)

                                              FEE
                                               $
     DESCRIPTION         ITEM     PRIOR                           SPECIAL              SCHEDULE
                                 APPROVAL (EXCL. GST)             REMARKS
Complete chemo-          *D415     No       210.15      See Note 9.                       A
mechanical               *S415     No       389.05                                        A
preparation of root
canal – one canal
Complete chemo-          *D416     No       100.10      See Note 9.                       A
mechanical               *S416     No       198.80                                        A
preparation of root
canal – each
additional canal
Root canal obturation    *D417     No       204.70      See Note 9.                       A
– one canal              *S417     No       389.05                                        A
Root canal obturation    *D418     No        95.75      See Note 9.                       A
– each additional        *S418     No       198.80                                        A
canal
Extirpation of pulp or   D419      No       135.35                                        A
debridement of root      S419      No       162.45                                        A
canal(s) – emergency
or palliative
Resorbable root canal    *D421     No       117.15      See note 9.                       A
filling – primary        *S421     No       187.30      Limit of one (1) per primary      A
tooth                                                   tooth




                                               18
PERIRADICULAR SURGERY
                                              FEE
                                 PRIOR                              SPECIAL
      DESCRIPTION        ITEM                   $                                      SCHEDULE
                                APPROVAL                            REMARKS
                                           (EXCL. GST)
Periapical curettage –   D431     No        296.80       See Note 9.                      A
per root                 S431     No        400.70       Item cannot be claimed with      A
                                                         432 and 434
Apicectomy – per         D432     No        296.80       See Note 9.                      A
root                     S432     No        400.70       Includes curettage.              A

Exploratory              D433     No        124.85       Limit of one (1) per 12          A
periradicular surgery                                    month period.
                         S433     No        156.10                                        A
                                                         Not claimable with items
                                                         431, 432, 434, 436, 437 and
                                                         438.
Apical seal - per        D434     No        356.10       See Note 9.                      A
canal                    S434     No        519.40       Includes apicectomy and          A
                                                         periapical curettage.
Sealing of perforation   D436     No        186.90       See Note 9.                      A
                         S436     No        370.95       Limit of one (1) per 12          A
                                                         month period.
Surgical treatment       D437     No        259.60       See Note 9.                      A
and repair of an         S437     No        363.45       Limit of one (1) per 12          A
external root                                            month period.
resorption – per tooth
Hemisection              D438     No        238.80       See Note 9.                      A
                         S438     No        345.15                                        A

OTHER ENDODONTIC SERVICES
                                              FEE
                                 PRIOR         $                    SPECIAL
     DESCRIPTION         ITEM                                                          SCHEDULE
                                APPROVAL                            REMARKS
                                           (EXCL. GST)
Exploration for a        D445     No        103.75       See Note 9.                      A
calcified root canal –   S445     No        138.30                                        A
per canal
Removal of root          D451     No        103.75       See Note 9.                      A
filling – per canal      S451     No        138.30                                        A
Removal of cemented      D452     No        103.75       See Note 9.                      A
root canal post or       S452     No        129.65                                        A
post crown



                                               19
OTHER ENDODONTIC SERVICES (Cont.)
                                             FEE
                                PRIOR         $                    SPECIAL
     DESCRIPTION       ITEM                                                             SCHEDULE
                               APPROVAL                            REMARKS
                                          (EXCL. GST)
Removal or             D453      No         86.50       See Note 9.                        A
bypassing fractured    S453      No        121.05                                          A
endodontic
instrument
Additional visit for   *D455     No        103.75       Within three months of items       A
irrigation and/or                                       415 or 416.
                       *S455     No        138.30                                          A
dressing of the root                                    Visit for irrigation only –
canal system – per                                      cannot be paid with any other
tooth                                                   item.


Obturation of          D457      No        103.75       See Note 9.                        A
resorption defect or   S457      No        138.30       Limit of one (1) per tooth.        A
perforation (non-
surgical)
Interim therapeutic    D458      No        138.30       No other endodontic                A
root filling – per                                      treatment on the same tooth
                       S458      No        155.60                                          A
tooth                                                   within three months.
                                                        Limit of three (3) in a 12
                                                        month period.

CATEGORY 500 RESTORATIVE SERVICES

METALLIC RESTORATIONS - DIRECT
                                             FEE
                                PRIOR         $                    SPECIAL
     DESCRIPTION       ITEM                                                             SCHEDULE
                               APPROVAL                            REMARKS
                                          (EXCL. GST)
Metallic restoration   D511      No        102.30                                          A
- one surface          S511      No        102.30                                          A
Metallic restoration   D512      No        125.40                                          A
- two surfaces         S512      No        125.40                                          A
Metallic restoration   D513      No        149.65                                          A
- three surfaces       S513      No        149.65                                          A
Metallic restoration   D514      No        170.60                                          A
- four surfaces        S514      No        170.60                                          A
Metallic restoration   D515      No        194.75                                          A
- five surfaces        S515      No        194.75                                          A



                                              20
ADHESIVE RESTORATIONS – ANTERIOR TEETH – DIRECT
                                            FEE
                               PRIOR         $                    SPECIAL
     DESCRIPTION       ITEM                                                            SCHEDULE
                              APPROVAL                            REMARKS
                                         (EXCL. GST)
Adhesive restoration   D521     No        113.30       Limit of five (5) single-          A
- one surface                                          surface adhesive restorations
                       S521     No        113.30                                          A
- anterior tooth                                       (521/531) per day.
Adhesive restoration   D522     No        137.55                                          A
- two surfaces         S522     No        137.55                                          A
- anterior tooth
Adhesive restoration   D523     No        162.90                                          A
– three surfaces       S523     No        162.90                                          A
- anterior tooth
Adhesive restoration   D524     No        188.25                                          A
– four surfaces        S524     No        188.25                                          A
- anterior tooth
Adhesive restoration   D525     No        221.25                                          A
– five surfaces        S525     No        263.00                                          A
- anterior tooth

ADHESIVE RESTORATIONS - POSTERIOR TEETH - DIRECT
                                            FEE
                               PRIOR         $                    SPECIAL
     DESCRIPTION       ITEM                                                            SCHEDULE
                              APPROVAL                            REMARKS
                                         (EXCL. GST)
Adhesive restoration   D531     No        121.00       Limit of five (5) single-          A
- one surface                                          surface adhesive restorations
                       S531     No        121.00                                          A
- posterior tooth                                      (521/531) per day.
Adhesive restoration   D532     No        151.90                                          A
- two surfaces         S532     No        151.90                                          A
- posterior tooth
Adhesive restoration   D533     No        182.65                                          A
– three surfaces
                       S533     No        182.65                                          A
– posterior tooth
Adhesive restoration   D534     No        205.80                                          A
– four surfaces        S534     No        205.80                                          A
– posterior tooth
Adhesive restoration   D535     No        237.70                                          A
– five surfaces        S535     No        308.00                                          A
– posterior tooth




                                             21
METALLIC RESTORATIONS - INDIRECT
                                            FEE
                               PRIOR         $                    SPECIAL
     DESCRIPTION       ITEM                                                    SCHEDULE
                              APPROVAL                            REMARKS
                                         (EXCL. GST)
Metallic restoration   D541     No        534.10       Annual limit applies.      C
– one surface          S541     No        534.10                                  C
Metallic restoration   D542     No        682.60       Annual limit applies.      C
– two surfaces         S542     No        682.60                                  C
Metallic restoration   D543     No        890.35       Annual limit applies.      C
– three surfaces       S543     No        890.35                                  C
Metallic restoration   D544     No        994.25       Annual limit applies.      C
- four surfaces        S544     No        994.25                                  C
Metallic restoration   D545     No        1112.80      Annual limit applies.      C
- five surfaces        S545     No        1468.90                                 C

TOOTH COLOURED RESTORATIONS - INDIRECT
                                            FEE
                               PRIOR         $                    SPECIAL
     DESCRIPTION       ITEM                                                    SCHEDULE
                              APPROVAL                            REMARKS
                                         (EXCL. GST)
Tooth-coloured         D551     No        667.75       Annual limit applies.      C
restoration            S551     No        890.35                                  C
- one surface
Tooth-coloured         D552     No        771.55       Annual limit applies.      C
restoration            S552     No        1009.00                                 C
- two surfaces
Tooth-coloured         D553     No        949.60       Annual limit applies.      C
restoration            S553     No        1276.00                                 C
- three surfaces
Tooth-coloured         D554     No        1142.60      Annual limit applies.      C
restoration            S554     No        1379.90                                 C
- four surfaces
Tooth-coloured         D555     No        1224.95      Annual limit applies.      C
restoration            S555     No        1468.90                                 C
- five surfaces




                                             22
OTHER RESTORATIVE SERVICES
                                                FEE
                                   PRIOR         $                    SPECIAL
      DESCRIPTION         ITEM                                                              SCHEDULE
                                  APPROVAL                            REMARKS
                                             (EXCL. GST)
Provisional               D572      No         47.85       Not claimable with                  A
(intermediate/                                             endodontic items except 419.
                          S572      No         47.85                                           A
temporary)                                                 Limit of three (3) per three
restoration                                                month period.
Metal band                D574      No         40.30                                           A
                          S574      No         40.30                                           A
Pin retention             D575      No         27.55       Limit of three (3) per tooth.       A
– per pin                                                  Limit of six (6) pins payable.
                          S575      No         27.55                                           A
Metallic crown            *D576     No        252.25       No other crown item number          A
                          *S576                            to be claimed on same tooth
- direct                            No        341.20                                           A
                                                           within six (6) months.


Cusp capping – per        D577      No         29.75       Limit of two (2) cusps per          A
cusp                                                       tooth.
                          S577      No         29.75                                           A
Restoration of an         D578      No         29.75       Limit of two (2) per tooth.         A
incisal corner – per      S578      No         29.75                                           A
corner
Bonding of tooth          D579      No         95.05       Limit of one (1) per visit          A
fragment                  S579      No        121.05                                           A
Veneer – direct           D582      No        248.75       Annual limit applies.               C
                          S582      No        320.60                                           C
Veneer – indirect         D583      No        816.50       Annual limit applies.               C
                          S583      No        890.35                                           C
Removal of                D595      No         95.05                                           A
inlay/onlay               S595      No        138.30                                           A
Recementing of            D596      No         77.70                                           A
inlay/onlay               S596      No         77.70                                           A
Post – direct
   1st post in a tooth   D597      No        147.00       Limit of two (2) posts per          A
                                                           tooth.
                          S597      No        190.10                                           A
   Step down fee for     D597      No         86.50                                           A
    subsequent posts      S597      No        103.75                                           A
    in the same tooth



                                                 23
CATEGORY 600 CROWN AND BRIDGE

CROWNS
                                              FEE
                                 PRIOR         $                    SPECIAL
      DESCRIPTION       ITEM                                                           SCHEDULE
                                APPROVAL                            REMARKS
                                           (EXCL. GST)
Full crown              D611      No        906.45       Annual limit applies.            C
- acrylic resin         S611      No        1205.65                                       C
- indirect
Full crown              D613      No        1318.25      Annual limit applies.            C
- non metallic          S613      No        1753.45                                       C
- indirect
Full crown              D615      No        1240.15      Annual limit applies.            C
- veneered                                  1934.80
                        S615      No                                                      C
- indirect
Full crown              D618      No        1162.05      Annual limit applies.            C
- metallic              S618      No        1547.75                                       C
- indirect
Core for crown          D625      No        313.70       Annual limit applies.            C
including post –        S625      No        417.20                                        C
indirect
Preliminary             D627      No        129.65       Annual limit applies.            C
restoration for crown   S627      No        172.95                                        C
– direct
Post and root cap –     D629      No        328.60       Annual limit applies.            C
indirect                S629      No        423.60                                        C
TEMPORARY (PROVISIONAL) CROWN AND BRIDGE
                                              FEE
                                 PRIOR         $                    SPECIAL
      DESCRIPTION       ITEM                                                           SCHEDULE
                                APPROVAL                            REMARKS
                                           (EXCL. GST)
Provisional crown       *D631     No        149.55       No other crown item number       A
                        *S631                            to be claimed on same tooth
                                  No        149.55                                        A
                                                         within six (6) months.


Provisional bridge -    *D632     No        296.80       No other crown item number       A
per pontic              *S632                            to be claimed on same tooth
                                  No        385.80                                        A
                                                         within six (6) months.




                                               24
BRIDGES
                                             FEE
                                PRIOR         $                    SPECIAL
     DESCRIPTION        ITEM                                                    SCHEDULE
                               APPROVAL                            REMARKS
                                          (EXCL. GST)
Bridge pontic           D642     No        949.60       Annual limit applies.      C
- direct                S642     No        1276.00                                 C
- per pontic
Bridge pontic           D643     No        1012.40      Annual limit applies.      C
- indirect              S643     No        1276.00                                 C
- per pontic
Semi-fixed              D644     No        228.45       Annual limit applies.      C
attachment              S644     No        415.35                                  C
Precision or magnetic   D645     No        290.75       Annual limit applies.      C
attachment              S645     No        373.85                                  C
Retainer for bonded     D649     No        385.80       Annual limit applies.      C
fixture – indirect –    S649     No        519.40                                  C
per tooth

CROWN AND BRIDGE REPAIRS AND OTHER SERVICES
                                             FEE
                                PRIOR         $                    SPECIAL
     DESCRIPTION        ITEM                                                    SCHEDULE
                               APPROVAL                            REMARKS
                                          (EXCL. GST)
Recementing crown       D651     No        101.25                                  A
or veneer               S651     No        115.15                                  A
Recementing bridge      D652     No         98.80                                  A
or splint – per         S652     No        131.50                                  A
abutment
Rebonding of bridge     D653     No         89.90                                  A
or splint where         S653     No        122.80                                  A
retreatment of bridge
surface is required
Removal of crown        D655     No         60.50                                  A
                        S655     No         77.90                                  A
Removal of bridge or    D656     No        181.55                                  A
splint                  S656     No        181.55                                  A




                                              25
CROWN AND BRIDGE REPAIRS AND OTHER SERVICES (Cont.)
                                                 FEE
                                    PRIOR         $                   SPECIAL
     DESCRIPTION           ITEM                                                                SCHEDULE
                                  APPROVAL                            REMARKS
                                             (EXCL. GST)
Repair of crown,          D658       No        228.45      Both items must be                      C
bridge or splint                                           claimed.
                           and
- indirect                                                 658 to be claimed for GST-
                          D472       No        182.75                                              C
                                                           free component of service.
                                                           472 (labour, lab. costs) to be
                                                           claimed for GST-able
                                                           component of service.
                                                           Annual limit applies.
Repair of                 S658       No        228.45      Both items must be                      C
crown/bridge or                                            claimed.
                           and
splint – indirect                                          658 to be claimed for GST-
                          S472       No        182.75                                              C
                                                           free component of service.
                                                           472 (labour, lab. costs) to be
                                                           claimed for GST-able
                                                           component of service.
                                                           Annual limit applies.
Repair of crown,          D659       No        290.75      Annual limit applies.                   C
bridge or splint
                          S659       No        436.10                                              C
- direct

IMPLANT PROSTHESES
Note 10: Requests for osseointegrated implants should be directed to DVA. Where implants are
provided in a public hospital, in some States, the cost of the prostheses are included in the bed rate
and therefore the specialist may need to liaise with the hospital as to payment or arrangements for
the equipment to be provided for the surgery.

                                                 FEE
                                    PRIOR         $                   SPECIAL
     DESCRIPTION           ITEM                                                                SCHEDULE
                                  APPROVAL                            REMARKS
                                             (EXCL. GST)
Fitting of implant        D661       Yes        FBN        Includes the cost of                    B
abutment – per                                             hardware.
                          S661       Yes        FBN                                                B
abutment
Provisional implant      *D662       No        149.55      No other crown item number              A
crown abutment – per     *S662                             to be claimed on same tooth
                                     No        149.55                                              A
abutment                                                   within 6 months.




                                                  26
IMPLANT PROSTHESES (Cont.)
                                                FEE
                                   PRIOR         $                    SPECIAL
      DESCRIPTION          ITEM                                                          SCHEDULE
                                  APPROVAL                            REMARKS
                                             (EXCL. GST)
Removal of implant         S663     Yes        FBN                                          B

Fitting of bar for         S664     Yes        FBN                                          B
denture – per
abutment
Prosthesis with metal      S666     Yes        FBN                                          B
frame attached to
implants – per tooth
Fixture or abutment        D668     Yes        FBN                                          B
screw removal and          S668     Yes        FBN                                          B
replacement
Removal and                D669     Yes        FBN                                          B
reattachment of
prosthesis fixed to        S669     Yes        FBN                                          B
implant(s) – per
implant
Full crown attached        D671     Yes       1318.25                                       B
to osseointegrated         S671     Yes       1753.45                                       B
implant
- non metallic
- indirect
Full crown attached        D672     Yes       1493.35                                       B
to osseointegrated         S672     Yes       1934.80                                       B
implant
- veneered
- indirect
Full crown attached        D673     Yes       1163.65                                       B
to osseointegrated
implant                    S673     Yes       1547.75                                       B
-metallic
-indirect
Diagnostic template        S678     Yes        FBN         Limit one (1) per 12 months      B
Surgical implant           S679     Yes        FBN                                          B
guide
Insertion of first stage   S684     Yes        FBN         Includes the cost of             B
of two-stage                                               hardware.
endosseous implant -
per implant


                                                 27
IMPLANT PROSTHESES (Cont.)
                                                 FEE
                                   PRIOR          $                   SPECIAL
     DESCRIPTION          ITEM                                                                SCHEDULE
                                 APPROVAL                             REMARKS
                                             (EXCL. GST)
Insertion of one-stage    S688      Yes         FBN        Includes the cost of                   B
endosseous implant –                                       hardware.
per implant
Provisional implant       S689      Yes         FBN        Maximum two (2) per course             B
                                                           of treatment. For use with
                                                           881only.
Second stage surgery      S691      Yes         FBN        Includes the cost of                   B
of two stage                                               hardware.
endosseous implant –
per implant



CATEGORY 700 PROSTHODONTICS
DENTURES AND DENTURE COMPONENTS

Note 11: DVA will pay for dentures every six (6) years and a reline every two (2) years. DVA will
not pay for a new denture if provided within twelve months of a reline of an existing denture. The
number of teeth for each individual partial denture should be specified for each claim.

If a patient has been assessed as requiring new dentures/relines outside of the above limits, providers
are no longer required to contact DVA for prior financial authorisation. If treatment is provided
outside of the above limits, providers must provide clinical justification to DVA if requested.

                                                 FEE
                                   PRIOR          $                   SPECIAL
     DESCRIPTION          ITEM                                                                SCHEDULE
                                 APPROVAL                             REMARKS
                                             (EXCL. GST)
Complete maxillary       D711        No        936.45      See Note 11.                          A
denture                   S711       No        936.45                                            A
Complete mandibular      D712        No        936.45      See Note 11.                          A
denture                   S712       No        936.45                                            A
Metal palate or plate    D716        No      As per lab    Additional to item 711, 712           A
                                              invoice      or 719.
                          S716       No                                                          A
                                                           Laboratory casting invoice
                                                           required. Maximum amount
                                                           payable $415.45.




                                                  28
DENTURES AND DENTURE COMPONENTS (Cont.)
                                            FEE
                               PRIOR         $                    SPECIAL
     DESCRIPTION       ITEM                                                          SCHEDULE
                              APPROVAL                            REMARKS
                                         (EXCL. GST)
Complete maxillary     D719     No        1660.55      See Note 11.                     A
and mandibular         S719     No        1660.55                                       A
dentures
Partial maxillary      D721     No                     See Note 11.                     A
denture – resin base   S721     No                                                      A
– one tooth                               392.65
– two teeth                               448.45
– three teeth                             524.75
– four teeth                              589.70
– five to nine teeth                      698.15
    inclusive
– ten to twelve                           807.00
    teeth
    inclusive
Partial mandibular     D722     No                     See Note 11.                     A
denture – resin base   S722     No                                                      A
– one tooth                               392.65
– two teeth                               448.45
– three teeth                             524.75
– four teeth                              589.70
– five to nine teeth                      698.15
    inclusive
– ten to twelve                           807.00
    teeth
    inclusive
Partial maxillary      D727     No                     See Note 11.                     A
denture – cast metal   S727     No                     For the cost of casting use      A
framework
                                           885.35      item 730.
– one tooth
– two teeth                                970.45
– three teeth                             1058.30
– four teeth                              1091.35
– five to nine teeth                      1256.40
    inclusive
– ten to twelve                           1386.00
    teeth
    inclusive




                                             29
DENTURES AND DENTURE COMPONENTS (Cont.)
                                             FEE
                                PRIOR         $                    SPECIAL
     DESCRIPTION        ITEM                                                             SCHEDULE
                               APPROVAL                            REMARKS
                                          (EXCL. GST)
Partial mandibular      D728     No                     See Note 11.                        A
denture – cast metal    S728     No                     For the cost of casting use         A
framework
                                            885.35      item 730.
– one tooth
– two teeth                                 970.45
– three teeth                              1058.30
– four teeth                               1091.35
– five to nine teeth                       1256.40
    inclusive
– ten to twelve teeth                      1386.00
    inclusive
Provision of casting    D730     No       As per lab    Invoice is not submitted with       A
                                           invoice      claim, but should be retained
                        S730     No                                                         A
                                           amount       by provider. Fee inclusive of
                                                        clasps, retainers, occlusal
                                                        rests, overlays, and backings.
                                                        Maximum amount payable
                                                        $712.10
Retainer – per tooth    D731     No         43.25       Additional to items 721 and         A
                                                        722.
                        S731     No         43.25                                           A
Occlusal rest - per     D732     No         21.00       Additional to items 721 and         A
rest                                                    722.
                        S732     No         21.00                                           A
Precision or magnetic   D735     No        259.60       Limit of two (2) items per 12       A
denture attachment                                      month period.
                        S735     No        259.60                                           A
Immediate tooth         D736     No          8.95                                           A
replacement - per       S736     No          8.95                                           A
tooth
Resilient lining        D737     No        185.60                                           A
                        S737     No        185.60                                           A
Wrought bar             D738     No        172.95                                           A
                        S738     No        172.95                                           A




                                              30
DENTURE MAINTENANCE

Note 12 A fee will not be paid for:
1. adjustment(s) to full or partial dentures within twelve (12) months following provision or relining;
or
2. reline(s) or remodel(s) to each upper or lower denture within two (2) years following provision or
relining (except for immediate dentures which can be relined once within two years of their provision
– please specify immediate denture reline on the claim form).
Upper or lower denture must be specified for each claim.
If a patient has been assessed as requiring adjustments or relines outside of the above limits, providers
are no longer required to contact DVA for prior financial authorisation.
If treatment is provided outside of the above limits, providers must provide clinical justification
to DVA if requested.



                                                 FEE
                                    PRIOR         $                   SPECIAL
     DESCRIPTION          ITEM                                                                 SCHEDULE
                                  APPROVAL                            REMARKS
                                             (EXCL. GST)
Adjustment of a           D741       No        51.25       See Note 12.                           A
denture                   S741       No        51.25       Adjustment(s) to full or               A
                                                           partial dentures within twelve
                                                           (12) months following
                                                           provision or relining by the
                                                           same provider.
Relining                  D743       No        326.80      See Note 12.                           A
- complete denture        S743       No        474.25      For soft relines, use items            A
- processed                                                743 and 737.
Relining                  D744       No        278.55      See Note 12.                           A
- partial denture         S744       No        368.70      For soft relines, use items            A
- processed                                                744 and 737.
Remodelling               D745      Yes         FBN        See Note 12.                           B
- complete denture        S745      Yes         FBN                                               B
Remodelling               D746      Yes         FBN        See Note 12.                           B
– partial denture         S746      Yes         FBN                                               B
Relining                  D751       No        178.05      See Note 12.                           A
- complete denture        S751       No        267.15      Limit of one (1) per denture           A
- direct                                                   every 2 years.
                                                           Chair-side only. Either hard
                                                           or soft material.
                                                           Not to be used for temporary
                                                           materials i.e. tissue
                                                           conditioners.


                                                  31
DENTURE MAINTENANCE (Cont.)
                                                FEE
                                   PRIOR         $                    SPECIAL
     DESCRIPTION          ITEM                                                               SCHEDULE
                                 APPROVAL                             REMARKS
                                            (EXCL. GST)
Relining                 D752       No        148.35      See Note 12. Limit of one              A
- partial denture                                         (1) per denture every 2 years.
                         S752       No        163.25                                             A
- direct                                                  Not to be used for temporary
                                                          materials i.e. tissue
                                                          conditioners.
Cleaning and             D753       No         41.55      Limit of one (1) per denture           A
polishing of pre-                                         every 2 years. Subject to
                         S753       No         55.30                                             A
existing denture                                          GST.

DENTURE REPAIRS

Note 13: Item 767/488 to be claimed for ANY second and subsequent
reattachment/repair/replacement items performed on the same denture on the same day. Items 761
and 762 for additional clasps or teeth replaced, use multiples of 767/488. UPR or LWR must be
specified for each claim. If a patient has been assessed as requiring repairs outside of the limits,
providers are no longer required to contact DVA for prior financial authorisation.
If treatment is provided outside of the limits, providers must provide clinical justification to
DVA if requested.



                                                FEE
                                   PRIOR         $                    SPECIAL
     DESCRIPTION          ITEM                                                               SCHEDULE
                                 APPROVAL                             REMARKS
                                            (EXCL. GST)
Reattaching pre-         D761       No         37.30      Both items must be claimed.            A
existing tooth or                                         761 to be claimed for GST-
                          and
clasp to denture                                          free component of service.
                         D482       No        104.20                                             A
                                                          482 (labour, laboratory costs)
                                                          to be claimed for GST-able
                                                          component of service.
                                                          Limit of one (1) per day per
                                                          denture. See Note 13.
Reattaching pre-         S761       No         37.30      Both items must be claimed.            A
existing tooth or                                         761 to be claimed for GST-
                          and
clasp to denture                                          free component of service.
                         S482       No        104.20                                             A
                                                          482 (labour, laboratory costs)
                                                          to be claimed for GST-able
                                                          component of service.
                                                          Limit of one (1) per day per
                                                          denture. See Note 13.
Replacing clasp on       D762       No        147.85      See Note 13. Limit of one (1)          A
denture                                                   per day per denture.
                         S762       No        147.85                                             A
                                                          GST free.
                                                 32
DENTURE REPAIRS (Cont.)
                                          FEE
                             PRIOR         $                    SPECIAL
     DESCRIPTION     ITEM                                                             SCHEDULE
                            APPROVAL                            REMARKS
                                       (EXCL. GST)
Repairing broken     D763     No         37.30       Both items must be claimed.         A
base of a complete                                   763 to be claimed for GST-
                     and
denture                                              free component of service.
                     D484     No        104.20                                           A
                                                     484 (labour, laboratory costs)
                                                     to be claimed for GST-able
                                                     component of service.
                                                     Limit of one (1) per day per
                                                     denture. See Note 13
Repairing broken     S763     No         37.30       Both items must be claimed.         A
base of a complete                                   763 to be claimed for GST-
                     and
denture                                              free component of service.
                     S484     No        104.20                                           A
                                                     484 (labour, laboratory costs)
                                                     to be claimed for GST-able
                                                     component of service.
                                                     Limit of one (1) per day per
                                                     denture. See Note 13
Repairing broken     D764     No         37.30       Both items must be claimed.         A
base of a partial                                    764 to be claimed for GST-
                     and
denture                                              free component of service.
                     D485     No        104.20                                           A
                                                     485 (labour, laboratory costs)
                                                     to be claimed for GST-able
                                                     component of service.
                                                     Limit of one (1) per day per
                                                     denture. See Note 13
Repairing broken     S764     No         37.30       Both items must be claimed.         A
base of a partial                                    764 to be claimed for GST-
                     and
denture                                              free component of service.
                     S485     No        104.20                                           A
                                                     485 (labour, laboratory costs)
                                                     to be claimed for GST-able
                                                     component of service.
                                                     Limit of one (1) per day per
                                                     denture. See Note 13




                                           33
DENTURE REPAIRS (Cont.)
                                               FEE
                                  PRIOR         $                    SPECIAL
      DESCRIPTION         ITEM                                                             SCHEDULE
                                 APPROVAL                            REMARKS
                                            (EXCL. GST)
Replacing first tooth     D765     No        147.85       Limit of one (1) per day per        A
on denture                                                denture.
                          S765     No        147.85                                           A
                                                          See Note 13


Any repair or tooth       D767     No         18.40       Both items must be claimed.         A
replacement in                                            767 to be claimed for GST-
                          and
addition to other                                         free component of service.
repairs, alterations or   D488     No         40.05                                           A
other modifications                                       488 (labour, laboratory costs)
for same denture on                                       to be claimed for GST-able
same day                                                  component of service.
Any repair or tooth       S767     No         18.40       Both items must be claimed.         A
replacement in                                            767 to be claimed for GST-
                          and
addition to other                                         free component of service.
repairs, alterations or   S488     No         40.05                                           A
other modifications                                       488 (labour, laboratory costs)
for same denture on                                       to be claimed for GST-able
same day                                                  component of service.
Adding tooth to           D768     No        149.65       Limit of one (1) per day per        A
partial denture to                                        denture.
                          S768     No        149.65                                           A
replace an extracted
                                                          See Note 13
or decoronated tooth
-per tooth
Repair or addition to     D769     No       As per lab    Limit of one (1) per day per        A
metal casting                                invoice      denture.
                          S769     No                                                         A
                                                          Laboratory casting invoice
                                                          required. Maximum amount
                                                          payable $296.80
                                                          Subject to GST.


                                                          See Note 13




                                                34
OTHER PROSTHODONTIC SERVICES
                                               FEE
                                  PRIOR         $                    SPECIAL
      DESCRIPTION        ITEM                                                               SCHEDULE
                                APPROVAL                             REMARKS
                                           (EXCL. GST)
For provision of        D770       Yes        FBN        Non ADA item number. To               B
dentures in difficult                                    be used in exceptional cases
                        S770       Yes        FBN                                              B
cases                                                    only – contact DVA
Tissue conditioning     D771       No        67.95       Limit of five (5) per three           A
treatment prior to                                       month period.
                        S771       No        67.95                                             A
impressions                                              UPR or LWR must be
                                                         specified.
Splint                  D772       No        341.20      A laboratory fabricated resin         A
- resin                                                  splint that is used to stabilise
                        S772       No        445.10                                            A
- indirect                                               mobile or displaced teeth.


Splint                  D773       No        341.20      A metal splint that is used to        A
- metal                                      445.10      stabilise mobile or displaced
                        S773       No                                                          A
- indirect                                               teeth.
Obturator               D774       Yes        FBN                                              B
                        S774       Yes        FBN                                              B
Impression where        D776       No        45.20                                             A
required for denture    S776       No        45.20                                             A
repair/modification
Identification          D777       No        36.15       Limit of one (1) per denture.         A
                         S777      No        36.15                                             A

CATEGORY 800 ORTHODONTICS
Note 14: Specify upper or lower for each claim. For diagnostic services see Category 000.

REMOVABLE APPLIANCES
                                               FEE
                                  PRIOR         $                    SPECIAL
      DESCRIPTION        ITEM                                                               SCHEDULE
                                APPROVAL                             REMARKS
                                           (EXCL. GST)
Passive removable       D811       Yes        FBN        See Note 14.                          B
appliance – per arch                                     Limit of one (1) per jaw.
                        S811       Yes        FBN                                              B
Active removable        D821       Yes        FBN        See Note 14.                          B
appliance – per arch                                     Limit of one (1) per jaw.
                        S821       Yes        FBN                                              B
Functional              D823       Yes        FBN        See Note 14.                          B
orthopaedic appliance                                    Limit of one (1) per jaw.
                        S823       Yes        FBN                                              B


                                                35
FIXED APPLIANCES
                                               FEE
                                  PRIOR         $                   SPECIAL
     DESCRIPTION         ITEM                                                             SCHEDULE
                                APPROVAL                            REMARKS
                                           (EXCL. GST)
Partial banding         D829       Yes        FBN        See Note 14.                         B
- per arch                                               Limit of one (1) per jaw.
                         S829      Yes        FBN                                             B

Full arch banding       D831       Yes        FBN        See Note 14.                         B
– per arch                                               Limit of one (1) per jaw.
                         S831      Yes        FBN                                             B
Bonding of               S862      Yes        FBN                                             B
attachment for
application of
orthodontic force

COMPLETE ORTHODONTIC TREATMENT
                                               FEE
                                  PRIOR         $                   SPECIAL
     DESCRIPTION         ITEM                                                             SCHEDULE
                                APPROVAL                            REMARKS
                                           (EXCL. GST)
Complete course of      D881       Yes        FBN        See Note 14.                         B
orthodontic treatment    S881      Yes        FBN                                             B

CATEGORY 900 GENERAL SERVICES

EMERGENCIES

Note 15: If two or more emergency treatments (item 911) have been paid for an entitled person in the
previous six months, the provider must provide clinical justification if requested by DVA.

                                               FEE
                                  PRIOR         $                   SPECIAL
     DESCRIPTION         ITEM                                                             SCHEDULE
                                APPROVAL                            REMARKS
                                           (EXCL. GST)
Palliative care         D911       No        67.10       See Note 15.                         A
                         S911      No        89.30       Not to be claimed with an            A
                                                         extraction, endodontic or
                                                         restorative treatment on same
                                                         tooth.
After hours callout     D915       No        90.15       Flat fee is claimable as an          A
                                                         emergency loading for
                         S915      No        90.15                                            A
                                                         services provided after hours.
                                                         Limit of 3 per 3 month
                                                         period.




                                                36
PROFESSIONAL VISITS
                                                FEE
                                   PRIOR         $                   SPECIAL
     DESCRIPTION          ITEM                                                               SCHEDULE
                                 APPROVAL                            REMARKS
                                            (EXCL. GST)
Travel to provide        D916       No         65.55                                             A
services                 S916       No         65.55                                             A

Note: Kilometre Allowance
A kilometre allowance may be paid in addition to a fee for Item 916 (travel to provide services) if
you are required to travel from your normal place of business to visit an entitled person at home or
in an institution. The allowance will not be paid for the first 10 kilometres travelled and you must
be the nearest suitable provider to the entitled person.


DRUG THERAPY
                                                FEE
                                   PRIOR         $                   SPECIAL
     DESCRIPTION          ITEM                                                               SCHEDULE
                                 APPROVAL                            REMARKS
                                            (EXCL. GST)
Individually made        *D926      No        155.60      Limit of one (1) per arch per          A
tray – medicaments       *S926                            12 month period.
                                    No        155.60                                             A
                                                          Not to be claimed for
                                                          bleaching.


Provision of             *D927      No         27.00      For non-prescribable (non-             A
medication/              *S927                            RPBS) items – Fluoride &
                                    No         27.00                                             A
medicament                                                Chlorhexidine. Limit of one
                                                          (1) per three month period.



ANAESTHESIA AND SEDATION
                                                FEE
                                   PRIOR         $                   SPECIAL
     DESCRIPTION          ITEM                                                               SCHEDULE
                                 APPROVAL                            REMARKS
                                            (EXCL. GST)
Treatment under          D949       Yes        FBN        Items D949 and S949 are                B
general anaesthesia                                       only claimable in cases
                         S949       Yes        FBN                                               B
                                                          where the patient is not part
                                                          of a surgeons regular theatre
                                                          session




                                                 37
OCCLUSAL THERAPY
                                             FEE
                                PRIOR         $                    SPECIAL
     DESCRIPTION        ITEM                                                            SCHEDULE
                               APPROVAL                            REMARKS
                                          (EXCL. GST)
Minor occlusal          D961     Yes        FBN         Not related to any other           B
adjustment                                              procedure.
                        S961     Yes        FBN                                            B
- per visit
Clinical occlusal       D963     No         86.50       Limit of one (1) per three         A
analysis including                                      year period.
                        S963     No        121.05                                          A
muscle and joint
palpation
Registration and        D964     No         74.15       Limit of one (1) per three         A
mounting of casts for                                   year period.
                        S964     No         89.10                                          A
occlusal analysis
                                                        Cannot be claimed with items
                                                        500-899 inclusive.
Occlusal splint         D965     No        522.70                                          A
                        S965     No        875.45                                          A
Adjustment of pre-      D966     No         74.15       Limit of four (4) per 12           A
existing occlusal                                       months.
                        S966     No         88.55                                          A
splint – per visit
Occlusal adjustment     D968     No        103.85       Can only be claimed following      A
following occlusal                                      D/S963 and/or D/S964
                        S968     No        133.55                                          A
analysis – per visit                                    Limit of four (4) per year
Adjunctive physical     D971     No         74.15       Limit of four (4) per 12           A
therapy for                                             month period.
                        S971     No         89.10                                          A
temporomandibular
joint and associated
structures
Repair/addition –       D972     No        281.90                                          A
occlusal splint         S972     No        281.90                                          A




                                              38
MISCELLANEOUS
                                               FEE
                                  PRIOR         $                   SPECIAL
      DESCRIPTION        ITEM                                                            SCHEDULE
                                 APPROVAL                           REMARKS
                                            (EXCL. GST)
Splinting and            D981      No         95.05                                         A
stabilisation – direct   S981      No        121.05                                         A
– per tooth
Enamel stripping         D982      No         93.45                                         A
- per visit              S982      No         93.45                                         A
Single arch oral         D983      Yes        FBN         Only on diagnosis of sleep        B
appliance for                                             apnoea and prescription from
                         S983      Yes        FBN                                           B
diagnosed snoring                                         a respiratory or ENT
and obstructive                                           physician and consideration
snoring and sleep                                         of treatment with CPAP.
apnoea
Bi-maxillary oral        D984      Yes        FBN         Only on diagnosis of sleep        B
appliance for                                             apnoea and prescription from
                         S984      Yes        FBN                                           B
diagnosed snoring                                         a respiratory or ENT
and obstructive                                           physician and consideration
snoring and sleep                                         of treatment with CPAP.
apnoea
Post-operative care      *D986     No         69.20       Limit of two (2) per 12           A
where not otherwise      *S986                            month period.
                                   No         86.50                                         A
included



TREATMENT NOT OTHERWISE INCLUDED
                                               FEE
                                  PRIOR         $                   SPECIAL
      DESCRIPTION        ITEM                                                            SCHEDULE
                                 APPROVAL                           REMARKS
                                            (EXCL. GST)
Treatment not            D990      Yes        FBN         Exceptional use item only –       B
otherwise included                                        contact DVA
                         S990      Yes        FBN                                           B
(specify)




                                                39

				
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