Percentage Payable – 80% of Applicable Fee Guide

Expenses incurred for the following items are considered eligible expenses:

1. Diagnostic Services
   • oral examinations, once every 12 months
   • occlusal, posterior bitewing or extra-oral films, limited to 4 of each type every 12 months
   • full mouth films once every 12 months
   • single films, limited to 10 every 12 months
   • consultation required by the attending dentist
2. Preventative Services
   • one unit of scaling and one unit of polishing, once every 12 months
   • topical fluoride treatment, once every 12 months
   • provision of space maintainers for missing primary teeth
   • provision of habit breaking appliances
3. Restorative Services
   • amalgam, silicate, acrylic and composite restorations
4. Endodontic Services
   • treatment of the diseases of the dental pulp (including root canal therapy)
5. Periodontal Services
   • treatment of diseases of the gums and other supporting tissue of the teeth including:
     1. scaling not covered under preventative services and root planing up to a combined maximum of 16 units per calendar year;
     2. provisional splinting; and
     3. occlusal equilibration, up to a maximum of 8 units per calendar year.

     However, procedures for guided tissue regeneration are considered eligible only if performed in conjunction with the following periodontal surgical procedures: Flap approach or Osseous grafts – autographs or allografts, provided natural teeth are involved.

6. Prosthodontic Services
   • relining, rebasing, and repairing an existing denture
   • repairing an existing bridge
7. Surgical Services
   • the following items required in relation to dental surgery:
     1. diagnostic radiographs
     2. laboratory procedures
     3. general anaesthetic
        • extractions (including extractions of impacted teeth)
        • simple alveolectomy at the time of tooth extraction
        • removal of tumours, cysts, neoplasms, plus the incision and drainage of an abscess
8. Protective athletic appliances for the teeth, limited to 1 in every 12 months.