Guide to the Child Dental Benefits Schedule



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Restorative Services


88511 Metallic restoration – one surface – direct

88512 Metallic restoration – two surfaces – direct

88513 Metallic restoration – three surfaces – direct

88514 Metallic restoration – four surfaces – direct

88515 Metallic restoration – five surfaces – direct

88521 Adhesive restoration – one surface – anterior tooth – direct

88522 Adhesive restoration – two surfaces – anterior tooth – direct

88523 Adhesive restoration – three surfaces – anterior tooth – direct

88524 Adhesive restoration – four surfaces – anterior tooth – direct

88525 Adhesive restoration – five surfaces – anterior tooth – direct

88531 Adhesive restoration – one surface – posterior tooth – direct

88532 Adhesive restoration – two surfaces – posterior tooth – direct

88533 Adhesive restoration – three surfaces – posterior tooth – direct

88534 Adhesive restoration – four surfaces – posterior tooth – direct

88535 Adhesive restoration – five surfaces – posterior tooth – direct

88572 Provisional (intermediate/temporary) restoration – per tooth

88574 Metal band

88575 Pin retention – per pin

88576 Metallic crown – preformed

88579 Bonding of tooth fragment

88597 Post – direct

Item

Service – Metallic Restorations – Direct

Benefit ($)

88511
Metallic restoration – one surface – direct

Direct metallic restoration involving one surface of a tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
Applicable restrictions

Limit of one (1) service under 88511-88535 per tooth per day.
104.25
88512
Metallic restoration – two surfaces – direct

Direct metallic restoration involving two surfaces of a tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
Applicable restrictions

Limit of one (1) service under 88511-88535 per tooth per day.
127.80
88513
Metallic restoration – three surfaces – direct

Direct metallic restoration involving three surfaces of a tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
Applicable restrictions

Limit of one (1) service under 88511-88535 per tooth per day.
152.50
88514
Metallic restoration – four surfaces – direct

Direct metallic restoration involving four surfaces of a tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
Applicable restrictions

Limit of one (1) service under 88511-88535 per tooth per day.
173.85
88515
Metallic restoration – five surfaces – direct

Direct metallic restoration involving five surfaces of a tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
Applicable restrictions

Limit of one (1) service under 88511-88535 per tooth per day.
198.45



Item

Service – Adhesive Restorations – Anterior Teeth – Direct

Benefit ($)

88521
Adhesive restoration – one surface – anterior tooth – direct

Direct restoration, using an adhesive technique and a tooth-coloured material, involving one surface of an anterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
Applicable restrictions

Limit of one (1) service under 88511-88535 per tooth per day.

Limit of five (5) single-surface adhesive restorations (88521 or 88531) per day.


115.45
88522
Adhesive restoration – two surfaces – anterior tooth – direct

Direct restoration, using an adhesive technique and a tooth-coloured material, involving two surfaces of an anterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
Applicable restrictions

Limit of one (1) service under 88511-88535 per tooth per day.
140.15
88523
Adhesive restoration – three surfaces – anterior tooth – direct

Direct restoration, using an adhesive technique and a tooth-coloured material, involving three surfaces of an anterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
Applicable restrictions

Limit of one (1) service under 88511-88535 per tooth per day.
166.00
88524
Adhesive restoration – four surfaces – anterior tooth – direct

Direct restoration, using an adhesive technique and a tooth-coloured material, involving four surfaces of an anterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
Applicable restrictions

Limit of one (1) service under 88511-88535 per tooth per day.
191.85
88525
Adhesive restoration – five surfaces – anterior tooth – direct

Direct restoration, using an adhesive technique and a tooth-coloured material, involving five surfaces of an anterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
Applicable restrictions

Limit of one (1) service under 88511-88535 per tooth per day.
225.45



Item

Service – Adhesive Restorations – Posterior Teeth – Direct

Benefit ($)

88531
Adhesive restoration – one surface – posterior tooth – direct

Direct restoration, using an adhesive technique and a tooth-coloured material, involving one surface of a posterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
Applicable restrictions

Limit of one (1) service under 88511-88535 per tooth per day.

Limit of five (5) single-surface adhesive restorations (88521 or 88531) per day.


123.30
88532
Adhesive restoration – two surfaces – posterior tooth – direct

Direct restoration, using an adhesive technique and a tooth-coloured material, involving two surfaces of a posterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
Applicable restrictions

Limit of one (1) service under 88511-88535 per tooth per day.
154.80
88533
Adhesive restoration – three surfaces – posterior tooth – direct

Direct restoration, using an adhesive technique and a tooth-coloured material, involving three surfaces of a posterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
Applicable restrictions

Limit of one (1) service under 88511-88535 per tooth per day.
186.10
88534
Adhesive restoration – four surfaces – posterior tooth – direct

Direct restoration, using an adhesive technique and a tooth-coloured material, involving four surfaces of a posterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
Applicable restrictions

Limit of one (1) service under 88511-88535 per tooth per day.
209.70
88535
Adhesive restoration – five surfaces – posterior tooth – direct

Direct restoration, using an adhesive technique and a tooth-coloured material, involving five surfaces of a posterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
Applicable restrictions

Limit of one (1) service under 88511-88535 per tooth per day.
242.20



Item

Service – Other Restorative Services

Benefit ($)

88572
Provisional (intermediate/temporary) restoration – per tooth

The provisional (intermediate) restoration of a tooth designed to last until the definitive restoration can be constructed or the tooth is removed. This item should only be used where the provisional (intermediate) restoration is not an intrinsic part of treatment. It does not include provisional (temporary) sealing of the access cavity during endodontic treatment or during construction of indirect restorations.
Applicable restrictions

Limit of three (3) per 3 month period.

A benefit does not apply if a benefit has been paid for item 88411, 88414, 88415, 88416, 88417, 88418, 88421, 88455 or 88458 on the same day.


48.75
88574
Metal band

The cementation of a metal band for diagnostic, protective purposes or for the placement of a provisional (intermediate) restoration.
41.05
88575
Pin retention – per pin

Use of a pin to aid the retention and support of direct or indirect restorations in a tooth.
Applicable restrictions

Limit of two (2) per tooth per day.

Limit of four (4) per day

A benefit only applies if the service is provided on the same tooth on the same day of a service under item 88511-88535.

28.05
88576
Metallic crown – preformed

Placing a preformed metallic crown as a coronal restoration for a tooth.
257.05
88579
Bonding of tooth fragment

The direct bonding of a tooth fragment as an alternative to placing a restoration.
96.85
88597
Post – direct

Insertion of a post into a prepared root canal to provide an anchor for an artificial crown or other restoration.
Applicable restrictions

Limit of two (2) per tooth per day.

A benefit only applies if the service is provided on the same tooth on the same day of a service under item 88511-88535.


88.15

Prosthodontics


88721 Partial maxillary denture – resin, base only

88722 Partial mandibular denture – resin, base only

88731 Retainer – per tooth

88733 Tooth/teeth (partial denture)

88736 Immediate tooth replacement – per tooth

88741 Adjustment of a denture

88761 Reattaching pre-existing clasp to denture

88762 Replacing/adding clasp to denture – per clasp

88764 Repairing broken base of a partial denture

88765 Replacing/adding new tooth on denture – per tooth

88766 Reattaching existing tooth on denture – per tooth

88768 Adding tooth to partial denture to replace an extracted or decoronated tooth – per tooth

88776 Impression - dental appliance repair/modification

Item

Service – Dentures and Denture Components

Benefit ($)

88721
Partial maxillary denture – resin, base only

Provision of a resin base for a removable dental prosthesis for the maxilla where some natural teeth remain.
Applicable restrictions

Limit of one (1) per 24 month period.
322.95
88722
Partial mandibular denture – resin, base only

Provision of a resin base for a removable dental prosthesis for the mandible where some natural teeth remain.
Applicable restrictions

Limit of one (1) per 24 month period.
322.95
88731
Retainer – per tooth

A retainer or attachment fitted to a tooth to aid retention of a partial denture. The number of retainers should be indicated.
Applicable restrictions

Limit of four (4) per denture base (88721 or 88722).
44.05
88733
Tooth/teeth (partial denture)

An item to describe each tooth added to the base of a new partial denture. The number of teeth should be indicated.
Applicable restrictions

Limited to anterior teeth.

Limit of four (4) per denture base (88721 or 88722).


67.00
88736
Immediate tooth replacement – per tooth

Provision within a denture to allow immediate replacement of an extracted tooth. The number of teeth so replaced should be indicated.
Applicable restrictions

Limit of four (4) per denture base (88721 or 88722).
9.10



Item

Service – Denture Maintenance

Benefit ($)

88741
Adjustment of a denture

Adjustment of a denture to improve comfort, function or aesthetics. This item does not apply to routine adjustments following the insertion of a new denture or the maintenance or repair of an existing denture.
Applicable restrictions

A benefit does not apply if the service is provided within 12 months of a service under items 88721 or 88722 by the same provider.
52.50



Item

Service – Denture Repairs

Benefit ($)

88761
Reattaching pre-existing clasp to denture

Repair, insertion and adjustment of a denture involving re-attachment of a pre-existing clasp.
144.20
88762
Replacing/adding clasp to denture – per clasp

Repair, insertion and adjustment of a denture involving replacement or addition of a new clasp or clasps.
150.65
88764
Repairing broken base of a partial denture

Repair, insertion and adjustment of a broken resin partial denture base.
144.20
88765
Replacing/adding new tooth on denture – per tooth

Repair, insertion and adjustment of a denture involving replacement with or addition of a new tooth or teeth to a previously existing denture.
150.65
88766
Reattaching existing tooth on denture – per tooth

Repair, insertion and adjustment of a denture involving reattachment of a pre-existing denture tooth or teeth.
144.20
88768
Adding tooth to partial denture to replace an extracted or decoronated tooth – per tooth

Modification, insertion and adjustment of a partial denture involving an addition to accommodate the loss of a natural tooth or its coronal section
Applicable restrictions

Limit of eight (8) per 24 month period.
152.50



Item

Service - Other Prosthodontic Services

Benefit ($)

88776
Impression – dental appliance repair/modification

An item to describe taking an impression where required for the repair or modification of a dental appliance.
46.05

General Services


88911 Palliative care

88942 Sedation – intravenous

88943 Sedation – inhalation

Item

Service – Emergencies

Benefit ($)

88911
Palliative care

An item to describe interim care to relieve pain, infection, bleeding or other problems not associated with other treatment.
Applicable restrictions

A benefit does not apply if the service is provided on the same day as any other service by the same provider.
68.35



Item

Service – Sedation

Benefit ($)

88942
Sedation – intravenous

Sedative drug(s) administered intravenously, usually in increments. The incremental administration may continue while dental treatment is being provided.
Applicable restrictions

Limit of one (1) per 12 month period.
134.00
88943
Sedation – inhalation

Nitrous oxide gas mixed with oxygen is inhaled by the patient while dental treatment is being provided.
67.00




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