| Metallic restoration –one surface –direct | 511
| Limit of 1 restorative service (511-535) to be reimbursed per tooth per day (see above note). | 120.82 | U, G
|
| Metallic restoration –two surfaces –direct | 512 | Limit of 1 restorative service (511-535) to be reimbursed per tooth per day (see above note). | 148.05 | U, G |
| Metallic restoration –three surfaces –direct | 513 | Limit of 1 restorative service (511-535) to be reimbursed per tooth per day (see above note).
| 176.77 | U, G |
| Metallic restoration –four surfaces –direct | 514 | Limit of 1 restorative service (511-535) to be reimbursed per tooth per day (see above note). | 201.50 | U, G |
| Metallic restoration –five surfaces –direct | 515 | Limit of 1 restorative service (511-535) to be reimbursed per tooth per day (see above note). | 230.01 | U, G |
Adhesive restoration –one surface –anterior tooth –direct | 521 | Limit of 1 restorative service (511-535) to be reimbursed per tooth per day (see above note). Limit of 5 adhesive single surface restorations (521/531) per day | 133.82 | U, G |
| Adhesive restoration –two surfaces –anterior tooth –direct | 522 | Limit of 1 restorative service (511-535) to be reimbursed per tooth per day (see above note). | 162.44 | U, G |
| Adhesive restoration –three surfaces –anterior tooth –direct | 523 | Limit of 1 restorative service (511-535) to be reimbursed per tooth per day (see above note). | 192.37 | U, G |
| Adhesive restoration –four surfaces –anterior tooth –direct | 524 | Limit of 1 restorative service (511-535) to be reimbursed per tooth per day (see above note). | 222.36 | U, G |
| Adhesive restoration –five surfaces –anterior tooth –direct | 525 | Limit of 1 restorative service (511-535) to be reimbursed per tooth per day (see above note). | 261.27 | U, G |
Adhesive restoration –one surface –posterior tooth –direct | 531 | Limit of 1 restorative service (511-535) to be reimbursed per tooth per day (see above note). Limit of 5 adhesive single surface restorations (521/531) per day | 142.95 | U, G |
| Adhesive restoration –two surfaces –posterior tooth –direct | 532 | Limit of 1 restorative service (511-535) to be reimbursed per tooth per day (see above note). | 179.47 | U, G |
| Adhesive restoration –three surfaces –posterior tooth –direct | 533 | Limit of 1 restorative service (511-535) to be reimbursed per tooth per day (see above note). | 215.73 | U, G |
| Adhesive restoration –four surfaces –posterior tooth –direct | 534 | Limit of 1 restorative service (511-535) to be reimbursed per tooth per day (see above note). | 243.02 | U, G |
| Adhesive restoration –five surfaces –posterior tooth –direct | 535 | Limit of 1 restorative service (511-535) to be reimbursed per tooth per day (see above note). | 280.65 | U, G |
| Provisional (intermediate/temporary) restoration –per tooth | 572 | Limit of 3 per three month period. Not claimable with endodontic items except 419. Not claimable with restorative item numbers (511-535) on same tooth on same day. | 56.51 | U, G |
| Metal band | 574 | | 47.63 | U, G |
| Pin retention -per pin | 575 | Limit of 3 per tooth. Limit of 6 per voucher.
| 32.59 | U, G
|
Cusp capping -per cusp
| 577
| Limit of 2 per tooth.
| 35.14
| U, G
|
Restoration of an incisal corner
-per corner
| 578
| Limit of 2 per tooth.
| 35.14
| U, G
|
Crown –metallic –with tooth preparation –preformed
| 586
| Not claimable with restorative item numbers (511-535) on same tooth.
No other crown item number to be claimed on the same tooth within six months.
| 297.89
| G
|
Crown -metallic -minimal tooth preparation -preformed
| 587
| Not claimable with restorative item numbers (511-535) on same tooth.
No other crown item number to be claimed on the same tooth within six months.
| 176.77
| G
|
Recementing of indirect restoration
| 596
| | 91.75
| U, G
|
|
|
| | |