Restorative Services 88511 Metallic restoration one surface direct – – Metallic restoration two surfaces direct – – 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 – – – 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 – 88579 Bonding of tooth fragment 88586 Crown metallic with tooth preparation - preformed – – 88587 Crown metallic minimal tooth preparation preformed – – – 88597 Post direct – Item Service Metallic Restorations Direct Benefit ($) – – Metallic restoration one surface direct 104.25 – – Direct metallic restoration involving one surface of a 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. 88512 Metallic restoration two surfaces direct 127.80 – – 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.
Restorative Services 88511 Metallic restoration – one surface – direct Metallic restoration – two surfaces – direct 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 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 88579 Bonding of tooth fragment 88586 Crown – metallic – with tooth preparation - preformed 88587 Crown – metallic – minimal tooth preparation – preformed 88597 Post – direct Item Service – Metallic Restorations – Direct Benefit ($) Metallic restoration – one surface – direct Direct metallic restoration involving one surface of a 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
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