21110 Rertorations, Amalgam, Non-Bonded, Primary Teeth
| 20000 | RESTORATION |
||
| 21000 | RESTORATIONS, AMALGAM |
||
| 21100 | RESTORATION, AMALGAM, PRIMARY TEETH |
||
| 21110 | Rertorations, Amalgam, Non-Bonded, Primary Teeth | ||
| 21111 | One surface |
101.55 | 101.55 |
| 21112 | Two surfaces |
134.44 | 134.44 |
| 21113 | Three surfaces |
184.01 | 184.01 |
| 21114 | Four surfaces |
224.92 | 224.92 |
| 21115 | Five surfaces or maximum surfaces per tooth |
263.12 | 263.12 |