21210 Restorations, Amalgam, Non-Bonded, Permanent Bicuspids and Anteriors
| 20000 | RESTORATION |
||
| 21000 | RESTORATIONS, AMALGAM |
||
| 21200 | RESTORATIONS, AMALGAM, PERMANENT TEETH |
||
| 21210 | Restorations, Amalgam, Non-Bonded, Permanent Bicuspids and Anteriors | ||
| 21211 | One surface |
111.99 | 111.99 |
| 21212 | Two surfaces |
139.98 | 139.98 |
| 21213 | Three surfaces |
196.54 | 196.54 |
| 21214 | Four surfaces |
241.62 | 241.62 |
| 21215 | Five surfaces or maximum surfaces per tooth |
263.12 | 263.12 |