21220 Restorations, Amalgam, Non-Bonded, Permanent Molars
| 20000 | RESTORATION |
||
| 21000 | RESTORATIONS, AMALGAM |
||
| 21200 | RESTORATIONS, AMALGAM, PERMANENT TEETH |
||
| 21220 | Restorations, Amalgam, Non-Bonded, Permanent Molars | ||
| 21221 | One surface |
118.25 | 118.25 |
| 21222 | Two surfaces |
146.93 | 146.93 |
| 21223 | Three surfaces |
200.71 | 200.71 |
| 21224 | Four surfaces |
253.1 | 253.1 |
| 21225 | Five surfaces or maximum surfaces per tooth |
282.95 | 282.95 |