21120 Rertorations, Amalgam, Bonded, Primary Teeth
| 20000 | RESTORATION |
||
| 21000 | RESTORATIONS, AMALGAM |
||
| 21100 | RESTORATION, AMALGAM, PRIMARY TEETH |
||
| 21120 | Rertorations, Amalgam, Bonded, Primary Teeth | ||
| 21121 | One surface |
133.55 | 133.55 |
| 21122 | Two surfaces |
177.14 | 177.14 |
| 21123 | Three surfaces |
212.82 | 212.82 |
| 21124 | Four surfaces |
250.6 | 250.6 |
| 21125 | Five surfaces or maximum surfaces per tooth |
290.87 | 290.87 |