21221 One surface
| 20000 | RESTORATION |
||
| 21000 | RESTORATIONS, AMALGAM |
||
| 21200 | RESTORATIONS, AMALGAM, PERMANENT TEETH |
||
| 21220 | Restorations, Amalgam, Non-Bonded, Permanent Molars |
||
| 21221 | One surface | $118.25 | $118.25 |