21230 Restorations, Amalgam, Bonded, Permanent Bicuspids and Anteriors
| 20000 | RESTORATION |
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| 21000 | RESTORATIONS, AMALGAM |
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| 21200 | RESTORATIONS, AMALGAM, PERMANENT TEETH |
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| 21230 | Restorations, Amalgam, Bonded, Permanent Bicuspids and Anteriors | ||
| 21231 | One surface |
141.9 | 141.9 |
| 21232 | Two surfaces |
176.1 | 176.1 |
| 21233 | Three surfaces |
219.08 | 219.08 |
| 21234 | Four surfaces |
262.08 | 262.08 |
| 21235 | Five surfaces or maximum surfaces per tooth |
294.0 | 294.0 |