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r--- 01204 ~-~-----~- -~~~ -~~----~. -~-~-~_._-~---~------, Topical application of fluoride (excluding prophylaxis) - - adult Space maintenance (passive appliances) 01510 01515 01520 01525 Space maintainer -- fixed unilateral Space maintainer -- fixed bilateral Space maintainer -- removable unilateral Space maintainer -- removable bilateral 02000-02999 -- RESTORATIVE Amalgam restorations (including polishing) 02110 02120 02130 02131 02140 02150 02160 02161 Amalgam -- Amalgam -- Amalgam -- Amalgam -- Amalgam -- Amalgam -- Amalgam -- Amalgam -- one surface, primary two surfaces, primary three surfaces, primary four or more surfaces, primary one surface, permanent two surfaces, permanent three surfaces, permanent four or more surfaces, permanent Silicate restorations 02210 Silicate cement -- per restoration Filled or unfilled resin restorations 02330 02335 02380 02381 02382 02385 02386 02387 Resin -- anterior Resin -- four or more surfaces or involving incisal angle (anterior) Resin -- one surface, posterior -- primary Resin -- two surfaces, posterior -- primary Resin -- three or more surfaces,posterior, primary Resin -- one surface, posterior -- permanent Resin -- two surfaces, posterior -- permanent Resin -- three or more surfaces, posterior --permanent Inlay restorations 02510 02520 02530 02540 02650 Inlay -- metallic -- one surface Inlay -- metallic -- two surfaces Inlay -- metallic -- three surfaces Onlay -- metallic -- per tooth (in addition Inlay -- composite/resin -- one surface, processed) to inlay) (laboratory 2 ~ ----- -~---~ - -------------~--