04733 Three units
| 00000 | DIAGNOSTIC |
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| 04000 | TEST/ANALYSIS/LABORATORY PROCEDURES/INTERPRETATION AND/OR REPORTS |
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| 04700 | SUPPLEMENTARY DIAGNOSTIC PROCEDURES (INTERPRETATION ONLY) |
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| 04730 | Split Cast Mounting, Diagnostic |
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| 04733 | Three units |
$233.72
+Lab Costs |
$233.72
+Lab Costs |