21113 Three surfaces
| 20000 | RESTORATION |
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| 21000 | RESTORATIONS, AMALGAM |
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| 21100 | RESTORATION, AMALGAM, PRIMARY TEETH |
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| 21110 | Rertorations, Amalgam, Non-Bonded, Primary Teeth |
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| 21113 | Three surfaces | $184.01 | $184.01 |