21124 Four surfaces
| 20000 | RESTORATION |
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| 21000 | RESTORATIONS, AMALGAM |
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| 21100 | RESTORATION, AMALGAM, PRIMARY TEETH |
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| 21120 | Rertorations, Amalgam, Bonded, Primary Teeth |
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| 21124 | Four surfaces | $250.6 | $250.6 |