21212 Two surfaces
| 20000 | RESTORATION |
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| 21000 | RESTORATIONS, AMALGAM |
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| 21200 | RESTORATIONS, AMALGAM, PERMANENT TEETH |
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| 21210 | Restorations, Amalgam, Non-Bonded, Permanent Bicuspids and Anteriors |
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| 21212 | Two surfaces | $139.98 | $139.98 |