21223 Three surfaces
| 20000 | RESTORATION |
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| 21000 | RESTORATIONS, AMALGAM |
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| 21200 | RESTORATIONS, AMALGAM, PERMANENT TEETH |
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| 21220 | Restorations, Amalgam, Non-Bonded, Permanent Molars |
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| 21223 | Three surfaces | $200.71 | $200.71 |