21233 Three surfaces
| 20000 | RESTORATION |
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| 21000 | RESTORATIONS, AMALGAM |
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| 21200 | RESTORATIONS, AMALGAM, PERMANENT TEETH |
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| 21230 | Restorations, Amalgam, Bonded, Permanent Bicuspids and Anteriors |
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| 21233 | Three surfaces | $219.08 | $219.08 |