23105 Five surfaces (maximum surfaces per tooth)
| 20000 | RESTORATION |
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| 23000 | RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT SILVER FILINGS |
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| 23100 | RESTORATIONS, TOOTH COLOURED, PERMANENT ANTERIORS, NON BONDED TECHNIQUE |
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| 23105 | Five surfaces (maximum surfaces per tooth) | $244.02 | $244.02 |