23215 Five surfaces or maximum surface per tooth
| 20000 | RESTORATION |
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| 23000 | RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT SILVER FILINGS |
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| 23200 | RESTORATIONS, TOOTH COLOURED/ PLASTIC WITH/WITHOUT SILVER FILINGS, PERMANENT |
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| 23210 | Permanent Bicuspids |
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| 23215 | Five surfaces or maximum surface per tooth | $232.57 | $232.57 |