23405 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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| 23400 | RESTORATIONS, TOOTH COLORED, PRIMARY, ANTERIOR, NON BONDED |
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| 23405 | Five surfaces (maximum surfaces per tooth) | $250.28 | $250.28 |