21224 Four 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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| 21224 | Four surfaces | $253.1 | $253.1 |