28102 Natural Tooth Preparation and Fluoride Application, Vital Tooth
| 20000 | RESTORATION |
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| 28000 | RESTORATIVE PROCEDURES, OVERDENTURES |
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| 28100 | RESTORATIVE PROCEDURES, OVERDENTURES, DIRECT |
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| 28102 | Natural Tooth Preparation and Fluoride Application, Vital Tooth | $273.25 | $273.25 |