41212 Two units
| 40000 | PERIODONTICS |
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| 41000 | PERIODONTAL SERVICES, NON SURGICAL |
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| 41200 | ORAL DISEASE, Management of |
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| 41210 | Oral Manifestations, Oral Mucosal Disorders, Mucocutaneous disorders and diseases of localized |
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| 41212 | Two units | $166.84 | $166.84 |