41222 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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| 41220 | Nervous and Muscular Disorders, Disorders of facial sensation and motor dysfunction at the jaw, e.g. |
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| 41222 | Two units | $166.84 | $166.84 |