SAFEGUARD HEALTH PLANS, INC. -1992

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-jCDIL BENEFITS AND CPj, 5 CITY OF SANTA i A A, CLIENT #1 COPAYMENT PC CODE MEMBER SERVICES: MEMBER PAYS: PROSTHETICS CONTINUED., 05410 ADJUST CmPL,ETE DENTURE - UPPER NO CHARGE 05411 ADJUST COMPLETE DENTURE - LOWER NO CHARGE 05421 ADJUST PARTIAL DENTURE - UPPER NO CHARGE 05422 ADJUST PARTIAL DENTURE } LOVER NO CHARGE 05510 REPAIR BROKEN COMPLETE DENTURE BASE NO CHARGE 05520 REPLACE MISSING OR BROKEN TEETH - NO CHARGE COMPLETE DENTURE (EACH TOOTH) NO CHARGE 05610 REPAIR RESIN ACRYLIC SADDLE OR BASE NO CHARGE 05620 REPAIR CAST FRAMEWORK NO CHARGE 05630 REPAIR OR REPLACE BROKEN CLASP NO CHARGE 05640 REPLACE BROKEN TEETH - PER TOOTH NO CHARGE 05650 ADD TOOTH TO EXISTING PARTIAL DENTURE NO CHARGE 05660 ADD CLASP TO EXISTING PARTIAL DENTURE NO CHARGE 05710 REBASE COMPLETE UPPER DENTURE NO CHARGE 05711 REBASE C OMPLETE LOWER ER DENTURE NO CHARGE 05720 REBASE PARTIAL UPPER DENTURE NO CHARGE 05721 REBASE PARTIAL L IA ER DEERE NO CHARGE 05730 RELINE COMPLETE UPPER DENTURE CHASIDE NO CAGE 05731 RELU�E COMPLETE LOWER DENTURE CHAIRSI E NO CHARGE 05740 RELINE UPPER PARTIAL DENTURE (LABORATORY) NO CHARGE 05741 RELINE L NNTR PARTIAL DENTURE (LABORATORY) NO CHARGE 05820 STA 'PLATE DENTURE (UPPER) NO CHARGE 05821 STAYPLATE DENTURE (LOWER) NO CHARGE 05850 TISSUE CONDITIONING } PER DENTURE UNIT NO CHARGE ORAL SURGERY: 07110 SINGLE TOOTH NO CHARGE 07120 EACH ADDITIONAL TOOTH NO CHARGE 07210 SURGICAL. REMOVAL OF ERUPTED TOOTH REQUIRING ELEVATION OF MUCOPERIOSTEAL FLAP AND REMOVAL F BONE AND/OR R SECTION OF TOOTH NO CHARGE 07220 REMOVAL OF IMPACTED TOOTH - SOFT TISSUE NO CHARGE 07230 REMOVAL OF IMPACTED TOOTH - PARTIAL BONY NO CILARGE 07240 REMOVAL OF IMPACTED TOOTH - COMPLETE BONY NO CHARGE 07285 BIOPSY OF ORAL TISSUE - LARD NO CHARGE 07286 BIOPSY OF ORAL TISSUE - SOFT NO CHARGE 07310 ALE PLASTY IN CONJUNCTION WITH EXTRACTIONS - PER QUAD. NO CHARGE 07320 ALEPL.ASTY NOT IN CONJUNCTION WITH EXTRACTIONS - PER QUAD. NO CHARGE 07960 FRENECTDMY NO CHARGE