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{ -.,CHEDULE OF BENEFITS AND COPAL ,ANT'S <br />CITY OF SANTA A T <br />CLIENT #41 <br />PRO C <br />CPA4YMNT <br />CODE <br />MEMBER SERVICES: <br />MEMBLR PAYS: <br />DIAGNOSTIC TREATMENT: <br />00110 <br />INITLAL ORAL. EXAM <br />NO CHARGE <br />00111 <br />INITIAL ORAL ELI - CHILD <br />NO CHARGE <br />00120 <br />PERIODIC ORAL EXAM <br />NO CHARGE <br />00130 <br />EMERGENCY ORAL EXAM <br />NO CHARGE <br />00210 <br />INTRAORAL } COMPLETE SERIES (INCLUDING BITEWIN <br />NO CHARGE <br />00220 <br />IN'I I_, } PERIAPICAL FIRST FILM <br />NO CHARGE <br />00230 <br />INTRA RAL - PERIAPICAL - EACH ADDITIONAL FILM <br />NO CHARGE <br />00240 <br />INTRARAL - OCCLUSAL FILM <br />NO CHARGE <br />00250 <br />EXTRA ORAL - FIRST FILM <br />NO CHARGE <br />00260 <br />EXTRA ORAL - EACH ADDITIONAL FILM <br />NO CHARGE <br />00270 <br />BITEWING - SINGLE FILM <br />NO CHARGE <br />00272 <br />BITE N - TWO FILMS <br />NO CHARGE <br />00273 <br />BTTEWINGS - THREE FILMS <br />NO CHARGE <br />00274 <br />BTTE�&qN S - FOUR FILMS <br />NO CHARGE <br />00275 <br />BITEWINGS - EACH ADDITIONAL FILM <br />NO CHARGE <br />00330 <br />PANORAMIC FILM <br />NO CHARGE <br />00460 <br />PULP VITALITY TESTS <br />NO CHARGE <br />00470 <br />DIAGNOSTIC CAS'T'S <br />NO CHARGE <br />00471 <br />DIAGNOSTIC PHOTOGRAPHS <br />N CHARGE <br />PRENTNTP& S R qCE . <br />01110 <br />PROPHYLAXIS - ADULT <br />NO CHARGE <br />01120 <br />PROPHYLAXIS YLAXI - CHILD <br />NO CHARGE <br />01201 <br />TOPICAL APPLICATION OF FLUORIDE <br />(INCLUDING PROPHYLAXIS) ` CHILD <br />NO CHARGE <br />01203 <br />TOPICAL APPLICATION OF FLUORIDE <br />(EXCLUDING PROPHYLAXIS) - CHILD <br />NO CHARGE <br />01204 <br />TOPICAL APPLICATION OF FLUORIDE <br />(EXCLUDING PROPHYLAXIS) - ADULT <br />NO CHARGE <br />01205 <br />TOPICAL. APPLICATION N F FLUORIDE <br />(INCLUDING PROPHYLAXIS) ADULT <br />NO CHARGE <br />01330 <br />ORAL HYGIENE INSTRUCTION <br />NO CHARGE <br />01351 <br />SE - PER TOOTH <br />NO CHARGE <br />01510 <br />SPACE MAINTAINER - FIXED - UNTLATERAL <br />NO CHARGE <br />01515 <br />SPACE MAINTAINER - FIXED BILATERAL. <br />NO CHARGE <br />01520 <br />SPACE MAINTAINER - REMOVABLE # UNILATERAL <br />NO CHARGE <br />01525 <br />SPACE MAINTAINER - REMOVABLE - BILATERAL <br />NO CHARGE <br />01-550 <br />RCEMENTATIN OF SPACE MAINTAINER <br />NO CHARGE <br />