SAFEGUARD HEALTH PLANS, INC. -1992

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-.,CHEDULE OF BETE 'I i S AND COPAL. �NTS CITY OF SANTA ANTA CLIENT #41 COA`MNT PRO C COTE MEMBER SERVICES: MEMBER PAD'S: RESTORATIVE TREATMENT: 02110 AMALGAM - ONE SURFACE, PRIMARY NO CHARGE 02120 AMALGAM - TWO SURFACES, PRIMARY NO CHARGE 221 GAM - THREE S RF CESy PRIMARY NO CHARGE 02131 AMALGAM - FOUR SURFACES, PRIMARY O CHARGE 02140 AMALGAM - ONE SURFACE, PERMANENT NO CHARGE 02150 AMALGAM - TWO SURFACES, PERMANENT NO CHARGE 02160 AMALGAM - THREE SURFACES, PERMANENT NO CHARGE 02161 AMALGAM - FOUR OR MORE SURFACES, PERMANENT NO CHARGE 02210 SILICATE CEMENT - PER RESTORATION NO CHARGE 02310 COMPOSITE RESTORATION NO CHARGE 02330 RESIN - ONE SURFACE, ANTERIOR NO CHARGE 02331 RESIN - TWO SURFACES, ANTERIOR NO CHARGE 02332 RESIN - THREE SI, F CES, ANTERIOR NO CHARGE 02335 RESIN - FOUR OR MORE SURFACES, ANTERIOR NO CHARGE CROWNS R BRIDGES - PER UNIT: 02740 PORCELAIN CERAMIC. SUBSTRATE NO CAGE 02750 PORCELAIN FUSED TO HIGH METAL NO CHARGE 02751 PORCELAIN FUSED TO PREDOMINANTLY BASE METAL NO CHARGE 02752 PORCELAIN FUSED TO NOBLE METAL NO CHARGE 02790 FALL CAST HIGH NOBLE METAL NO CHARGE 02791 FULL CAST PREDOMINANTLY BASE METAL NO CHARGE 02792 FULL CAST NOBLE METAL NO CHARGE 02810 3 OAST METALLIC NO CHARGE 02830 STAINLESS STEEL. CROP NO CHARGE 02891 CAST POST & CORE NO CHARGE 02892 DOWEL POST WITH CORE NO CAGE 02910 REOENIENT UqlAy NO CHARGE 02920 RECEMENT CROWS NO CHARGE 02930 RECEMENT BRIDGE NO CHARGE 02940 SEDATIVE FILLING NO CHARGE 02950 CROWN BUILDUP, INCLUDING ANY PINS NO CHARGE 02951 PIN RETENTION ` PER TOOTH, IN ADDITION TO RESTORATION NO CHARGE 02952 CAST POST AND CORE IN ADDITION TO CROWN NO CHARGE 02953 CAST POST AS PART OF CROWN NO CHARGE 02954 PREFABRICATED POST AND CORE I' ADDITION TO CROWN NO CHARGE