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'CHEDULE OF BENEFITS AND C PA ENTS <br />CITE' OF SANTA AAA <br />CLINT #I <br />R C <br />C PA <br />CODE <br />MEMBER SERVICES. <br />MEMBER PA.'S. <br />END ICS : <br />03110 <br />PULP CAP - DIRECT (EXCLUDING FINAL RESTORATION) <br />NO CHARGE <br />03120 <br />PULP CAP - INDIRECT (EXCLUDING FINAL RESTORATION) <br />NO CHARGE <br />03220 <br />THERAPEUTIC P LP T MY EXCL. FINAL. RESTORATION) <br />NO CHARGE <br />03310 <br />ANTERIOR (EXCLUDING FINAL RESTORATION) <br />NO CHARGE <br />03320 <br />BICUSPID (EXCLUDING FINAL RES'T'ORATION) <br />NO CHARGE <br />03410 <br />APIC ECT MY (PER TOOTH) - FIRST ROOT <br />NO CHARGE <br />03411 <br />APIC ECT M (PER TOOTH) - EACH ADDITIONAL ROOT <br />NO CHARGE <br />03430 <br />RETROGRADE SLING - PER ROOT <br />NO CHARGE <br />03940 <br />RECAL.CIFICATI ON <br />NO CHARGE <br />PERIODONTICS: <br />04210 <br />GINGIVECT MY OR GIN IV PL.AST ' PER QUADRANT <br />NO CHARGE <br />04220 <br />GINGIVAL CURETTAGE <br />NO CHARGE <br />04260 <br />OSSEOUS SURGERY (INCLUDING FLAP ENTRY <br />AND CLOSURE) i PER QUADRANT <br />NO CHARGE <br />04330 <br />OCCLUSAL ADJUSTMENT t PER OUADRANT <br />NO CHARGE <br />04331 <br />OCCLUSAL ADJUSTMENT COMPLETE <br />NO CHARGE <br />04341 <br />PERIODONTAL SCALING AND ROOT PLANING - PER QUAD. <br />NO CHARGE <br />04345 <br />PERIODONTAL SCALING PERFORMED IN THE PRESENCE OF <br />GINGIVAL INFLAMMATION <br />NO CHARGE <br />04910 <br />PERIODONTAL MMNTENANCE PROCEDURE <br />NO CHARGE <br />04930 <br />PERIODONTAL ABSCESS <br />NO CHARGE <br />PROSTHETICS. <br />0110 <br />COMPLETE TAPPER DENTURE <br />NO CHARGE <br />05120 <br />COMPLETE LEER DENTURE <br />NO CHARGE <br />05130 <br />]IMMEDIATE UPPER DENTURE <br />NO CHARGE <br />05140 <br />IMMEDIATE TE LOWER DENTURE <br />NO CHARGE <br />05211 <br />UPPER PARTIAL ACRYLIC BASE <br />(INCLUDES ANY CONVENTIONAL CLASPS AND RESTS) <br />NO CHARGE <br />05212 <br />LOWER PARTIAL ACRYLIC BASE <br />(INCLUDES ANY CONVENTIONAL CLASPS AND RESTS) <br />NO CHARGE <br />05213 <br />UPPER PARTIAL - PREDOMINANTLY BASE OAST BASE WITH ACRYLIC <br />SADDLES (INCLUDING ANY CONVENTIONAL CLASPS AND RESTS) <br />NO CHANCE <br />05214 <br />LOWER PARTIAL F PREDOMINANTLY BASE CAST BASE WITH ACRYLIC <br />SADDLES (INCLUDING ING ANY CONVENTIONAL CLASPS AND RESTS) <br />NO CHARGE <br />