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SCHEDULE OF BENEFITS (Continued) <br />Code Service <br />Your and Your <br />Dependent's <br />Co -Payment <br />02794 <br />Crown—titanium <br />$0 <br />D2910 <br />Re -cement or re -bond inlay, onlay, veneer or partial coverage restoration <br />$0 <br />D2915 <br />Re -cement or re -bond Indirectly fabricated or prefabricated post and cora <br />$0 <br />D2920 <br />Re -cement or re -bond crown <br />$0 <br />D2930 <br />Prefabricated stainless steel crown — primary tooth <br />$0 <br />D2931 <br />Prefabricated stainless steel crown — permanent tooth <br />$0 <br />D2940 <br />Protective restoration <br />$0 <br />D2950 <br />Core buildup, Including any pins when required <br />$0 <br />D2951 <br />Pin retention — per tooth, in addition to restoration <br />$0 <br />D2952 <br />Post and core in addition to crown, Indirectly fabricated <br />$0 <br />D2953 <br />Each additional Indirectly fabricated post—same tooth <br />$0 <br />D2954 <br />Prefabricated post and core In addition to crown <br />$0 <br />D2970 <br />Temporary crown (fractured tooth) <br />$0 <br />Endodontics <br />All procedures exclude final restoration. <br />$0 <br />D3110 <br />Pulp cap — direct (excluding final restoration) <br />$0 <br />D3120 <br />Pulpcap--indirect(excludingfinalrestoration) <br />$0 <br />D3220 <br />Therapeutic pulpotomy (excluding final restoration) — removal of pulp coronal to <br />$0 <br />the dentinocemental Junction and application of medicament <br />D3310 <br />Endodontic therapy, anterior tooth (excluding final restoration) <br />$0 <br />D3320 <br />Endodontlo therapy, bicuspid tooth (excluding final restoration) <br />$0 <br />D3330 <br />Endodontic therapy, molar tooth (excluding final restoration) <br />$0 <br />D3332 <br />Incomplete endodontic therapy; Inoperable, unrestorable or fractured tooth <br />$0 <br />D3346 <br />Retreatment of previous root canal therapy -- anterior <br />$0 <br />03347 <br />Retreatment of previous root canal therapy — bicuspid <br />$0 <br />03348 <br />Retreatment of previous root canal therapy — molar <br />$0 <br />D3351 <br />Apexifloatlonlrecalcificatlon — initial visit (apical closure / calcific repair of <br />$0 <br />perforations, root resorption, etc.) <br />D3410 <br />Apicoectomy—anterior <br />$0 <br />D3421 <br />Apicoectomy — bicuspid (first root) <br />$0 <br />D3426 <br />Apicoectomy — molar (first root) <br />$0 <br />D3426 <br />Apicoeotomy (each additional root) <br />$0 <br />D3430 <br />Retrograde filling — per root <br />$0 <br />Periodontics <br />D4210 <br />Gingivectomy or gingivoplasty—four or more contiguous teeth or tooth <br />$0 <br />bounded spaces per quadrant <br />04211 <br />Gingivectomy or gingivoplasty — one to three contiguous teeth or tooth bounded <br />$0 <br />spaces per quadrant <br />D4240 <br />Gingival flap procedure, including root planing — four or more contiguous teeth <br />$0 <br />or tooth bounded spaces per quadrant <br />D4241 <br />Gingival flap procedure, including root planing — one to three contiguous teeth <br />$0 <br />or tooth bounded spaces per quadrant <br />04260 <br />Osseous surgery (including elevation of a full thickness flap and closure) —four <br />$0 <br />or more contiguous teeth or tooth bounded spaces per quadrant <br />0041 -0 -SOB <br />3 <br />25C-42 <br />