Fee Schedule Detail Procedure Procedure Description Code Fee

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1 Fee Schedule Detail Procedure Procedure Description Code Fee D0120 PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT $ D0140 LIMITED ORAL EVALUATION-PROBLEM FOCUSED $ D0150 COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED $ D0160 DETAILED AND EXTENSIVE ORAL EVAL-PROBLEM FOCUSED, BY $ D0170 RE-EVALUATION, LIMITED PROBLEM FOCUSED $ D0180 COMPREHENSIVE PERIODONTAL EVALUATION - NEW OR $ D0210 INTRAORAL - COMPLETE SERIES OF RADIOGRAPHIC IMAGES $ D0220 INTRAORAL - PERIAPICAL FIRST RADIOGRAPHIC IMAGE $ D0230 INTRAORAL - PERIAPICAL EACH ADDITIONAL RADIOGRAPHIC $ D0240 INTRAORAL - OCCLUSAL RADIOGRAPHIC IMAGE $ D0270 BITEWING - SINGLE RADIOGRAPHIC IMAGE $ D0272 BITEWINGS - TWO RADIOGRAPHIC IMAGES $ D0274 BITEWINGS - FOUR RADIOGRAPHIC IMAGES $ D0277 VERTICAL BITEWINGS - 7 TO 8 FILMS $ D0330 PANORAMIC RADIOGRAPHIC IMAGE $ D0340 CEPHALOMETRIC RADIOGRAPHIC IMAGE $ D0350 2D ORAL/FACIAL PHOTOGRAPHIC IMAGE OBTAINED INTRA- ORALLY OR EXTRA-ORALLY $ D0391 INTERPRETATION OF DIAGNOSTIC IMAGE BY A PRACTITIONER NOT ASSOCIATED WITH CAPTURE OF THE IMAGE $ D0470 DIAGNOSTIC CASTS $ D1110 PROPHYLAXIS - ADULT $ D1120 PROPHYLAXIS - CHILD $ D1206 TOPICAL APPLICATION OF FLUORIDE VARNISH $ D1208 TOPICAL APPLICATION OF FLUORIDE - EXCLUDING VARNISH $ D1351 SEALANT - PER TOOTH $ D1352 PREVENTIVE RESIN RESTORATION IS A MOD. TO HIGH CARIES RISK PATIENT PERM TOOTH CONSERVATIVE REST OF AN ACTIVE CAVITATED LESION IN A PIT OR FISSURE THAT DOESN'T EXTEND INTO DENTIN: INCLUDES PLACMT OF A SEALANT IN RADIATING $ D1510 SPACE MAINTAINER-FIXED-UNILATERAL $ D1515 SPACE MAINTAINER - FIXED - BILATERAL $ D1520 SPACE MAINTAINER-REMOVABLE-UNILATERAL $ D1525 SPACE MAINTAINER-REMOVABLE-BILATERAL $ D1550 RE-CEMENT OR RE-BOND SPACE MAINTAINER $ D2140 AMALGAM - ONE SURFACE, PRIMARY OR PERMANENT $ D2150 AMALGAM - TWO SURFACES, PRIMARY OR PERMANENT $ D2160 AMALGAM - THREE SURFACES, PRIMARY OR PERMANENT $ D2161 AMALGAM - FOUR OR MORE SURFACES, PRIMARY OR $ D2330 RESIN-BASED COMPOSITE - ONE SURFACE, ANTERIOR $ D2331 RESIN-BASED COMPOSITE - TWO SURFACES, ANTERIOR $ D2332 RESIN-BASED COMPOSITE - THREE SURFACES, ANTERIOR $ D2335 RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE (ANTERIOR) $ D2390 RESIN-BASED COMPOSITE CROWN, ANTERIOR $ D2391 RESIN-BASED COMPOSITE - ONE SURFACE, POSTERIOR $ Page 1 of 7

2 D2392 RESIN-BASED COMPOSITE - TWO SURFACES, POSTERIOR $ D2393 RESIN-BASED COMPOSITE - THREE SURFACES, POSTERIOR $ D2394 RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES, $ D2510 INLAY - METALLIC -1 SURFACE $ D2520 INLAY-METALLIC-2 SURFACES $ D2530 INLAY-METALLIC-3+ SURFACES $ D2542 ONLAY - METALLIC - TWO SURFACES $ D2543 ONLAY-METALLIC-3 SURFACES $ D2544 ONLAY-METALLIC-4+ SURFACES $ D2740 CROWN - PORCELAIN/CERAMIC SUBSTRATE $ D2750 CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL $ D2751 CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL $ D2752 CROWN - PORCELAIN FUSED TO NOBLE METAL $ D2780 CROWN - ¾ CAST HIGH NOBLE METAL $ D2781 CROWN - ¾ CAST PREDOMINANTLY BASE METAL $ D2783 CROWN - ¾ PORCELAIN/CERAMIC $ D2790 CROWN - FULL CAST HIGH NOBLE METAL $ D2791 CROWN - FULL CAST PREDOMINANTLY BASE METAL $ D2792 CROWN - FULL CAST NOBLE METAL $ D2794 CROWN - TITANIUM $ D2910 RE-CEMENT OR RE-BOND INLAY, ONLAY, VENEER OR PARTIAL COVERAGE RESTORATION $ D2920 RE-CEMENT OR RE-BOND CROWN $ D2929 PREFABRICATED PORCELAIN/CERAMIC CROWN PRIMARY $ D2930 TOOTH PREFABRICATED STAINLESS STEEL CROWN - PRIMARY TOOTH $ D2931 PREFABRICATED STAINLESS STEEL CROWN-PERMANENT TOOTH $ D2940 PROTECTIVE RESTORATION $ D2950 CORE BUILDUP, INCLUDING ANY PINS WHEN REQUIRED $ D2951 PIN RETENTION - PER TOOTH, IN ADDITION TO RESTORATION $ D2954 PREFABRICATED POST AND CORE IN ADDITION TO CROWN $ D2980 CROWN REPAIR, BY REPORT $ D2981 INLAY REPAIR NECESSITATED BY RESTORATIVE MATERIAL $ D2982 ONLAY REPAIR NECESSITATED BY RESTORATIVE MATERIAL $ D2983 VENEER REPAIR NECESSITATED BY RESTORATIVE MATERIAL $ D2990 RESIN INFILTRATION OF INCIPIENT SMOOTH SURFACE LESIONS $ D3220 THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) - REMOVAL OF PULP CORONAL TO THE DENTINOCEMENTAL JUNCTION AND APPLICATION OF MEDICAMENT $ D3222 PARTIAL PULPOTOMY FOR APEXOGENESIS - PERMANENT TOOTH WITH INCOMPLETE ROOT DEVELOPMENT $ D3230 PULPAL THERAPY (RESORBABLE FILLING) - ANTERIOR, PRIMARY TOOTH (EXCLUDING FINAL RESTORATION) $ D3240 PULPAL THERAPY (RESORBABLE FILLING) - POSTERIOR, PRIMARY TOOTH (EXCLUDING FINAL RESTORATION) $ D3310 ENDODONTIC THERAPY, ANTERIOR TOOTH (EXCLUDING FINAL $ D3320 ENDODONTIC THERAPY, BICUSPID TOOTH (EXCLUDING FINAL $ D3330 ENDODONTIC THERAPY, MOLAR (EXCLUDING FINAL $ D3346 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY-ANTERIOR $ D3347 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY-BICUSPID $ D3348 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY-MOLAR $ 1, Page 2 of 7

3 D3351 APEXIFICATION/RECALCIFICATION - INITIAL VISIT (APICAL CLOSURE / CALCIFIC REPAIR OF PERFORATIONS, ROOT $ D3352 APEXIFICATION/RECALCIFICATION - INTERIM MEDICATION $ D3353 APEXIFICATION/RECALCIFICATION - FINAL VISIT (INCLUDES COMPLETED ROOT CANAL THERAPY - APICAL CLOSURE/CALCIFIC REPAIR OF PERFORATIONS, ROOT $ D3354 PULPAL REGENERATION INCLUDES COMPLETED REGENERATIVE TRT OF AN IMMATURE PERM TOOTH WITH A NECROTIC PULP. INCLUDES REMOVAL OF INTRACANAL MEDICATION AND PROCS NECESSARY TO REGENERATE CONT'D ROOT DEVELOPMENT $ D3410 APICOECTOMY - ANTERIOR $ D3421 APICOECTOMY - BICUSPID (FIRST ROOT) $ D3425 APICOECTOMY - MOLAR (FIRST ROOT) $ D3426 APICOECTOMY (EACH ADDITIONAL ROOT) $ D3450 ROOT AMPUTATION - PER ROOT $ D3920 HEMISECTION (INCLUDING ANY ROOT REMOVAL), NOT INCL ROOT CANAL THERAPY $ D4210 GINGIVECTOMY OR GINGIVOPLASTY - FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER $ D4211 GINGIVECTOMY OR GINGIVOPLASTY - ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER $ D4212 GINGIVECTOMY OR GINGIVOPLASTY TO ALLOW ACCESS FOR RESTORATIVE PROCEDURE, PER TOOTH $ D4240 GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING - FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES $ D4260 OSSEOUS SURGERY (INCLUDING ELEVATION OF A FULL THICKNESS FLAP AND CLOSURE) - FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER $ D4341 PERIODONTAL SCALING AND ROOT PLANING - FOUR OR MORE TEETH PER QUADRANT $ D4342 PERIODONTAL SCALING AND ROOT PLANING - ONE TO THREE TEETH PER QUADRANT $ D4355 FULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE EVALUATION AND DIAGNOSIS $ D4910 PERIODONTAL MAINTENANCE PROCEDURES $ D5110 COMPLETE DENTURE - MAXILLARY $ 1, D5120 COMPLETE DENTURE - MANDIBULAR $ 1, D5130 IMMEDIATE DENTURE - MAXILLARY $ D5140 IMMEDIATE DENTURE - MANDIBULAR $ D5211 MAXILLARY PARTIAL DENTURE - RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) $ D5212 MANDIBULAR PARTIAL DENTURE - RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) $ 1, D5213 MAXILLARY PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL $ D5214 MANDIBULAR PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL $ 1, D5225 MAXILLARY PARTIAL DENTURE-FLEXIBLE BASE $ D5226 MANDIBULAR PARTIAL DENTURE-FLEXIBLE BASE $ 1, Page 3 of 7

4 D5281 REMOVABLE UNILATERAL PARTIAL DENTURE - ONE PIECE CAST $ 1, D5410 ADJUST COMPLETE DENTURE - MAXILLARY $ D5411 ADJUST COMPLETE DENTURE - MANDIBULAR $ D5421 ADJUST PARTIAL DENTURE-MAXILLARY $ D5422 ADJUST PARTIAL DENTURE - MANDIBULAR $ D5510 REPAIR BROKEN COMPLETE DENTURE BASE $ D5520 REPLACE MISSING OR BROKEN TEETH - COMPLETE DENTURE $ D5610 REPAIR RESIN DENTURE BASE $ D5620 REPAIR CAST FRAMEWORK $ D5630 REPAIR OR REPLACE BROKEN CLASP $ D5640 REPLACE BROKEN TEETH-PER TOOTH $ D5650 ADD TOOTH TO EXISTING PARTIAL DENTURE $ D5660 ADD CLASP TO EXISTING PARTIAL DENTURE $ D5710 REBASE COMPLETE MAXILLARY DENTURE $ D5720 REBASE MAXILLARY PARTIAL DENTURE $ D5721 REBASE MANDIBULAR PARTIAL DENTURE $ D5730 RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) $ D5731 RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) $ D5740 RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) $ D5741 RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE) $ D5750 RELINE COMPLETE MAXILLARY DENTURE (LABORATORY) $ D5751 RELINE COMPLETE MANDIBULAR DENTURE (LABORATORY) $ D5760 RELINE MAXILLARY PARTIAL DENTURE (LABORATORY) $ D5761 RELINE MANDIBULAR PARTIAL DENTURE (LABORATORY) $ D5850 TISSUE CONDITIONING, MAXILLARY $ D5851 TISSUE CONDITIONING,MANDIBULAR $ D6010 SURGICAL PLACEMENT OF IMPLANT BODY: ENDOSTEAL IMPLANT $ 1, D6012 SURGICAL PLACEMENT OF INTERIM IMPLANT BODY-ENDOSTEAL $ D6040 SURGICAL PLACEMENT:EPOSTEAL IMPLNT $ 4, D6050 SURGICAL PLACEMENT-TRANSOSTEAL IMPLANT $ 3, D6053 IMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE FOR COMPLETELY EDENTULOUS ARCH $ D6054 IMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE FOR PARTIALLY ENDENTULOUS ARCH $ D6055 CONNECTING BAR - IMPLANT SUPPORTED OR ABUTMENT $ 1, D6056 PREFABRICATED ABUTMENT $ D6058 ABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWN $ D6059 ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (HIGH NOBLE METAL) $ D6060 ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (PREDOMINANTLY BASE METAL) $ D6061 ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN $ D6062 ABUTMENT SUPPORTED CAST METAL CROWN (HIGH NOBLE $ D6063 ABUTMENT SUPPORTED CAST METAL CROWN (PREDOMINANTLY $ D6064 ABUTMENT SUPPORTED CAST METAL CROWN (NOBLE METAL) $ D6065 IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWN $ D6066 D6067 IMPLANT SUPPORTED PORCELAIN FUSED TO METAL CROWN (TITANIUM, TITANIUM ALLOY, HIGH NOBLE METAL) $ IMPLANT SUPPORTED METAL CROWN (TITANIUM, TITANIUM ALLOY, HIGH NOBLE METAL) $ Page 4 of 7

5 D6068 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN/CERAMIC $ D6069 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (HIGH NOBLE METAL) $ D6070 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (PREDOMINANTLY BASE METAL) $ D6071 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (NOBLE METAL) $ D6072 ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (HIGH $ D6073 ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (PREDOMINANTLY BASE METAL) $ D6074 ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD $ D6075 IMPLANT SUPPORTED RETAINER FOR CERAMIC FPD $ D6076 IMPLANT SUPPORTED RETAINER FOR PORCELAIN FUSED TO $ D6077 IMPLANT SUPPORTED RETAINER FOR CAST METAL FPD (TITANIUM, TITANIUM ALLOY, OR HIGH NOBLE METAL) $ D6078 IMPLANT/ABUTMENT SUPPORTED FIXED DENTURE FOR COMPLETELY EDENTULOUS ARCH $ 1, D6079 IMPLANT/ABUTMENT SUPPORTED FIXED DENTURE FOR PARTIALLY EDENTULOUS ARCH $ 1, D6080 IMPLANT MAINTENANCE PROCEDURE $ D6090 REPAIR IMPLANT PROSTHESIS $ D6091 REPLACEMENT OF ATTACHMENT- IMPLANT/ABUTMENT $ D6095 REPAIR IMPLANT ABUTMENT $ D6100 IMPLANT REMOVAL, BY REPORT $ D6101 DEBRIDEMENT OF A PERIIMPLANT DEFECT AND SURFACE CLEANING OF EXPOSED IMPLANT SURFACES, INCLUDING FLAP $ D6102 DEBRIDEMENT OF IMPLANT SITE $ D6103 BONE GRAFT FOR REPAIR OF PERIIMPLANT DEFECT NOT INCLUDING FLAP ENTRY AND CLOSURE OR, WHEN INDICATE $ D6104 BONE GRAFT AT TIME OF IMPLANT PLACEMENT $ D6190 RADIOGRAPHIC/SURGICAL IMPLANT INDEX, BY REPORT $ D6210 PONTIC - CAST HIGH NOBLE METAL $ D6211 PONTIC-CAST BASE METAL $ D6212 PONTIC - CAST NOBLE METAL $ D6214 PONTIC - TITANIUM $ D6240 PONTIC-PORCELAIN FUSED-HIGH NOBLE $ D6241 PONTIC-PORCELAIN FUSED TO BASE METAL $ D6242 PONTIC-PORCELAIN FUSED-NOBLE METAL $ D6245 PROSTHODONTICS FIXED, PONTIC - PORCELAIN/CERAMIC $ D6545 RETAINER - CAST METAL FIXED $ D6548 PROSTHODONTICS FIXED, RETAINER - PORCELAIN/CERAMIC FOR RESIN BONDED FIXED PROSTHODONTIC $ D6740 RETAINER CROWN PORCELAIN/CERAMIC $ D6750 CROWN-PORCELAIN FUSED HIGH NOBLE $ D6751 CROWN-PORCELAIN FUSED TO BASE METAL $ D6752 CROWN-PORCELAIN FUSED NOBLE METAL $ D6780 CROWN-3/4 CST HIGH NOBLE METAL $ D6781 PROSTHODONTICS FIXED, CROWN ¾ CAST PREDOMINANTLY $ D6782 PROSTHODONTICS FIXED, CROWN ¾ CAST NOBLE METAL $ Page 5 of 7

6 D6783 PROSTHODONTICS FIXED, CROWN ¾ PORCELAIN/CERAMIC $ D6790 CROWN-FULL CAST HIGH NOBLE $ D6791 CROWN - FULL CAST BASE METAL $ D6792 CROWN - FULL CAST NOBLE METAL $ D6930 RE-CEMENT OR RE-BOND FIXED PARTIAL DENTURE $ D6980 FIXED PARTIAL DENTURE REPAIR $ D7140 EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMOVAL) $ D7210 SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING REMOVAL OF BONE AND/OR SECTIONING OF TOOTH, AND INCLUDING ELEVATION OF MUCOPERIOSTEAL FLAP IF INDICATED $ D7220 REMOVAL OF IMPACTED TOOTH-SOFT TISSUE $ D7230 REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY $ D7240 REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY $ D7241 REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY, WITH UNUSUAL SURGICAL COMPLICATIONS $ D7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING $ D7251 CORONECTOMY-INTENTIONAL PARTIAL TOOTH REMOVAL IS PERFORMED WHEN A NEUROVASCULAR COMPLICATION IS LIKELY IF THE ENTIRE IMPACTED TOOTH IS REMOVED. $ D7270 TOOTH REIMPLANTATION AND/OR STABILIZATION OF ACCIDENTALLY EVULSED OR DISPLACED TOOTH $ D7280 SURGICAL ACCESS OF AN UNERUPTED TOOTH $ D7310 ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH SPACES, PER QUADRANT $ D7311 ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR TOOTH SPACES, PER QUADRANT $ D7320 ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH SPACES, PER QUADRANT $ D7321 ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR TOOTH SPACES, PER QUADRANT $ D7471 REMOVAL OF EXOSTOSIS - PER SITE $ D7510 INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE $ D7910 SUTURE SMALL WOUNDS UP TO 5 CM $ D7921 COLLECTION AND APPLICATION OF AUTOLOGOUS BLOOD CONCENTRATE PRODUCT $ D7971 EXCISION OF PERICORONAL GINGIVA $ D8010 LIMITED ORTHODONTIC TREATMENT OF THE PRIMARY $ 1, D8020 LIMITED ORTHODONTIC TREATMENT OF THE TRANSITIONAL $ 1, D8030 LIMITED ORTHODONTIC TREATMENT OF THE ADOLESCENT $ 1, D8050 INTERCEPTIVE ORTHODONTIC TREATMENT OF THE PRIMARY $ 2, D8060 INTERCEPTIVE ORTHODONTIC TREATMENT OF THE $ 2, D8070 COMPREHENSIVE ORTHODONTIC TREATMENT OF THE $ 4, D8080 COMPREHENSIVE ORTHODONTIC TREATMENT OF THE $ 5, D8210 REMOVABLE APPLIANCE THERAPY (INCLUDES APPLIANCES FOR THUMB SUCKING AND TONGUE THRUSTING) $ Page 6 of 7

7 D8220 FIXED APPLIANCE THERAPY (INCLUDES APPLIANCES FOR THUMB SUCKING AND TONGUE THRUSTING) $ 1, D8660 PRE-ORTHODONTIC TREATMENT EXAMINATION TO MONITOR GROWTH AND DEVELOPMENT $ D8680 ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES) $ D9110 PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN - MINOR $ D9223 DEEP SEDATION/GENERAL ANESTHESIA EACH 15 MINUTE $ D9243 INTRAVENOUS MODERATE (CONSCIOUS) SEDATION/ANALGESIA EACH 15 MINUTE INCREMENT $ D9310 CONSULTATION $ D9610 THERAPEUTIC DRUG INJECTION, BY REPORT $ D9930 TREATMENT OF COMPLICATIONS (POST-SURGICAL) - UNUSUAL CIRCUMSTANCES, BY REPORT $ D9940 OCCLUSAL GUARD, BY REPORT $ Page 7 of 7

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