pbp_a_hnumber	pbp_a_plan_identifier	segment_id	pbp_a_ben_cov	pbp_a_plan_type	orgtype	bid_id	version	pbp_d_opt_cost_share_mand_yn	pbp_b16b_bendesc_yn	pbp_b16b_bendesc_ehc	pbp_b16b_bendesc_amo_es	pbp_b16b_bendesc_lim_es	pbp_b16b_bendesc_numv_es	pbp_b16b_bendesc_per_es	pbp_b16b_bendesc_per_es_d	pbp_b16b_bendesc_amo_ds	pbp_b16b_bendesc_lim_ds	pbp_b16b_bendesc_numv_ds	pbp_b16b_bendesc_per_ds	pbp_b16b_bendesc_per_ds_d	pbp_b16b_bendesc_amo_rs	pbp_b16b_bendesc_lim_rs	pbp_b16b_bendesc_numv_rs	pbp_b16b_bendesc_per_rs	pbp_b16b_bendesc_per_rs_d	pbp_b16b_bendesc_amo_end	pbp_b16b_bendesc_lim_end	pbp_b16b_bendesc_num_end	pbp_b16b_bendesc_per_end	pbp_b16b_bendesc_per_end_d	pbp_b16b_bendesc_amo_peri	pbp_b16b_bendesc_lim_peri	pbp_b16b_bendesc_num_peri	pbp_b16b_bendesc_per_peri	pbp_b16b_bendesc_per_peri_d	pbp_b16b_bendesc_amo_ext	pbp_b16b_bendesc_lim_ext	pbp_b16b_bendesc_num_ext	pbp_b16b_bendesc_per_ext	pbp_b16b_bendesc_per_ext_d	pbp_b16b_bendesc_amo_poo	pbp_b16b_bendesc_lim_poo	pbp_b16b_bendesc_numv_poo	pbp_b16b_bendesc_per_poo	pbp_b16b_bendesc_per_poo_d	pbp_b16b_maxplan_yn	pbp_b16b_maxplan_in_oon	pbp_b16b_maxbene_type	pbp_b16b_maxplan_amt	pbp_b16b_maxplan_per	pbp_b16b_maxplan_per_desc	pbp_b16b_maxenr_yn	pbp_b16b_maxenr_type	pbp_b16b_maxenr_amt	pbp_b16b_maxenr_per	pbp_b16b_maxenr_per_desc	pbp_b16b_coins_yn	pbp_b16b_coins_ehc	pbp_b16b_coins_pct_mc_min	pbp_b16b_coins_pct_mc_max	pbp_b16b_coins_pct_es_min	pbp_b16b_coins_pct_es_max	pbp_b16b_coins_pct_ds_min	pbp_b16b_coins_pct_ds_max	pbp_b16b_coins_pct_rs_min	pbp_b16b_coins_pct_rs_max	pbp_b16b_coins_pct_end_min	pbp_b16b_coins_pct_end_max	pbp_b16b_coins_pct_peri_min	pbp_b16b_coins_pct_peri_max	pbp_b16b_coins_pct_ext_min	pbp_b16b_coins_pct_ext_max	pbp_b16b_coins_pct_poo_min	pbp_b16b_coins_pct_poo_max	pbp_b16b_ded_yn	pbp_b16b_ded_amt	pbp_b16b_copay_yn	pbp_b16b_copay_ehc	pbp_b16b_copay_amt_mc_min	pbp_b16b_copay_amt_mc_max	pbp_b16b_copay_amt_es_min	pbp_b16b_copay_amt_es_max	pbp_b16b_copay_amt_ds_min	pbp_b16b_copay_amt_ds_max	pbp_b16b_copay_amt_rs_min	pbp_b16b_copay_amt_rs_max	pbp_b16b_copay_amt_end_min	pbp_b16b_copay_amt_end_max	pbp_b16b_copay_amt_peri_min	pbp_b16b_copay_amt_peri_max	pbp_b16b_copay_amt_ext_min	pbp_b16b_copay_amt_ext_max	pbp_b16b_copay_amt_poo_min	pbp_b16b_copay_amt_poo_max	pbp_b16b_auth_yn	pbp_b16b_refer_yn	pbp_d_opt_identifier
H0028	016	0	1	02	01	H0028_016_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H0028	017	0	1	01	01	H0028_017_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 up to unlimited per year, recementation of crown $25 up to 1 every 5 years, recementation of dentures $25 up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Services include bridges up to 1 every 5 years, oral surgery up to 2 per year, tissue conditioning up to 1 per year, occlusal adjustments up to 1 every 3 years.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H0028	017	0	1	01	01	H0028_017_0	6	2	1	1101111	3	2	2	3							3	2	5	6	Restorative services include fillings 0% up to unlimited per year, recementation of crown and recementation of dentures $25 copayment up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Partial and complete dentures 50% up to 1 every 5 years. Denture adjustment, reline, repair, rebase and tissue conditioning 50% up to 1 per year. Oral surgery 50% up to 2 per year. Occlusal adjustment	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H0028	017	0	1	01	01	H0028_017_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H0028	021	0	1	01	01	H0028_021_0	6	2	1	1101111	3	2	2	3							3	2	3	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H0028	021	0	1	01	01	H0028_021_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H0028	021	0	1	01	01	H0028_021_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H0028	023	0	1	01	01	H0028_023_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling unlimited per year, bridge recementation & crown recementation 1 every 5 years, crown & core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	12	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years,	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1	001
H0028	023	0	1	01	01	H0028_023_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Root canal and Root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H0028	023	0	1	01	01	H0028_023_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H0028	027	0	1	01	01	H0028_027_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years,	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H0028	027	0	1	01	01	H0028_027_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H0028	027	0	1	01	01	H0028_027_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H0028	028	0	1	01	01	H0028_028_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years,	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H0028	028	0	1	01	01	H0028_028_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H0028	028	0	1	01	01	H0028_028_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H0028	041	0	1	01	01	H0028_041_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H0028	043	2	1	01	01	H0028_043_2	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H0028	047	0	1	01	01	H0028_047_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H0028	048	2	1	01	01	H0028_048_2	5	1	1	1101101	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.						3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	2											1	10001100							50	50	50	50					50	50	2		1	00101001			25.00	25.00			25.00	25.00					25.00	25.00			1	1	001
H0028	048	2	1	01	01	H0028_048_2	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	2											1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	002
H0028	048	2	1	01	01	H0028_048_2	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	003
H0028	053	1	1	01	01	H0028_053_1	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H0028	053	3	1	01	01	H0028_053_3	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H0028	053	4	1	01	01	H0028_053_4	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H0028	053	4	1	01	01	H0028_053_4	6	2	1	1101111	3	2	2	3							3	2	4	6	Restorative services include fillings 0% up to unlimited per year, recementation of crown and recementation of dentures $25 copayment up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adjust/rebase/reline/repair,tissue cond 1/yr,bridges-crown 2/5 yrs,bridges-pontic, complete+prtl dentures 1/5 yrs, occlusal adj 1/3 yrs, oral surgery 2/yr, restoration implant 1/tooth/lifetime	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H0028	053	4	1	01	01	H0028_053_4	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2	003
H0028	057	0	1	01	01	H0028_057_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H0028	062	0	1	01	01	H0028_062_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H0107	003	0	1	04	01	H0107_003_0	7		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H0107	004	0	1	04	01	H0107_004_0	6		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H0107	005	0	1	04	01	H0107_005_0	6		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H0107	006	0	1	04	01	H0107_006_0	6		1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10101111			20	20			20	20	20	20	20	20	20	20	20	20	2		2																		2	2	001
H0107	011	0	1	04	01	H0107_011_0	5		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H0292	001	0	1	01	01	H0292_001_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H0292	002	0	1	01	01	H0292_002_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H0292	003	0	1	01	01	H0292_003_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H0294	004	0	1	04	01	H0294_004_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	011	0	1	04	01	H0294_011_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	023	0	1	04	01	H0294_023_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	026	0	1	04	01	H0294_026_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	030	0	1	04	01	H0294_030_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	031	0	1	04	01	H0294_031_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	032	0	1	04	01	H0294_032_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	033	0	1	04	01	H0294_033_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	037	0	1	04	01	H0294_037_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	038	0	1	04	01	H0294_038_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	039	0	1	04	01	H0294_039_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	040	0	1	04	01	H0294_040_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	041	0	1	04	01	H0294_041_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	042	0	1	04	01	H0294_042_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	043	0	1	04	01	H0294_043_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	044	0	1	04	01	H0294_044_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	046	0	1	04	01	H0294_046_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0294	047	0	1	04	01	H0294_047_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0332	002	0	1	01	01	H0332_002_0	12	2	1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1		2	3000.00	3							1	10101111			20	20			20	50	50	50	50	50	50	50	50	50	1	25.00	2																		2	2	001
H0473	004	0	1	04	01	H0473_004_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H0504	015	0	1	01	01	H0504_015_0	5	2	1	1011111						3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											2																		2		1	10011111					0.00	10.00	0.00	295.00	5.00	425.00	20.00	293.00	10.00	94.00	0.00	310.00	2	1	001
H0504	015	0	1	01	01	H0504_015_0	5	2	1	1011111						3	2	1	6	Periodicity range: No frequency limit for pulp vitality casts, diagnostic casts covered once every 24 months from last date of service.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity range: No frequency limit for removal of lateral exostosis (maxilla or mandible), removal of impacted tooth - soft tissue limited to 2 per lifetime (exact tooth).	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											1	10011111					0	30	20	50	50	50	50	50	50	50	20	50	2		2																		2	2	002
H0504	017	0	1	01	01	H0504_017_0	5	2	1	1011111						3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											2																		2		1	10011111					0.00	10.00	0.00	295.00	5.00	425.00	20.00	293.00	10.00	94.00	0.00	310.00	2	1	001
H0504	017	0	1	01	01	H0504_017_0	5	2	1	1011111						3	2	1	6	Periodicity range:  No frequency limit for re-evaluation - limited, problem focused (established patient; not post - operative visit), diagnostic casts 1 every 24 months from date of last service	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity range: No frequency limit for removal of lateral exostosis (maxilla or mandible), removal of impacted tooth - soft tissue limited to 2 per lifetime (exact tooth).	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											1	10011111					0	30	20	50	50	50	50	50	50	50	20	50	2		2																		2	2	002
H0504	021	0	1	01	01	H0504_021_0	5	2	1	1011111						3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											2																		2		1	10011111					0.00	10.00	0.00	295.00	5.00	425.00	20.00	293.00	10.00	94.00	0.00	310.00	2	1	001
H0504	021	0	1	01	01	H0504_021_0	5	2	1	1011111						3	2	1	6	Periodicity range:  No frequency limit for re-evaluation - limited, problem focused (established patient; not post - operative visit), diagnostic casts 1 every 24 months from date of last service	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity range: No frequency limit for removal of lateral exostosis (maxilla or mandible), removal of impacted tooth - soft tissue limited to 2 per lifetime (exact tooth).	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											1	10011111					0	30	20	50	50	50	50	50	50	50	20	50	2		2																		2	2	002
H0504	026	0	1	01	01	H0504_026_0	6	2	1	1011111						3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											2																		2		1	10011111					0.00	10.00	0.00	295.00	5.00	425.00	20.00	293.00	10.00	94.00	0.00	310.00	2	1	001
H0504	026	0	1	01	01	H0504_026_0	6	2	1	1011111						3	2	1	6	Periodicity range:  No frequency limit for re-evaluation - limited, problem focused (established patient; not post - operative visit), diagnostic casts 1 every 24 months from date of last service.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity range: No frequency limit for removal of lateral exostosis (maxilla or mandible), removal of impacted tooth - soft tissue limited to 2 per lifetime (exact tooth).	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											1	10011111					0	30	20	50	50	50	50	50	50	50	20	50	2		2																		2	2	002
H0504	028	0	1	01	01	H0504_028_0	5	2	1	1011111						3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											2																		2		1	10011111					0.00	10.00	0.00	295.00	5.00	425.00	20.00	293.00	10.00	94.00	0.00	310.00	2	1	001
H0504	028	0	1	01	01	H0504_028_0	5	2	1	1011111						3	2	1	6	Periodicity range:  No frequency limit for re-evaluation - limited, problem focused (established patient; not post - operative visit), diagnostic casts 1 every 24 months from date of last service.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity range: No frequency limit for removal of lateral exostosis (maxilla or mandible), removal of impacted tooth - soft tissue limited to 2 per lifetime (exact tooth).	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											1	10011111					0	30	20	50	50	50	50	50	50	50	20	50	2		2																		2	2	002
H0504	038	0	1	01	01	H0504_038_0	5		1	1011111						3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											2																		2		1	10011111					0.00	10.00	0.00	295.00	5.00	425.00	20.00	293.00	10.00	94.00	0.00	310.00	2	1	001
H0504	038	0	1	01	01	H0504_038_0	5		1	1011111						3	2	1	6	Periodicity range:  No frequency limit for re-evaluation - limited, problem focused (established patient; not post - operative visit), diagnostic casts 1 every 24 months from date of last service.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity range: No frequency limit for removal of lateral exostosis (maxilla or mandible), removal of impacted tooth - soft tissue limited to 2 per lifetime (exact tooth).	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											1	10011111					0	30	20	50	50	50	50	50	50	50	20	50	2		2																		2	2	002
H0504	039	0	1	01	01	H0504_039_0	5		1	1011111						3	2	1	6	Periodicity range:  No frequency limit for re-evaluation - limited, problem focused (established patient; not post - operative visit), diagnostic casts 1 every 24 months from date of last service.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity range: No frequency limit for removal of lateral exostosis (maxilla or mandible), removal of impacted tooth - soft tissue limited to 2 per lifetime (exact tooth).	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											1	10011111					0	30	20	50	50	50	50	50	50	50	20	50	2		2																		2	2	001
H0504	040	0	1	01	01	H0504_040_0	5	2	1	1011111						3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											2																		2		1	10011111					0.00	10.00	0.00	295.00	5.00	425.00	20.00	293.00	10.00	94.00	0.00	310.00	2	1	001
H0504	040	0	1	01	01	H0504_040_0	5	2	1	1011111						3	2	1	6	Periodicity range:  No frequency limit for re-evaluation - limited, problem focused (established patient; not post - operative visit), diagnostic casts 1 every 24 months from date of last service.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity range: No frequency limit for removal of lateral exostosis (maxilla or mandible), removal of impacted tooth - soft tissue limited to 2 per lifetime (exact tooth).	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											1	10011111					0	30	20	50	50	50	50	50	50	50	20	50	2		2																		2	2	002
H0504	041	0	1	01	01	H0504_041_0	7		1	1011111						3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											2																		2		1	10011111					0.00	10.00	0.00	295.00	5.00	425.00	20.00	293.00	10.00	94.00	0.00	310.00	2	1	001
H0504	041	0	1	01	01	H0504_041_0	7		1	1011111						3	2	1	6	Periodicity range:  No frequency limit for re-evaluation - limited, problem focused (established patient; not post - operative visit), diagnostic casts 1 every 24 months from date of last service.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity range: No frequency limit for removal of lateral exostosis (maxilla or mandible), removal of impacted tooth - soft tissue limited to 2 per lifetime (exact tooth).	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											1	10011111					0	30	20	50	50	50	50	50	50	50	20	50	2		2																		2	2	002
H0504	043	0	1	01	01	H0504_043_0	6	2	1	1011111						3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											2																		2		1	10011111					0.00	10.00	0.00	295.00	5.00	425.00	20.00	293.00	10.00	94.00	0.00	310.00	2	1	001
H0504	043	0	1	01	01	H0504_043_0	6	2	1	1011111						3	2	1	6	Periodicity range:  No frequency limit for re-evaluation - limited, problem focused (established patient; not post - operative visit), diagnostic casts 1 every 24 months from date of last service.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity range: No frequency limit for removal of lateral exostosis (maxilla or mandible), removal of impacted tooth - soft tissue limited to 2 per lifetime (exact tooth).	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											1	10011111					0	30	20	50	50	50	50	50	50	50	20	50	2		2																		2	2	002
H0504	047	0	1	01	01	H0504_047_0	6		1	1011111						3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											2																		2		1	10011111					0.00	10.00	0.00	295.00	5.00	425.00	20.00	293.00	10.00	94.00	0.00	310.00	2	1	001
H0504	047	0	1	01	01	H0504_047_0	6		1	1011111						3	2	1	6	Periodicity range:  No frequency limit for re-evaluation - limited, problem focused (established patient; not post - operative visit), diagnostic casts 1 every 24 months from date of last service.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity range: No frequency limit for removal of lateral exostosis (maxilla or mandible), removal of impacted tooth - soft tissue limited to 2 per lifetime (exact tooth).	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											1	10011111					0	30	20	50	50	50	50	50	50	50	20	50	2		2																		2	2	002
H0504	049	0	1	01	01	H0504_049_0	6	2	1	1011111						3	2	1	6	Periodicity range:  No frequency limit for re-evaluation - limited, problem focused (established patient; not post - operative visit), diagnostic casts 1 every 24 months from date of last service.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity range: No frequency limit for removal of lateral exostosis (maxilla or mandible), removal of impacted tooth - soft tissue limited to 2 per lifetime (exact tooth).	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											1	10011111					0	30	20	50	50	50	50	50	50	50	20	50	2		2																		1	1	001
H0524	003	0	1	01	01	H0524_003_0	14	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	97.00	0.00	194.00	9.00	396.00	31.00	498.00	0.00	515.00	43.00	229.00	0.00	1441.00	1	1	001
H0524	008	0	1	01	01	H0524_008_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	013	0	1	01	01	H0524_013_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	015	0	1	01	01	H0524_015_0	13	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	97.00	0.00	194.00	9.00	396.00	31.00	498.00	0.00	515.00	43.00	229.00	0.00	1441.00	1	1	001
H0524	031	0	1	01	01	H0524_031_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	032	0	1	01	01	H0524_032_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	033	0	1	01	01	H0524_033_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	034	0	1	01	01	H0524_034_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	97.00	0.00	194.00	9.00	396.00	31.00	498.00	0.00	515.00	43.00	229.00	0.00	1441.00	1	1	001
H0524	035	0	1	01	01	H0524_035_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	97.00	0.00	194.00	9.00	396.00	31.00	498.00	0.00	515.00	43.00	229.00	0.00	1441.00	1	1	001
H0524	036	0	1	01	01	H0524_036_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	97.00	0.00	194.00	9.00	396.00	31.00	498.00	0.00	515.00	43.00	229.00	0.00	1441.00	1	1	001
H0524	037	0	1	01	01	H0524_037_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	97.00	0.00	194.00	9.00	396.00	31.00	498.00	0.00	515.00	43.00	229.00	0.00	1441.00	1	1	001
H0524	038	0	1	01	01	H0524_038_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	039	0	1	01	01	H0524_039_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	040	0	1	01	01	H0524_040_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	041	0	1	01	01	H0524_041_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	042	0	1	01	01	H0524_042_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	043	0	1	01	01	H0524_043_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	046	0	1	01	01	H0524_046_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	051	0	1	01	01	H0524_051_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	054	0	1	01	01	H0524_054_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	059	0	1	01	01	H0524_059_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	060	0	1	01	01	H0524_060_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	061	0	1	01	01	H0524_061_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	062	0	1	01	01	H0524_062_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	063	0	1	01	01	H0524_063_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	064	0	1	01	01	H0524_064_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	065	0	1	01	01	H0524_065_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	153.00	0.00	214.00	41.00	533.00	38.00	492.00	0.00	518.00	50.00	265.00	0.00	1585.00	1	1	001
H0524	078	0	1	01	01	H0524_078_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	97.00	0.00	194.00	9.00	396.00	31.00	498.00	0.00	515.00	43.00	229.00	0.00	1441.00	1	1	001
H0524	081	0	1	01	01	H0524_081_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	97.00	0.00	194.00	9.00	396.00	31.00	498.00	0.00	515.00	43.00	229.00	0.00	1441.00	1	1	001
H0524	082	0	1	01	01	H0524_082_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	97.00	0.00	194.00	9.00	396.00	31.00	498.00	0.00	515.00	43.00	229.00	0.00	1441.00	1	1	001
H0524	083	0	1	01	01	H0524_083_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	97.00	0.00	194.00	9.00	396.00	31.00	498.00	0.00	515.00	43.00	229.00	0.00	1441.00	1	1	001
H0543	013	0	1	02	01	H0543_013_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	019	0	1	02	01	H0543_019_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	028	0	1	02	01	H0543_028_0	8	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	035	0	1	02	01	H0543_035_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	036	0	1	02	01	H0543_036_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	086	0	1	02	01	H0543_086_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	089	0	1	02	01	H0543_089_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	121	0	1	02	01	H0543_121_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	140	0	1	02	01	H0543_140_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	145	0	1	02	01	H0543_145_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	146	0	1	02	01	H0543_146_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	147	0	1	02	01	H0543_147_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	152	0	1	02	01	H0543_152_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	167	0	1	02	01	H0543_167_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	176	0	1	02	01	H0543_176_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	193	0	1	02	01	H0543_193_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	195	0	1	02	01	H0543_195_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	196	0	1	02	01	H0543_196_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	210	0	1	02	01	H0543_210_0	8	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	215	0	1	02	01	H0543_215_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	216	0	1	02	01	H0543_216_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	222	0	1	02	01	H0543_222_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	223	0	1	02	01	H0543_223_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	224	0	1	02	01	H0543_224_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	228	0	1	02	01	H0543_228_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	229	0	1	02	01	H0543_229_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	230	0	1	02	01	H0543_230_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	231	0	1	02	01	H0543_231_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	232	0	1	02	01	H0543_232_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	234	0	1	02	01	H0543_234_0	8	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	235	0	1	02	01	H0543_235_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	236	0	1	02	01	H0543_236_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	237	0	1	02	01	H0543_237_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0543	238	0	1	02	01	H0543_238_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0544	002	0	1	01	01	H0544_002_0	13	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	002	0	1	01	01	H0544_002_0	13		1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	004	0	1	01	01	H0544_004_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	004	0	1	01	01	H0544_004_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	005	0	1	01	01	H0544_005_0	9	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	005	0	1	01	01	H0544_005_0	9	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	007	0	1	01	01	H0544_007_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	007	0	1	01	01	H0544_007_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	008	0	1	01	01	H0544_008_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	008	0	1	01	01	H0544_008_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	010	0	1	01	01	H0544_010_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	010	0	1	01	01	H0544_010_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	014	0	1	01	01	H0544_014_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	014	0	1	01	01	H0544_014_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	015	0	1	01	01	H0544_015_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	015	0	1	01	01	H0544_015_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	019	0	1	01	01	H0544_019_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	019	0	1	01	01	H0544_019_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	020	0	1	01	01	H0544_020_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	020	0	1	01	01	H0544_020_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	056	0	1	01	01	H0544_056_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	056	0	1	01	01	H0544_056_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	058	0	1	01	01	H0544_058_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	058	0	1	01	01	H0544_058_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	061	0	1	01	01	H0544_061_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	061	0	1	01	01	H0544_061_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	062	0	1	01	01	H0544_062_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	062	0	1	01	01	H0544_062_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	063	0	1	01	01	H0544_063_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	063	0	1	01	01	H0544_063_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	064	0	1	01	01	H0544_064_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	064	0	1	01	01	H0544_064_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	065	0	1	01	01	H0544_065_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	065	0	1	01	01	H0544_065_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	066	0	1	01	01	H0544_066_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	066	0	1	01	01	H0544_066_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	069	0	1	01	01	H0544_069_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	069	0	1	01	01	H0544_069_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	095	0	1	01	01	H0544_095_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	095	0	1	01	01	H0544_095_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	096	0	1	01	01	H0544_096_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	096	0	1	01	01	H0544_096_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	098	0	1	01	01	H0544_098_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	098	0	1	01	01	H0544_098_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	108	0	1	01	01	H0544_108_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	108	0	1	01	01	H0544_108_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0544	127	0	1	01	01	H0544_127_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H0544	127	0	1	01	01	H0544_127_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H0571	001	0	1	01	01	H0571_001_0	7		1	1011101						3	1				3	1				3	1									3	1				3	2	1	3		2											2																		2		1	10011101					0.00	0.00	15.00	375.00	12.00	275.00			30.00	150.00	0.00	375.00	2	2	001
H0571	007	0	1	01	01	H0571_007_0	7		1	1011111						3	1				3	1				3	1				3	2	1	3		3	1				3	2	1	3		2											2																		2		1	10011111					35.00	35.00	15.00	375.00	12.00	275.00	0.00	450.00	30.00	150.00	0.00	375.00	2	2	001
H0609	026	0	1	02	01	H0609_026_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0609	054	0	1	02	01	H0609_054_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0609	066	0	1	02	01	H0609_066_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0609	067	0	1	02	01	H0609_067_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0609	068	0	1	02	01	H0609_068_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0630	013	0	1	01	01	H0630_013_0	11	2	1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		2																		2	2	001
H0630	015	0	1	02	01	H0630_015_0	11	2	1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		2																		2	2	001
H0630	016	0	1	02	01	H0630_016_0	11	2	1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		2																		2	2	001
H0630	017	0	1	01	01	H0630_017_0	12	2	1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		2																		2	2	001
H0630	020	0	1	01	01	H0630_020_0	11	2	1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		2																		2	2	001
H0630	021	0	1	02	01	H0630_021_0	11	2	1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		2																		2	2	001
H0630	023	0	1	02	01	H0630_023_0	11	2	1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		2																		2	2	001
H0630	025	0	1	02	01	H0630_025_0	11	2	1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		2																		2	2	001
H0630	026	0	1	02	01	H0630_026_0	10	2	1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		2																		2	2	001
H0755	030	0	1	02	01	H0755_030_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0755	031	0	1	02	01	H0755_031_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0755	032	0	1	02	01	H0755_032_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0755	033	0	1	02	01	H0755_033_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0755	038	0	1	02	01	H0755_038_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0755	044	0	1	02	01	H0755_044_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0755	045	0	1	02	01	H0755_045_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H0783	003	0	1	01	01	H0783_003_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H0783	004	0	1	01	01	H0783_004_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H0978	001	0	1	01	01	H0978_001_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H0978	002	0	1	01	01	H0978_002_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H0978	003	0	1	01	01	H0978_003_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H0978	005	0	1	01	01	H0978_005_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H0978	006	0	1	01	01	H0978_006_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H0978	007	0	1	01	01	H0978_007_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H0978	009	0	1	01	01	H0978_009_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H1036	153	0	1	01	01	H1036_153_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H1036	219	0	1	01	01	H1036_219_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H1036	308	0	1	01	01	H1036_308_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		1	2	001
H1170	002	0	1	01	01	H1170_002_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1600.00	3							1	10000000															75	75	2		1	10111111			0.00	1440.00	71.00	94.00	18.00	580.00	18.00	308.00	0.00	331.00	48.00	48.00	0.00	1440.00	1	1	001
H1170	008	0	1	01	01	H1170_008_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1600.00	3							1	10000000															75	75	2		1	10111111			0.00	1440.00	71.00	94.00	18.00	580.00	18.00	308.00	0.00	331.00	48.00	48.00	0.00	1440.00	1	1	001
H1170	009	0	1	01	01	H1170_009_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1600.00	3							1	10000000															75	75	2		1	10111111			0.00	1440.00	71.00	94.00	18.00	580.00	18.00	308.00	0.00	331.00	48.00	48.00	0.00	1440.00	1	1	001
H1170	010	0	1	01	01	H1170_010_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1600.00	3							1	10000000															75	75	2		1	10111111			0.00	1440.00	71.00	94.00	18.00	580.00	18.00	308.00	0.00	331.00	48.00	48.00	0.00	1440.00	1	1	001
H1170	011	0	1	01	01	H1170_011_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1600.00	3							1	10000000															75	75	2		1	10111111			0.00	1440.00	71.00	94.00	18.00	580.00	18.00	308.00	0.00	331.00	48.00	48.00	0.00	1440.00	1	1	001
H1170	012	0	1	01	01	H1170_012_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1600.00	3							1	10000000															75	75	2		1	10111111			0.00	1440.00	71.00	94.00	18.00	580.00	18.00	308.00	0.00	331.00	48.00	48.00	0.00	1440.00	1	1	001
H1170	013	0	1	02	01	H1170_013_0	9	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1600.00	3							1	10000000															75	75	2		1	10111111			0.00	1440.00	71.00	94.00	18.00	580.00	18.00	308.00	0.00	331.00	48.00	48.00	0.00	1440.00	1	1	001
H1170	014	0	1	01	01	H1170_014_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1600.00	3							1	10000000															75	75	2		1	10111111			0.00	1440.00	71.00	94.00	18.00	580.00	18.00	308.00	0.00	331.00	48.00	48.00	0.00	1440.00	1	1	001
H1181	001	0		07	02	H1181_001_0	5	2	1	1001111											3	1				3	1				3	1				3	1				3	1				2											1	10001111							50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H1225	001	0	1	01	01	H1225_001_0	10	2	1	1001111											3	2	1	6	See notes for details	3	2	1	6	See notes for details	3	2	1	6	See notes for details	3	2	1	6	Frequency of services: • Extractions, coronectomy, surgical access of an unerupted tooth-once per tooth Services covered with a $100 copayment • Extractions and coronectomy	3	2	1	6	See notes for details	1		2	1000.00	3							2																		2		1	10001111							50.00	50.00	100.00	100.00	50.00	50.00	100.00	100.00	50.00	100.00	1	2	001
H1230	001	0	1	01	01	H1230_001_0	13	2	1	1111111	3	1				3	2	2	3		3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10111111			30	30	0	30	30	50	30	30	30	30	30	30	30	50	2		2																		2	2	001
H1230	003	0	1	01	01	H1230_003_0	13	2	1	1111111	3	1				3	2	2	3		3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10111111			30	30	0	30	30	50	30	30	30	30	30	30	30	50	2		2																		2	2	001
H1230	013	0	1	01	01	H1230_013_0	13	2	1	1111111	3	1				3	2	2	3		3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10111111			30	30	0	30	30	50	30	30	30	30	30	30	30	50	2		2																		2	2	001
H1230	014	0	1	01	01	H1230_014_0	13	2	1	1111111	3	1				3	2	2	3		3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10111111			30	30	0	30	30	50	30	30	30	30	30	30	30	50	2		2																		2	2	001
H1278	003	0	1	04	01	H1278_003_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1278	004	0	1	04	01	H1278_004_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1278	007	0	1	04	01	H1278_007_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1278	009	0	1	04	01	H1278_009_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1278	010	0	1	04	01	H1278_010_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1278	014	0	1	04	01	H1278_014_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1278	020	0	1	04	01	H1278_020_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1278	021	0	1	04	01	H1278_021_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1278	022	0	1	04	01	H1278_022_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1278	024	0	1	04	01	H1278_024_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1278	029	0	1	04	01	H1278_029_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1278	030	0	1	04	01	H1278_030_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1350	026	0	1	01	01	H1350_026_0	4		1	1101111	3	1									3	2	1	6	Same tooth surface restoration is covered once in a two year period.	3	2	1	6	Root canals not to exceed one per tooth per lifetime.	3	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	3	1				3	2	1	6	Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1		2	1000.00	3							1	10101111			20	20			20	20	50	50	20	20	20	20	50	50	1	50.00	2																		1	2	001
H1350	028	0	1	01	01	H1350_028_0	4		1	0101001	3	1									3	2	1	6	Same tooth surface restoration covered once in a two-year period.											3	1									2											1	00101001			20	20			20	20					20	20			1	50.00	2																		1	2	001
H1350	029	0	1	01	01	H1350_029_0	5		1	0101001	3	1									3	2	1	6	Same tooth surface restoration covered once in a two-year period.											3	1									2											1	00101001			20	20			20	20					20	20			1	50.00	2																		1	2	001
H1350	030	0	1	01	01	H1350_030_0	4		1	1101111	3	1									3	2	1	6	Same tooth surface restoration is covered once in a two year period.	3	2	1	6	Root canals not to exceed one per tooth per lifetime.	3	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	3	1				3	2	1	6	Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	2											1	10101111			20	20			20	20	50	50	20	20	20	20	50	50	1	50.00	2																		1	2	001
H1423	001	0	1	01	01	H1423_001_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H1423	001	0	1	01	01	H1423_001_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H1423	002	0	1	01	01	H1423_002_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H1423	002	0	1	01	01	H1423_002_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H1423	004	0	1	01	01	H1423_004_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H1423	004	0	1	01	01	H1423_004_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H1423	005	0	1	01	01	H1423_005_0	7		1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H1423	005	0	1	01	01	H1423_005_0	7		1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H1423	007	0	1	01	01	H1423_007_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H1423	007	0	1	01	01	H1423_007_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H1423	008	0	1	01	01	H1423_008_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H1423	008	0	1	01	01	H1423_008_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H1423	009	0	1	01	01	H1423_009_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H1423	009	0	1	01	01	H1423_009_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H1468	014	0	1	01	01	H1468_014_0	4	2	1	1101111	3	2	2	3							3	2	3	6	Fillings $25 up to unlimited per year, recementation of crown $25 up to 1 every 5 years, recementation of dentures $25 up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	5	6	Include bridges up to 1 every 5 years, oral surgery up to 2 per year, tissue conditioning up to 1 per year, occlusal adjustments up to 1 every 3 years.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1	001
H1468	014	0	1	01	01	H1468_014_0	4	2	1	1101111	3	2	2	3							3	2	3	6	Amalgam and/or composite filling 0% up to unlimited per year, bridge recementation and crown recementation $25 up to 1 every 5 years, crown and other restorative services	3	2	2	3		3	2	5	3		3	1				3	2	3	3		1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	002
H1468	014	0	1	01	01	H1468_014_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	003
H1607	012	0	1	04	01	H1607_012_0	9	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H1607	012	0	1	04	01	H1607_012_0	9	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H1607	015	0	1	04	01	H1607_015_0	13	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H1607	015	0	1	04	01	H1607_015_0	13	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H1666	006	0	1	04	01	H1666_006_0	6		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H1666	012	0	1	04	01	H1666_012_0	6		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H1666	013	0	1	04	01	H1666_013_0	5		1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10101111			20	20			20	20	20	20	20	20	20	20	20	20	2		2																		2	2	001
H1666	015	0	1	04	01	H1666_015_0	6		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H1666	018	0	1	04	01	H1666_018_0	5		1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10101111			20	20			20	20	20	20	20	20	20	20	20	20	2		2																		2	2	001
H1822	001	0	1	01	01	H1822_001_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H1822	002	0	1	01	01	H1822_002_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H1822	003	0	1	01	01	H1822_003_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H1846	004	0	1	04	01	H1846_004_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1	2	2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H1846	004	0	1	04	01	H1846_004_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H1846	005	0	1	04	01	H1846_005_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1	2	2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H1846	005	0	1	04	01	H1846_005_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H1846	006	0	1	04	01	H1846_006_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1	2	2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H1846	006	0	1	04	01	H1846_006_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H1846	007	0	1	04	01	H1846_007_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1	2	2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H1846	007	0	1	04	01	H1846_007_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H1889	017	0	1	04	01	H1889_017_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1889	021	0	1	04	01	H1889_021_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1894	008	0	1	01	01	H1894_008_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H1894	008	0	1	01	01	H1894_008_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H1944	004	0	1	02	01	H1944_004_0	8	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1944	006	0	1	02	01	H1944_006_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1944	017	0	1	02	01	H1944_017_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1944	018	0	1	02	01	H1944_018_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1944	032	0	1	02	01	H1944_032_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H1951	024	0	1	01	01	H1951_024_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H1951	028	0	1	01	01	H1951_028_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H1951	039	0	1	01	01	H1951_039_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	2											1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H1951	039	0	1	01	01	H1951_039_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	2											1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H1951	039	0	1	01	01	H1951_039_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H1951	048	2	1	01	01	H1951_048_2	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H1951	049	1	1	01	01	H1951_049_1	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H1951	049	3	1	01	01	H1951_049_3	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H1951	052	0	1	01	01	H1951_052_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H1951	054	0	1	01	01	H1951_054_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H1951	054	0	1	01	01	H1951_054_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H1951	054	0	1	01	01	H1951_054_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H2001	001	0	1	04	01	H2001_001_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2001	010	0	1	04	01	H2001_010_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2001	018	0	1	04	01	H2001_018_0	7	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2108	022	0	1	01	01	H2108_022_0	9	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	20000.00	3							2																		2		1	10101110			0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	2	2	001
H2108	036	0	1	01	01	H2108_036_0	9	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	20000.00	3							2																		2		1	10101110			0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	2	2	001
H2108	042	2	1	01	01	H2108_042_2	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	20000.00	3							2																		2		1	10101110			0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	2	2	001
H2172	001	0	1	02	01	H2172_001_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	500.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	001
H2172	001	0	1	02	01	H2172_001_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	002
H2172	002	0	1	02	01	H2172_002_0	10	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	500.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	001
H2172	002	0	1	02	01	H2172_002_0	10	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	002
H2172	003	0	1	02	01	H2172_003_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	500.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	001
H2172	003	0	1	02	01	H2172_003_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	002
H2172	004	0	1	02	01	H2172_004_0	10	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	500.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	001
H2172	004	0	1	02	01	H2172_004_0	10	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	002
H2172	005	0	1	01	01	H2172_005_0	6	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	500.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	001
H2172	005	0	1	01	01	H2172_005_0	6	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	002
H2172	006	0	1	01	01	H2172_006_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	500.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	001
H2172	006	0	1	01	01	H2172_006_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	002
H2172	008	0	1	02	01	H2172_008_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	500.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	001
H2172	008	0	1	02	01	H2172_008_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	002
H2172	009	0	1	02	01	H2172_009_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	500.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	001
H2172	009	0	1	02	01	H2172_009_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	002
H2172	010	0	1	02	01	H2172_010_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	500.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	001
H2172	010	0	1	02	01	H2172_010_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	002
H2172	011	0	1	01	01	H2172_011_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	500.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	001
H2172	011	0	1	01	01	H2172_011_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	002
H2172	012	0	1	02	01	H2172_012_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	500.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	001
H2172	012	0	1	02	01	H2172_012_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	002
H2172	013	0	1	02	01	H2172_013_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	500.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	001
H2172	013	0	1	02	01	H2172_013_0	9	2	1	1101111	3	1									3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	3	2	1	6	Extractions are limited to one per tooth.	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3							1	10101111			50	50			50	50	50	50	50	50	50	50	50	50	2		2																		1	2	002
H2235	001	0	1	01	01	H2235_001_0	15	1	1	0001100											3	2	1	6	See note below.	3	2	3	3																	2											2																		2		2																		2	2	001
H2235	002	0	1	01	01	H2235_002_0	15	1	1	0001100											3	2	1	6	See note below.	3	2	3	3																	2											2																		2		2																		2	2	001
H2235	003	0	1	01	01	H2235_003_0	15	1	1	0001100											3	2	1	6	See note below.	3	2	3	3																	2											2																		2		2																		2	2	001
H2235	005	0	1	01	01	H2235_005_0	15	1	1	0001100											3	2	1	6	See note below.	3	2	3	3																	2											2																		2		2																		2	2	001
H2235	006	0	1	02	01	H2235_006_0	15	1	1	0001100											3	2	1	6	See note below.	3	2	3	3																	2											2																		2		2																		2	2	001
H2256	001	1	1	01	01	H2256_001_1	7		1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	001	2	1	01	01	H2256_001_2	7		1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	001	6	1	01	01	H2256_001_6	7		1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	015	1	1	01	01	H2256_015_1	7		1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	015	2	1	01	01	H2256_015_2	7		1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	015	6	1	01	01	H2256_015_6	7		1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	016	1	1	01	01	H2256_016_1	5		1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	016	2	1	01	01	H2256_016_2	5		1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	018	1	1	01	01	H2256_018_1	7	2	1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	018	7	1	01	01	H2256_018_7	7	2	1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	018	8	1	01	01	H2256_018_8	6	2	1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	019	1	1	01	01	H2256_019_1	5	2	1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	019	7	1	01	01	H2256_019_7	5	2	1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	026	1	1	01	01	H2256_026_1	7	2	1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	026	2	1	01	01	H2256_026_2	7	2	1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	026	3	1	01	01	H2256_026_3	7	2	1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	028	0	1	01	01	H2256_028_0	5	2	1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	033	0	1	01	01	H2256_033_0	7		1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	034	0	1	01	01	H2256_034_0	8	2	1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	036	0	1	01	01	H2256_036_0	8	2	1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	039	0	1	01	01	H2256_039_0	5		1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	040	0	1	01	01	H2256_040_0	5	2	1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	041	0	1	01	01	H2256_041_0	5	2	1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2256	042	0	1	01	01	H2256_042_0	5	2	1	1111111	3	2	1	3		3	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	3	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	3	2	1	6	Root canals are covered once per tooth per lifetime.	3	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	3	2	1	6	Simple extraction covered once per tooth.	3	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	2											1	10111111			20	20	20	20	20	50	50	50	20	50	20	20	20	50	2		2																		2	2	001
H2320	022	1	1	02	01	H2320_022_1	6	2	1	1001101											3	2	1	6	Every 60 months, full description of services in notes	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Surgical extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							50	50	50	50			50	50	0	50	2		2																		2	2	001
H2320	022	2	1	02	01	H2320_022_2	6	2	1	1001101											3	2	1	6	Every 60 months, full description of services in notes	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Surgical extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							50	50	50	50			50	50	0	50	2		2																		2	2	001
H2320	022	3	1	02	01	H2320_022_3	6	2	1	1001101											3	2	1	6	Every 60 months, full description of services in notes	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Surgical Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							50	50	50	50			50	50	0	50	2		2																		2	2	001
H2320	022	4	1	02	01	H2320_022_4	6	2	1	1001101											3	2	1	6	Every 60 months, full description of services in notes	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Surgical Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							50	50	50	50			50	50	0	50	2		2																		2	2	001
H2320	022	5	1	02	01	H2320_022_5	6	2	1	1001101											3	2	1	6	Every 60 months, full description of services in notes	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Surgical extractions are covered once per tooth per lifetime	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							50	50	50	50			50	50	0	50	2		2																		2	2	001
H2320	028	1	1	02	01	H2320_028_1	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H2320	028	2	1	02	01	H2320_028_2	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H2320	028	3	1	02	01	H2320_028_3	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H2320	028	4	1	02	01	H2320_028_4	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H2320	028	5	1	02	01	H2320_028_5	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H2320	029	1	1	02	01	H2320_029_1	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H2320	029	2	1	02	01	H2320_029_2	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H2320	029	3	1	02	01	H2320_029_3	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H2320	029	4	1	02	01	H2320_029_4	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H2320	029	5	1	02	01	H2320_029_5	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H2320	030	1	1	02	01	H2320_030_1	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Extractions are covered once per tooth per lifetime	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H2320	030	2	1	02	01	H2320_030_2	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Extractions are covered once per tooth per lifetime	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H2322	008	0	1	04	01	H2322_008_0	17	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001100							50	50	50	50					0	50	2		2																		2	2	001
H2322	008	0	1	04	01	H2322_008_0	17	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	002
H2322	008	0	1	04	01	H2322_008_0	17	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	30	30			30	50	2		2																		2	2	003
H2322	011	0	1	04	01	H2322_011_0	19	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001100							50	50	50	50					0	50	2		2																		2	2	001
H2322	011	0	1	04	01	H2322_011_0	19	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	002
H2322	011	0	1	04	01	H2322_011_0	19	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	30	30			30	50	2		2																		2	2	003
H2354	015	0	1	01	01	H2354_015_0	16	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001100							50	50	50	50					0	50	2		2																		2	2	001
H2354	015	0	1	01	01	H2354_015_0	16	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	002
H2354	015	0	1	01	01	H2354_015_0	16	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	30	30			30	50	2		2																		2	2	003
H2354	018	0	1	01	01	H2354_018_0	17	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001100							50	50	50	50					0	50	2		2																		2	2	001
H2354	018	0	1	01	01	H2354_018_0	17	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	002
H2354	018	0	1	01	01	H2354_018_0	17	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	30	30			30	50	2		2																		2	2	003
H2354	019	0	1	01	01	H2354_019_0	15	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001100							50	50	50	50					0	50	2		2																		2	2	001
H2354	019	0	1	01	01	H2354_019_0	15	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	002
H2354	019	0	1	01	01	H2354_019_0	15	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	30	30			30	50	2		2																		2	2	003
H2354	021	0	1	02	01	H2354_021_0	17	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001100							50	50	50	50					0	50	2		2																		2	2	001
H2354	021	0	1	02	01	H2354_021_0	17	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	002
H2354	021	0	1	02	01	H2354_021_0	17	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	30	30			30	50	2		2																		2	2	003
H2354	028	0	1	01	01	H2354_028_0	18	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001100							50	50	50	50					0	50	2		2																		2	2	001
H2354	028	0	1	01	01	H2354_028_0	18	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	002
H2354	028	0	1	01	01	H2354_028_0	18	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	30	30			30	50	2		2																		2	2	003
H2406	039	0	1	04	01	H2406_039_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	040	0	1	04	01	H2406_040_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	041	0	1	04	01	H2406_041_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	060	0	1	04	01	H2406_060_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	070	0	1	04	01	H2406_070_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	071	0	1	04	01	H2406_071_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	076	0	1	04	01	H2406_076_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	083	0	1	04	01	H2406_083_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	087	0	1	04	01	H2406_087_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	095	0	1	04	01	H2406_095_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	096	0	1	04	01	H2406_096_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	097	0	1	04	01	H2406_097_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	101	0	1	04	01	H2406_101_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	103	0	1	04	01	H2406_103_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	104	0	1	04	01	H2406_104_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	105	0	1	04	01	H2406_105_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	106	0	1	04	01	H2406_106_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	112	0	1	04	01	H2406_112_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	113	0	1	04	01	H2406_113_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2406	119	0	1	04	01	H2406_119_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2459	021	1	1	02	01	H2459_021_1	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			20	50	20	20	50	50	20	20	20	20	20	20	20	50	2		2																		2	2	001
H2459	021	2	1	02	01	H2459_021_2	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			20	50	20	20	50	50	20	20	20	20	20	20	20	50	2		2																		2	2	001
H2459	021	3	1	02	01	H2459_021_3	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			20	50	20	20	50	50	20	20	20	20	20	20	20	50	2		2																		2	2	001
H2459	023	1	1	02	01	H2459_023_1	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			30	60	30	30	60	60	30	30	0	30	30	30	30	60	2		2																		2	2	001
H2459	023	2	1	02	01	H2459_023_2	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			30	60	30	30	60	60	30	30	0	30	30	30	30	60	2		2																		2	2	001
H2459	024	0	1	02	01	H2459_024_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			30	60	30	30	60	60	30	30	0	30	30	30	30	60	2		2																		2	2	001
H2459	030	0	1	02	01	H2459_030_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			30	60	30	30	60	60	30	30	0	30	30	30	30	60	2		2																		2	2	001
H2462	027	0	1	18	06	H2462_027_0	4		1	1111111	3	1				3	1				3	1				3	1				3	2	1	2		3	1				3	1				1		2	500.00	3							1	10101111			0	50			50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H2462	028	0	1	18	06	H2462_028_0	5		1	1111111	3	1				3	1				3	1				3	1				3	2	1	2		3	1				3	1				1		2	500.00	3							1	10101111			0	50			50	50	50	50	50	50	50	50	50	50	2		2																		2	2	002
H2463	001	0	1	01	01	H2463_001_0	8	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	001
H2463	001	0	1	01	01	H2463_001_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	002
H2486	003	0	1	01	01	H2486_003_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H2486	005	0	1	01	01	H2486_005_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H2486	006	0	1	01	01	H2486_006_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H2486	007	0	1	01	01	H2486_007_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H2486	009	0	1	01	01	H2486_009_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	2											1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	001
H2486	009	0	1	01	01	H2486_009_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	002
H2486	010	0	1	01	01	H2486_010_0	5	2	1	1101111	3	2	2	3							3	2	3	6	Amalgam and/or composite filling $25 unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services-core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1	001
H2486	010	0	1	01	01	H2486_010_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling 0% unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services - core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	002
H2486	010	0	1	01	01	H2486_010_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H2577	001	1	1	04	01	H2577_001_1	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2577	001	2	1	04	01	H2577_001_2	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2577	002	0	1	04	01	H2577_002_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2577	003	1	1	04	01	H2577_003_1	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2577	003	2	1	04	01	H2577_003_2	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2577	004	0	1	04	01	H2577_004_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2577	007	0	1	04	01	H2577_007_0	4	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2577	009	0	1	04	01	H2577_009_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2577	011	0	1	04	01	H2577_011_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2577	013	0	1	04	01	H2577_013_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2577	014	0	1	04	01	H2577_014_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2577	015	0	1	04	01	H2577_015_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2577	016	0	1	04	01	H2577_016_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2577	017	0	1	04	01	H2577_017_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2577	023	0	1	04	01	H2577_023_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2577	027	0	1	04	01	H2577_027_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2577	028	0	1	04	01	H2577_028_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2582	004	0	1	02	01	H2582_004_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2593	001	0	1	01	01	H2593_001_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H2593	001	0	1	01	01	H2593_001_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H2593	003	0	1	01	01	H2593_003_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H2593	003	0	1	01	01	H2593_003_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H2593	005	0	1	01	01	H2593_005_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H2593	005	0	1	01	01	H2593_005_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H2593	006	0	1	01	01	H2593_006_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H2593	006	0	1	01	01	H2593_006_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H2593	029	0	1	01	01	H2593_029_0	7		1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H2593	029	0	1	01	01	H2593_029_0	7		1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H2593	040	0	1	01	01	H2593_040_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H2593	040	0	1	01	01	H2593_040_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H2593	043	0	1	01	01	H2593_043_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H2593	043	0	1	01	01	H2593_043_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H2802	008	0	1	02	01	H2802_008_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2802	029	0	1	02	01	H2802_029_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2802	048	0	1	02	01	H2802_048_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2802	059	0	1	02	01	H2802_059_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2802	063	0	1	02	01	H2802_063_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H2836	005	0	1	04	01	H2836_005_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H2836	005	0	1	04	01	H2836_005_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3138	001	0	1	04	01	H3138_001_0	12	2	1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		2																		2	2	001
H3138	002	0	1	04	01	H3138_002_0	7	2	1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		2																		2	2	001
H3152	082	0	1	01	01	H3152_082_0	10		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1		2	1000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H3152	084	0	1	01	01	H3152_084_0	9		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1		2	1000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H3152	088	0	1	01	01	H3152_088_0	9		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1		2	1000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H3204	001	0	1	01	01	H3204_001_0	7		1	1001111											3	2	1	6	Optional restorative services include fillings, in/on lays, protective restorations, recement and crowns.	3	2	1	6	Optional endodontic services include debridement, root canals, Apicocoectomy and Periadicular surgeries and retrograde fills.	3	2	1	6	Optional periodontic services include gingivectomy / gingiovoplasty, clinical crown lengthening, periodontal scaling and root planning and full mouth debridement.	3	2	1	6	Optional extraction services include extractions and coronectomy.	3	2	1	6	Prosthodontics, other oral/maxillofacial surgery, and other services include such services as vestibuloplasty, frenectomy and denture repair. This is not an all-inclusive list, please see notes.	1		2	4000.00	3							1	10001111							20	50	50	50	50	50	20	20	20	50	2		2																		2	2	001
H3204	007	0	1	01	01	H3204_007_0	7		1	1001111											3	2	1	6	Optional restorative services include fillings, in/on lays, protective restorations, recement and crowns.	3	2	1	6	Optional endodontic services include debridement, root canals, apicocoectomy and periadicular surgeries and retrograde fills.	3	2	1	6	Optional periodontic services include gingivectomy / gingiovoplasty, clinical crown lengthening, periodontal scaling and root planning and full mouth debridement.	3	2	1	6	Optional extraction services include extractions and coronectomy.	3	2	1	6	Prosthodontics, other oral/maxillofacial surgery, and other services include such services as vestibuloplasty, frenectomy and denture repair. This is not an all-inclusive list, please see notes.	1		2	4000.00	3							1	10001111							20	50	50	50	50	50	20	20	20	50	2		2																		2	2	001
H3204	008	0	1	01	01	H3204_008_0	6		1	1001111											3	2	1	6	Optional restorative services include fillings, in/on lays, protective restorations, recement and crowns.	3	2	1	6	Optional endodontic services include debridement, root canals, apicocoectomy and periadicular surgeries and retrograde fills.	3	2	1	6	Optional periodontic services include gingivectomy / gingiovoplasty, clinical crown lengthening, periodontal scaling and root planning and full mouth debridement.	3	2	1	6	Optional extraction services include extractions and coronectomy.	3	2	1	6	Prosthodontics, other oral/maxillofacial surgery, and other services include such services as vestibuloplasty, frenectomy and denture repair. This is not an all-inclusive list, please see notes.	1		2	4000.00	3							1	10001111							20	50	50	50	50	50	20	20	20	50	2		2																		2	2	001
H3204	015	0	1	02	01	H3204_015_0	8		1	1001111											3	2	1	6	Optional restorative services include fillings, in/on lays, protective restorations, recement and crowns.	3	2	1	6	Optional endodontic services include debridement, root canals, apicocoectomy and periadicular surgeries and retrograde fills.	3	2	1	6	Optional periodontic services include gingivectomy / gingiovoplasty, clinical crown lengthening, periodontal scaling and root planning and full mouth debridement.	3	2	1	6	Optional extraction services include extractions and coronectomy.	3	2	1	6	Prosthodontics, other oral/maxillofacial surgery, and other services include such services as vestibuloplasty, frenectomy and denture repair. This is not an all-inclusive list, please see notes.	1		2	4000.00	3							1	10001111							20	50	50	50	50	50	20	20	20	50	2		2																		2	2	001
H3206	001	0	1	04	01	H3206_001_0	9		1	1001111											3	2	1	6	Optional restorative services include fillings, in/on lays, protective restorations, recement and crowns.	3	2	1	6	Optional endodontic services include debridement, root canals, apicocoectomy and periadicular surgeries and retrograde fills.	3	2	1	6	Optional periodontic services include gingivectomy / gingiovoplasty, clinical crown lengthening, periodontal scaling and root planning and full mouth debridement.	3	2	1	6	Optional extraction services include extractions and coronectomy.	3	2	1	6	Prosthodontics, other oral/maxillofacial surgery, and other services include such services as vestibuloplasty, frenectomy and denture repair. This is not an all-inclusive list, please see notes.	1	2	2	4000.00	3							1	10001111							20	50	50	50	50	50	20	20	20	50	2		2																		2	2	001
H3206	003	0	1	04	01	H3206_003_0	5		1	1001111											3	2	1	6	Optional restorative services include fillings, in/on lays, protective restorations, recement and crowns.	3	2	1	6	Optional endodontic services include debridement, root canals, apicocoectomy and periadicular surgeries and retrograde fills.	3	2	1	6	Optional periodontic services include gingivectomy / gingiovoplasty, clinical crown lengthening, periodontal scaling and root planning and full mouth debridement.	3	2	1	6	Optional extraction services include extractions and coronectomy.	3	2	1	6	Prosthodontics, other oral/maxillofacial surgery, and other services include such services as vestibuloplasty, frenectomy and denture repair. This is not an all-inclusive list, please see notes.	1	2	2	4000.00	3							1	10001111							20	50	50	50	50	50	20	20	20	50	2		2																		2	2	001
H3307	002	0	1	02	01	H3307_002_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3307	012	0	1	02	01	H3307_012_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3307	015	0	1	02	01	H3307_015_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3307	018	0	1	02	01	H3307_018_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3307	023	0	1	02	01	H3307_023_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3312	002	0	1	01	01	H3312_002_0	8		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1		2	2000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H3312	064	0	1	01	01	H3312_064_0	8		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1		2	2000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H3312	072	0	1	01	01	H3312_072_0	8		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1		2	1000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H3342	023	1	1	04	01	H3342_023_1	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3342	023	1	1	04	01	H3342_023_1	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3342	023	2	1	04	01	H3342_023_2	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3342	023	2	1	04	01	H3342_023_2	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3379	001	0	1	02	01	H3379_001_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3379	041	0	1	02	01	H3379_041_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3379	043	0	1	02	01	H3379_043_0	4	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3379	046	0	1	02	01	H3379_046_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3379	050	0	1	02	01	H3379_050_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3379	051	0	1	02	01	H3379_051_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3418	001	0	1	04	01	H3418_001_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3418	002	0	1	04	01	H3418_002_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3418	003	0	1	04	01	H3418_003_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3418	005	0	1	04	01	H3418_005_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3418	006	0	1	04	01	H3418_006_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3418	007	0	1	04	01	H3418_007_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3418	009	0	1	04	01	H3418_009_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3418	010	0	1	04	01	H3418_010_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3443	005	0	1	01	01	H3443_005_0	12		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3447	001	0	1	01	01	H3447_001_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	001	0	1	01	01	H3447_001_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	003	0	1	01	01	H3447_003_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	003	0	1	01	01	H3447_003_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	004	0	1	01	01	H3447_004_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00000011											50	50	50	50			2		1	00011100					0.00	0.00	0.00	0.00	0.00	0.00							2	2	002
H3447	004	0	1	01	01	H3447_004_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	005	0	1	01	01	H3447_005_0	6		1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	005	0	1	01	01	H3447_005_0	6		1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	010	0	1	01	01	H3447_010_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	010	0	1	01	01	H3447_010_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	013	0	1	01	01	H3447_013_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	013	0	1	01	01	H3447_013_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	024	0	1	01	01	H3447_024_0	11	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	024	0	1	01	01	H3447_024_0	11	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	025	0	1	01	01	H3447_025_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	025	0	1	01	01	H3447_025_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	033	0	1	01	01	H3447_033_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	033	0	1	01	01	H3447_033_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	037	0	1	01	01	H3447_037_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	037	0	1	01	01	H3447_037_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	038	1	1	01	01	H3447_038_1	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	038	1	1	01	01	H3447_038_1	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	038	2	1	01	01	H3447_038_2	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	038	2	1	01	01	H3447_038_2	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	039	0	1	01	01	H3447_039_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	039	0	1	01	01	H3447_039_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	042	1	1	01	01	H3447_042_1	9	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	042	1	1	01	01	H3447_042_1	9	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	042	2	1	01	01	H3447_042_2	9	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	042	2	1	01	01	H3447_042_2	9	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	042	3	1	01	01	H3447_042_3	10	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	042	3	1	01	01	H3447_042_3	10	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	042	4	1	01	01	H3447_042_4	9	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	042	4	1	01	01	H3447_042_4	9	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3447	043	0	1	01	01	H3447_043_0	10	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3447	043	0	1	01	01	H3447_043_0	10	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3528	010	0	1	02	01	H3528_010_0	12		1	1111111	3	1				3	1				3	2	1	6	Restorative: 1 filing per tooth per year	3	2	1	6	Endodontics: 1 per tooth per lifetime	3	2	1	6	Periodontics: 1 every 36 months per quadrant	3	2	1	6	Extractions: 1 per tooth per lifetime	3	2	1	6	Prosthodontics: Oral/Maxillofacial Surgery 1 every 5 years	1		2	2000.00	3							1	10111111			20	20	20	20	20	20	50	50	50	50	50	50	50	50	1	100.00	2																		1	2	001
H3528	010	0	1	02	01	H3528_010_0	12		1	1111111	3	1				3	1				3	2	1	6	Restorative: 1 filing per tooth per year	3	2	1	6	Endodontics: 1 per tooth per lifetime	3	2	1	6	Periodontics: 1 every 36 months per quadrant	3	2	1	6	Extractions: 1 per tooth per lifetime	3	2	1	6	Prosthodontics: Oral/Maxillofacial Surgery 1 every 5 years	1		2	3000.00	3							1	10111111			20	20	20	20	20	20	50	50	50	50	50	50	50	50	1	100.00	2																		1	2	002
H3528	010	0	1	02	01	H3528_010_0	12	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		2																		2	2	003
H3528	011	1	1	02	01	H3528_011_1	10		1	1111111	3	1				3	1				3	2	1	6	Restorative: 1 filing per tooth per year	3	2	1	6	Endodontics: 1 per tooth per lifetime	3	2	1	6	Periodontics: 1 every 36 months per quadrant	3	2	1	6	Extractions: 1 per tooth per lifetime	3	2	1	6	Prosthodontics: Oral/Maxillofacial Surgery 1 every 5 years	1		2	2000.00	3							1	10111111			20	20	20	20	20	20	50	50	50	50	50	50	50	50	1	100.00	2																		1	2	001
H3528	011	1	1	02	01	H3528_011_1	10		1	1111111	3	1				3	1				3	2	1	6	Restorative: 1 filing per tooth per year	3	2	1	6	Endodontics: 1 per tooth per lifetime	3	2	1	6	Periodontics: 1 every 36 months per quadrant	3	2	1	6	Extractions: 1 per tooth per lifetime	3	2	1	6	Prosthodontics: Oral/Maxillofacial Surgery 1 every 5 years	1		2	3000.00	3							1	10111111			20	20	20	20	20	20	50	50	50	50	50	50	50	50	1	100.00	2																		1	2	002
H3528	011	1	1	02	01	H3528_011_1	10		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	3500.00	3							1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		2																		2	2	003
H3528	011	2	1	02	01	H3528_011_2	11		1	1111111	3	1				3	1				3	2	1	6	Restorative: 1 filing per tooth per year	3	2	1	6	Endodontics: 1 per tooth per lifetime	3	2	1	6	Periodontics: 1 every 36 months per quadrant	3	2	1	6	Extractions: 1 per tooth per lifetime	3	2	1	6	Prosthodontics: Oral/Maxillofacial Surgery 1 every 5 years	1		2	2000.00	3							1	10111111			20	20	20	20	20	20	50	50	50	50	50	50	50	50	1	100.00	2																		1	2	001
H3528	011	2	1	02	01	H3528_011_2	11		1	1111111	3	1				3	1				3	2	1	6	Restorative: 1 filing per tooth per year	3	2	1	6	Endodontics: 1 per tooth per lifetime	3	2	1	6	Periodontics: 1 every 36 months per quadrant	3	2	1	6	Extractions: 1 per tooth per lifetime	3	2	1	6	Prosthodontics: Oral/Maxillofacial Surgery 1 every 5 years	1		2	3000.00	3							1	10111111			20	20	20	20	20	20	50	50	50	50	50	50	50	50	1	100.00	2																		1	2	002
H3528	011	2	1	02	01	H3528_011_2	11		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	3500.00	3							1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		2																		2	2	003
H3528	014	0	1	02	01	H3528_014_0	12		1	1111111	3	1				3	1				3	2	1	6	Restorative: 1 filing per tooth per year	3	2	1	6	Endodontics: 1 per tooth per lifetime	3	2	1	6	Periodontics: 1 every 36 months per quadrant	3	2	1	6	Extractions: 1 per tooth per lifetime	3	2	1	6	Prosthodontics: Oral/Maxillofacial Surgery 1 every 5 years	1		2	2000.00	3							1	10111111			20	20	20	20	20	20	50	50	50	50	50	50	50	50	1	100.00	2																		1	2	001
H3528	014	0	1	02	01	H3528_014_0	12		1	1111111	3	1				3	1				3	2	1	6	Restorative: 1 filing per tooth per year	3	2	1	6	Endodontics: 1 per tooth per lifetime	3	2	1	6	Periodontics: 1 every 36 months per quadrant	3	2	1	6	Extractions: 1 per tooth per lifetime	3	2	1	6	Prosthodontics: Oral/Maxillofacial Surgery 1 every 5 years	1		2	3000.00	3							1	10111111			20	20	20	20	20	20	50	50	50	50	50	50	50	50	1	100.00	2																		1	2	002
H3528	014	0	1	02	01	H3528_014_0	12	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	3500.00	3							1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		2																		2	2	003
H3528	015	0	1	02	01	H3528_015_0	10		1	1111111	3	1				3	1				3	2	1	6	Restorative: 1 filing per tooth per year	3	2	1	6	Endodontics: 1 per tooth per lifetime	3	2	1	6	Periodontics: 1 every 36 months per quadrant	3	2	1	6	Extractions: 1 per tooth per lifetime	3	2	1	6	Prosthodontics: Oral/Maxillofacial Surgery 1 every 5 years	1		2	2000.00	3							1	10111111			20	20	20	20	20	20	50	50	50	50	50	50	50	50	1	100.00	2																		1	2	001
H3528	015	0	1	02	01	H3528_015_0	10		1	1111111	3	1				3	1				3	2	1	6	Restorative: 1 filing per tooth per year	3	2	1	6	Endodontics: 1 per tooth per lifetime	3	2	1	6	Periodontics: 1 every 36 months per quadrant	3	2	1	6	Extractions: 1 per tooth per lifetime	3	2	1	6	Prosthodontics: Oral/Maxillofacial Surgery 1 every 5 years	1		2	3000.00	3							1	10111111			20	20	20	20	20	20	50	50	50	50	50	50	50	50	1	100.00	2																		1	2	002
H3528	015	0	1	02	01	H3528_015_0	10		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		2																		2	2	003
H3528	016	0	1	02	01	H3528_016_0	10		1	1111111	3	1				3	1				3	2	1	6	Restorative: 1 filing per tooth per year	3	2	1	6	Endodontics: 1 per tooth per lifetime	3	2	1	6	Periodontics: 1 every 36 months per quadrant	3	2	1	6	Extractions: 1 per tooth per lifetime	3	2	1	6	Prosthodontics: Oral/Maxillofacial Surgery 1 every 5 years	1		2	2000.00	3							1	10111111			20	20	20	20	20	20	50	50	50	50	50	50	50	50	1	100.00	2																		1	2	001
H3528	016	0	1	02	01	H3528_016_0	10		1	1111111	3	1				3	1				3	2	1	6	Restorative: 1 filing per tooth per year	3	2	1	6	Endodontics: 1 per tooth per lifetime	3	2	1	6	Periodontics: 1 every 36 months per quadrant	3	2	1	6	Extractions: 1 per tooth per lifetime	3	2	1	6	Prosthodontics: Oral/Maxillofacial Surgery 1 every 5 years	1		2	3000.00	3							1	10111111			20	20	20	20	20	20	50	50	50	50	50	50	50	50	1	100.00	2																		1	2	002
H3528	016	0	1	02	01	H3528_016_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		2																		2	2	003
H3533	006	0	1	01	01	H3533_006_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	2											1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H3533	006	0	1	01	01	H3533_006_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	2											1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H3533	006	0	1	01	01	H3533_006_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H3533	010	0	1	01	01	H3533_010_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H3533	027	0	1	01	01	H3533_027_0	7		1	1101111	3	2	2	3							3	2	4	6	amalgam and/or composite filling: Unlimited bridge & crown recementation: 1 every 5 yearsCrown & other restorative services - core buildup and prefabricated post and core: 1 per tooth per lifetime	3	2	2	6	root canal & root canal retreatment - 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	bridges-crown- 2 every 5 yearsbridges-pontic- 1 every 5 yearsocclusal adjustment- 1 every 3 yearsoral surgery - 2 per year	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H3533	027	0	1	01	01	H3533_027_0	7		1	1101111	3	2	2	3							3	2	4	6	amalgam and/or composite filling- unlimitedbridge & crown recementation- 1 every 5 yearscrown & other restorative services - core buildup and prefabricated post and core- 1 per tooth per lifetime	3	2	2	6	root canal & root canal retreatment- 1 per tooth per lifetime	3	2	2	1		3	1				3	2	13	6	adjustments to dentures, tissue conditioning, denture rebase, reline, repair- 1 per yearocclusal adjustment- 1 every 3 yearsbridges-pontic, complete/partial dentures- 1 every 5 yearsoral surgery-	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H3533	027	0	1	01	01	H3533_027_0	7		1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1		1									1	10101111			0	0			0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H3533	033	0	1	01	01	H3533_033_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H3533	033	0	1	01	01	H3533_033_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H3533	033	0	1	01	01	H3533_033_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H3536	002	0	1	01	01	H3536_002_0	9	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3536	002	0	1	01	01	H3536_002_0	9	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3655	034	0	1	01	01	H3655_034_0	10	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3655	034	0	1	01	01	H3655_034_0	10	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3655	041	0	1	01	01	H3655_041_0	9	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3655	041	0	1	01	01	H3655_041_0	9	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3655	042	0	1	01	01	H3655_042_0	9	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3655	042	0	1	01	01	H3655_042_0	9	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3655	045	1	1	01	01	H3655_045_1	10	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3655	045	1	1	01	01	H3655_045_1	10	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3655	045	2	1	01	01	H3655_045_2	10	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3655	045	2	1	01	01	H3655_045_2	10	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3655	045	3	1	01	01	H3655_045_3	9	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3655	045	3	1	01	01	H3655_045_3	9	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3655	045	4	1	01	01	H3655_045_4	14	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3655	045	4	1	01	01	H3655_045_4	14	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3655	047	0	1	01	01	H3655_047_0	10	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H3655	047	0	1	01	01	H3655_047_0	10	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H3660	028	0	1	02	01	H3660_028_0	7	1	1	1001111											3	2	1	6	Minor restorative services are unlimited. Relines & repairs (to bridges & dentures) covered once per 36 months. Cast restorations (including crowns & onlays)  covered once per tooth per 5 years.	3	1				3	2	1	6	Scaling and root planing is payable once per quadrant per 24-month period. Full mouth debridement is payable once per lifetime. Periodontal surgical procedures are payable once per 36-month period.	3	1				3	2	1	6	Some services are covered once per 36-month period, once per 5-year period or once per lifetime.	2											1	10001111							50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H3660	029	0	1	02	01	H3660_029_0	7	1	1	1001111											3	2	1	6	Minor restorative services are unlimited. Relines & repairs (to bridges & dentures) covered once per 36-months. Cast restorations (including crowns & onlays)  covered once per tooth per 5-years.	3	1				3	2	1	6	Scaling and root planing is payable once per quadrant per 24-month period. Full mouth debridement is payable once per lifetime. Periodontal surgical procedures are payable once per 36-month period.	3	1				3	2	1	6	Some services are covered once per 36-month period, once per 5-year period or once per lifetime.	2											1	10001111							50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H3660	044	0	1	01	01	H3660_044_0	7	1	1	1000010																					3	2	1	6	Scaling and root planing is payable once per quadrant per 24-month period. Full mouth debridement is payable once per lifetime. Periodontal surgical procedures are payable once per 36-month period.						3	2	1	6	Some services are covered once per 36-month period, once per 5-year period or once per lifetime.												1	10000010											50	50			50	50			2																		2	2	001
H3660	050	0	1	01	01	H3660_050_0	9	1	1	1001111											3	2	1	6	Minor restorative services are unlimited. Relines & repairs (to bridges & dentures) covered once per 36 months. Cast restorations (including crowns & onlays)  covered once per tooth per 5 years.	3	1				3	2	1	6	Scaling and root planing is payable once per quadrant per 24-month period. Full mouth debridement is payable once per lifetime. Periodontal surgical procedures are payable once per 36-month period.	3	1				3	2	1	6	Some services are covered once per 36-month period, once per 5-year period or once per lifetime.	2											1	10001111							0	50	0	50	50	50	0	50	20	50	2		2																		2	2	001
H3660	052	1	1	01	01	H3660_052_1	7	1	1	1001111											3	2	1	6	Minor restorative services are unlimited. Relines & repairs (to bridges & dentures) covered once per 36 months. Cast restorations (including crowns & onlays) covered once per tooth per 5 years.	3	1				3	2	1	6	Scaling and root planing is payable once per quadrant per 24-month period. Full mouth debridement is payable once per lifetime. Periodontal surgical procedures are payable once per 36-month period.	3	1				3	2	1	6	Some services are covered once per 36-month period, once per 5-year period or once per lifetime.	2											1	10001111							0	50	0	50	50	50	0	50	50	50	2		2																		2	2	001
H3660	052	2	1	01	01	H3660_052_2	7	1	1	1001111											3	2	1	6	Minor restorative services are unlimited. Relines & repairs (to bridges & dentures) covered once per 36 months. Cast restorations (including crowns & onlays)  covered once per tooth per 5 years.	3	1				3	2	1	6	Scaling and root planing is payable once per quadrant per 24-month period. Full mouth debridement is payable once per lifetime. Periodontal surgical procedures are payable once per 36-month period.	3	1				3	2	1	6	Some services are covered once per 36-month period, once per 5-year period or once per lifetime.	2											1	10001111							0	50	0	50	50	50	0	50	50	50	2		2																		2	2	001
H3660	053	1	1	01	01	H3660_053_1	9	1	1	1001111											3	2	1	6	Minor restorative services are unlimited. Relines & repairs (to bridges & dentures) covered once per 36 months. Cast restorations (including crowns & onlays)  covered once per tooth per 5 years.	3	1				3	2	1	6	Scaling and root planing is payable once per quadrant per 24-month period. Full mouth debridement is payable once per lifetime. Periodontal surgical procedures are payable once per 36-month period.	3	1				3	2	1	6	Some services are covered once per 36-month period, once per 5-year period or once per lifetime.	2											1	10001111							0	50	0	50	0	50	0	50	0	50	2		2																		2	2	001
H3660	053	2	1	01	01	H3660_053_2	9	1	1	1001111											3	2	1	6	Minor restorative services are unlimited. Relines & repairs (to bridges & dentures) covered once per 36 months. Cast restorations (including crowns & onlays)  covered once per tooth per 5 years.	3	1				3	2	1	6	Scaling and root planing is payable once per quadrant per 24-month period. Full mouth debridement is payable once per lifetime. Periodontal surgical procedures are payable once per 36-month period.	3	1				3	2	1	6	Some services are covered once per 36-month period, once per 5-year period or once per lifetime.	2											1	10001111							0	50	0	50	0	50	0	50	0	50	2		2																		2	2	001
H3660	056	1	1	01	01	H3660_056_1	9	1	1	1001111											3	2	1	6	Minor restorative services are unlimited. Relines & repairs (to bridges & dentures) covered once per 36 months. Cast restorations (including crowns & onlays)  covered once per tooth per 5 years.	3	1				3	2	1	6	Scaling and root planing is payable once per quadrant per 24-month period. Full mouth debridement is payable once per lifetime. Periodontal surgical procedures are payable once per 36-month period.	3	1				3	2	1	6	Some services are covered once per 36-month period, once per 5-year period or once per lifetime.	2											1	10001111							0	50	0	50	50	50	0	50	20	50	2		2																		2	2	001
H3660	056	2	1	01	01	H3660_056_2	10	1	1	1001111											3	2	1	6	Minor restorative services are unlimited. Relines & repairs (to bridges & dentures) covered once per 36 months. Cast restorations (including crowns & onlays)  covered once per tooth per 5 years.	3	1				3	2	1	6	Scaling and root planing is payable once per quadrant per 24-month period. Full mouth debridement is payable once per lifetime. Periodontal surgical procedures are payable once per 36-month period.	3	1				3	2	1	6	Some services are covered once per 36-month period, once per 5-year period or once per lifetime.	2											1	10001111							0	50	0	50	50	50	0	50	20	50	2		2																		2	2	001
H3668	013	0	1	01	01	H3668_013_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H3668	013	0	1	01	01	H3668_013_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H3668	018	1	1	01	01	H3668_018_1	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H3668	018	1	1	01	01	H3668_018_1	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H3668	018	2	1	01	01	H3668_018_2	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H3668	018	2	1	01	01	H3668_018_2	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H3668	019	1	1	01	01	H3668_019_1	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H3668	019	1	1	01	01	H3668_019_1	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H3668	019	2	1	01	01	H3668_019_2	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H3668	019	2	1	01	01	H3668_019_2	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H3668	020	0	1	01	01	H3668_020_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H3668	020	0	1	01	01	H3668_020_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H3668	022	0	1	01	01	H3668_022_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H3668	022	0	1	01	01	H3668_022_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H3668	023	0	1	01	01	H3668_023_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H3668	023	0	1	01	01	H3668_023_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H3668	025	0	1	01	01	H3668_025_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H3668	025	0	1	01	01	H3668_025_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H3668	026	0	1	01	01	H3668_026_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H3668	026	0	1	01	01	H3668_026_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H3668	029	0	1	01	01	H3668_029_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H3668	029	0	1	01	01	H3668_029_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H3672	013	0	1	01	01	H3672_013_0	13	2	1	1001111											3	2	1	6	Restorative Services: Fillings- 20% - 50% coinsurance for Fillings-1 per tooth every 3 years, 50% - 75% coinsurance for Crowns -1 per tooth every 5 years	3	1				3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3	2	1	6	Extractions: 1 service per tooth per lifetime, excision of lesion - unlimited.	3	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1		2	1500.00	3							1	10001111							20	75	50	75	50	75	50	75	50	75	2		2																		1	2	001
H3672	014	0	1	01	01	H3672_014_0	13	2	1	1001111											3	2	1	6	Restorative Services: Fillings- 20% - 50% coinsurance for Fillings-1 per tooth every 3 years, 50% - 75% coinsurance for Crowns -1 per tooth every 5 years	3	2	1	6	Endodontics: Unlimited.	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3	2	1	6	Extractions: 1 service per tooth per lifetime, excision of lesion - unlimited.	3	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1		2	1500.00	3							1	10001111							20	75	50	75	50	75	50	75	50	75	2		2																		1	2	001
H3672	020	0	1	01	01	H3672_020_0	13	2	1	1001111											3	2	1	6	Restorative Services: Fillings- 20% - 50% coinsurance for Fillings-1 per tooth every 3 years, 50% - 75% coinsurance for Crowns -1 per tooth every 5 years	3	1				3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3	2	1	6	Extractions: 1 service per tooth per lifetime, excision of lesion - unlimited.	3	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1		2	1500.00	3							1	10001111							20	75	50	75	50	75	50	75	50	75	2		2																		1	2	001
H3672	021	0	1	01	01	H3672_021_0	13	2	1	1001111											3	2	1	6	Restorative Services: Fillings- 20% - 50% coinsurance for Fillings-1 per tooth every 3 years, 50% - 75% coinsurance for Crowns -1 per tooth every 5 years	3	1				3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3	2	1	6	Extractions: 1 service per tooth per lifetime, excision of lesion - unlimited.	3	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1		2	1500.00	3							1	10001111							20	75	50	75	50	75	50	75	50	75	2		2																		1	2	001
H3672	023	0	1	01	01	H3672_023_0	12	2	1	1001111											3	2	1	6	Restorative Services: Fillings- 20% - 50% coinsurance for Fillings-1 per tooth every 3 years, 50% - 75% coinsurance for Crowns -1 per tooth every 5 years	3	1				3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3	2	1	6	Extractions: 1 service per tooth per lifetime, excision of lesion - unlimited.	3	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1		2	1500.00	3							1	10001111							20	75	50	75	50	75	50	75	50	75	2		2																		1	2	001
H3672	024	0	1	01	01	H3672_024_0	13	2	1	1001111											3	2	1	6	Restorative Services: Fillings- 20% - 50% coinsurance for Fillings-1 per tooth every 3 years, 50% - 75% coinsurance for Crowns -1 per tooth every 5 years	3	1				3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3	2	1	6	Extractions: 1 service per tooth per lifetime, excision of lesion - unlimited.	3	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1		2	1500.00	3							1	10001111							20	75	50	75	50	75	50	75	50	75	2		2																		1	2	001
H3805	015	0	1	02	01	H3805_015_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3805	017	0	1	02	01	H3805_017_0	4	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3805	037	0	1	02	01	H3805_037_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H3810	001	0	1	01	01	H3810_001_0	4		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			25.00	25.00	0.00	25.00	67.00	900.00	550.00	800.00	0.00	900.00	109.00	180.00	60.00	1100.00	2	2	001
H3810	003	0	1	01	01	H3810_003_0	11		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			25.00	25.00	0.00	25.00	67.00	900.00	550.00	800.00	0.00	900.00	109.00	180.00	60.00	1100.00	2	2	001
H3810	021	0	1	01	01	H3810_021_0	4		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			25.00	25.00	0.00	25.00	67.00	900.00	550.00	800.00	0.00	900.00	109.00	180.00	60.00	1100.00	2	2	001
H3810	022	0	1	01	01	H3810_022_0	8		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			25.00	25.00	0.00	25.00	67.00	900.00	550.00	800.00	0.00	900.00	109.00	180.00	60.00	1100.00	2	2	001
H3810	024	0	1	01	01	H3810_024_0	7		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			25.00	25.00	0.00	25.00	67.00	900.00	550.00	800.00	0.00	900.00	109.00	180.00	60.00	1100.00	2	2	001
H3815	007	0	1	01	01	H3815_007_0	19	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	008	0	1	01	01	H3815_008_0	19	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	010	0	1	01	01	H3815_010_0	16	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	011	0	1	01	01	H3815_011_0	14	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	013	0	1	01	01	H3815_013_0	15	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	019	0	1	01	01	H3815_019_0	16	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	020	0	1	01	01	H3815_020_0	16	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	021	0	1	01	01	H3815_021_0	16	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	023	0	1	01	01	H3815_023_0	16	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	026	0	1	02	01	H3815_026_0	14	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	028	0	1	01	01	H3815_028_0	15	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	031	0	1	01	01	H3815_031_0	14	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	033	0	1	01	01	H3815_033_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	034	0	1	01	01	H3815_034_0	16		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	035	0	1	01	01	H3815_035_0	16	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	036	0	1	01	01	H3815_036_0	17	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	037	0	1	01	01	H3815_037_0	15	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	038	0	1	01	01	H3815_038_0	15	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3815	040	0	1	01	01	H3815_040_0	15	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H3822	001	0	1	01	01	H3822_001_0	6		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H3822	007	0	1	02	01	H3822_007_0	6		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H3828	001	0	1	04	01	H3828_001_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1	2	2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H3828	001	0	1	04	01	H3828_001_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H3864	041	0	1	01	01	H3864_041_0	6		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	20	50	50	50	50	20	20	50	50	2		2																		2	2	002
H3890	002	0	1	04	01	H3890_002_0	10	2	1	1001111											3	2	1	6	See notes for benefit details.	3	2	1	6	See notes for benefit details.	3	2	1	6	See notes for benefit details.	3	2	1	6	Frequency of services:  • Extractions, coronectomy, surgical access of an unerupted tooth-once per tooth   Services covered with a $100 copayment  • Extractions and coronectomy	3	2	1	6	See notes for benefit details.	1	2	2	1000.00	3							2																		2		1	10001111							50.00	50.00	100.00	100.00	50.00	50.00	100.00	100.00	50.00	100.00	1	2	001
H3924	059	21	1	04	01	H3924_059_21	5		1	1001111											3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H3924	059	22	1	04	01	H3924_059_22	5		1	1001111											3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H3924	065	0	1	04	01	H3924_065_0	5		1	1001111											3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H4036	008	0	1	04	01	H4036_008_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4036	008	0	1	04	01	H4036_008_0	6		1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4036	017	0	1	04	01	H4036_017_0	10	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4036	017	0	1	04	01	H4036_017_0	10	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4036	020	0	1	04	01	H4036_020_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4036	020	0	1	04	01	H4036_020_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4036	022	0	1	04	01	H4036_022_0	9	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4036	022	0	1	04	01	H4036_022_0	9	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4036	024	0	1	04	01	H4036_024_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4036	024	0	1	04	01	H4036_024_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4036	025	0	1	04	01	H4036_025_0	9	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4036	025	0	1	04	01	H4036_025_0	9	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4036	026	0	1	04	01	H4036_026_0	10	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4036	026	0	1	04	01	H4036_026_0	10	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4036	028	0	1	04	01	H4036_028_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4036	028	0	1	04	01	H4036_028_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4036	029	0	1	04	01	H4036_029_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4036	029	0	1	04	01	H4036_029_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4036	030	0	1	04	01	H4036_030_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4036	030	0	1	04	01	H4036_030_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4036	031	0	1	04	01	H4036_031_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4036	031	0	1	04	01	H4036_031_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4036	033	0	1	04	01	H4036_033_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4036	033	0	1	04	01	H4036_033_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4036	034	0	1	04	01	H4036_034_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4036	034	0	1	04	01	H4036_034_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4036	035	0	1	04	01	H4036_035_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4036	035	0	1	04	01	H4036_035_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4036	036	0	1	04	01	H4036_036_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4036	036	0	1	04	01	H4036_036_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4141	015	0	1	01	01	H4141_015_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H4141	017	3	1	01	01	H4141_017_3	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H4141	017	5	1	01	01	H4141_017_5	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H4161	002	0	1	01	01	H4161_002_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4161	002	0	1	01	01	H4161_002_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4161	004	0	1	01	01	H4161_004_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4161	004	0	1	01	01	H4161_004_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4161	005	0	1	01	01	H4161_005_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4161	005	0	1	01	01	H4161_005_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4161	006	0	1	01	01	H4161_006_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4161	006	0	1	01	01	H4161_006_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4161	007	0	1	01	01	H4161_007_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4161	007	0	1	01	01	H4161_007_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4161	009	0	1	01	01	H4161_009_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4161	009	0	1	01	01	H4161_009_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4161	010	0	1	01	01	H4161_010_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4161	010	0	1	01	01	H4161_010_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4161	011	0	1	01	01	H4161_011_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4161	011	0	1	01	01	H4161_011_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4161	012	0	1	01	01	H4161_012_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4161	012	0	1	01	01	H4161_012_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4161	013	0	1	01	01	H4161_013_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4161	013	0	1	01	01	H4161_013_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4346	001	0	1	01	01	H4346_001_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4346	001	0	1	01	01	H4346_001_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4346	005	0	1	01	01	H4346_005_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4346	005	0	1	01	01	H4346_005_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4346	006	0	1	01	01	H4346_006_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4346	006	0	1	01	01	H4346_006_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4346	009	0	1	01	01	H4346_009_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4346	009	0	1	01	01	H4346_009_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4346	010	0	1	01	01	H4346_010_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4346	010	0	1	01	01	H4346_010_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4346	012	0	1	01	01	H4346_012_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4346	012	0	1	01	01	H4346_012_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4346	017	0	1	01	01	H4346_017_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4346	017	0	1	01	01	H4346_017_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4346	019	0	1	01	01	H4346_019_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4346	019	0	1	01	01	H4346_019_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4346	029	0	1	01	01	H4346_029_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4346	029	0	1	01	01	H4346_029_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4461	039	0	1	01	01	H4461_039_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H4497	001	1	1	04	01	H4497_001_1	12	2	1	0111111	3	1				3	1				3	1				3	1				3	1				3	1									1	2	2	1000.00	3							1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		2																		2	2	001
H4497	001	2	1	04	01	H4497_001_2	12	2	1	0111111	3	1				3	1				3	1				3	1				3	1				3	1									1	2	2	1000.00	3							1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		2																		2	2	001
H4497	001	3	1	04	01	H4497_001_3	15	2	1	0111111	3	1				3	1				3	1				3	1				3	1				3	1									1	2	2	1000.00	3							1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		2																		2	2	001
H4497	002	1	1	04	01	H4497_002_1	12	2	1	0111111	3	1				3	1				3	1				3	1				3	1				3	1									1	2	2	1000.00	3							1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		2																		2	2	001
H4497	002	2	1	04	01	H4497_002_2	12	2	1	0111111	3	1				3	1				3	1				3	1				3	1				3	1									1	2	2	1000.00	3							1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		2																		2	2	001
H4497	002	3	1	04	01	H4497_002_3	12	2	1	0111111	3	1				3	1				3	1				3	1				3	1				3	1									1	2	2	1000.00	3							1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		2																		2	2	001
H4497	005	3	1	04	01	H4497_005_3	12	1	1	0000001																										3	1									1	2	2	1000.00	3							1	00000001													30	30			2		2																		2	2	001
H4497	005	4	1	04	01	H4497_005_4	12	1	1	0000001																										3	1									1	2	2	1000.00	3							1	00000001													30	30			2		2																		2	2	001
H4514	007	0	1	02	01	H4514_007_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H4527	024	0	1	02	01	H4527_024_0	4	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H4527	037	0	1	02	01	H4527_037_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H4527	051	0	1	02	01	H4527_051_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H4754	004	0	1	04	01	H4754_004_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	20	50	50	50	50	20	20	50	50	2		2																		2	2	001
H4754	017	0	1	04	01	H4754_017_0	5		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	20	50	50	50	50	20	20	50	50	2		2																		2	2	002
H4801	002	0	1	04	01	H4801_002_0	7		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H4801	007	0	1	04	01	H4801_007_0	7		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H4801	013	0	1	04	01	H4801_013_0	6		1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10101111			20	20			20	20	20	20	20	20	20	20	20	20	2		2																		2	2	001
H4801	014	0	1	04	01	H4801_014_0	6		1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10101111			20	20			20	20	20	20	20	20	20	20	20	20	2		2																		2	2	001
H4801	015	0	1	04	01	H4801_015_0	6		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H4801	019	0	1	04	01	H4801_019_0	5		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H4801	020	0	1	04	01	H4801_020_0	5		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H4875	016	1	1	04	01	H4875_016_1	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	016	2	1	04	01	H4875_016_2	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	016	3	1	04	01	H4875_016_3	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	016	4	1	04	01	H4875_016_4	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	016	5	1	04	01	H4875_016_5	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	017	1	1	04	01	H4875_017_1	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	017	2	1	04	01	H4875_017_2	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	017	3	1	04	01	H4875_017_3	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	017	4	1	04	01	H4875_017_4	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	017	5	1	04	01	H4875_017_5	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	018	1	1	04	01	H4875_018_1	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Extractions are covered once per tooth per lifetime	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	018	2	1	04	01	H4875_018_2	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Extractions are covered once per tooth per lifetime	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	018	3	1	04	01	H4875_018_3	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Extractions are covered once per tooth per lifetime	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	018	4	1	04	01	H4875_018_4	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Extractions are covered once per tooth per lifetime	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	018	5	1	04	01	H4875_018_5	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Extractions are covered once per tooth per lifetime	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	020	1	1	04	01	H4875_020_1	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	020	2	1	04	01	H4875_020_2	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	020	3	1	04	01	H4875_020_3	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	021	1	1	04	01	H4875_021_1	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	021	2	1	04	01	H4875_021_2	6	2	1	1001101											3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Extractions are covered once per tooth per lifetime	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							0	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	022	1	1	04	01	H4875_022_1	6	2	1	1001101											3	2	1	6	Every 60 months, full description of services in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Surgical Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines & repairs and bridge repairs once every 36 months, implants every 5 years and anesthesia & emergency palliative care at no limit - full description in notes	1		1									1	10001101							50	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	022	2	1	04	01	H4875_022_2	6	2	1	1001101											3	2	1	6	Every 60 months, full description of services in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Surgical Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines & repairs and bridge repairs once every 36 months, implants every 5 years and anesthesia & emergency palliative care at no limit - full description in notes	1		1									1	10001101							50	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	022	5	1	04	01	H4875_022_5	6	2	1	1001101											3	2	1	6	Every 60 months, full description of services in notes.	3	2	1	6	Root canals are covered once per tooth per lifetime.						3	2	1	6	Surgical Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines & repairs and bridge repairs once every 36 months, implants every 5 years and anesthesia & emergency palliative care at no limit - full description in notes	1		1									1	10001101							50	50	50	50			50	50	0	50	2		2																		2	2	001
H4875	023	0	1	04	01	H4875_023_0	6	2	1	1001101											3	2	1	6	Every 60 months, full description of services in notes	3	2	1	6	Root canals are covered once per tooth per lifetime						3	2	1	6	Surgical Extractions are covered once per tooth per lifetime.	3	2	1	6	Dentures, denture relines/repairs, bridge repairs, implants and implant related services, emergency palliative treatement & anesthesia are covered - full description in notes.	1		1									1	10001101							50	50	50	50			50	50	0	50	2		2																		2	2	001
H4882	003	0	1	04	01	H4882_003_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	2	1	2		3	1				3	1				1	2	2	500.00	3							1	10101111			0	50			50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H4882	009	1	1	04	01	H4882_009_1	8	2	1	1111111	3	1				3	1				3	1				3	1				3	2	1	2		3	1				3	1				1	2	2	500.00	3							1	10101111			0	50			50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H4882	009	2	1	04	01	H4882_009_2	9	2	1	1111111	3	1				3	1				3	1				3	1				3	2	1	2		3	1				3	1				1	2	2	500.00	3							1	10101111			0	50			50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H4882	010	2	1	04	01	H4882_010_2	7	2	1	1111111	3	1				3	1				3	1				3	1				3	2	1	2		3	1				3	1				1	2	2	500.00	3							1	10101111			0	50			50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H4882	011	1	1	04	01	H4882_011_1	8	2	1	1111111	3	1				3	1				3	1				3	1				3	2	1	2		3	1				3	1				1	2	2	500.00	3							1	10101111			0	50			50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H4882	011	2	1	04	01	H4882_011_2	8	2	1	1111111	3	1				3	1				3	1				3	1				3	2	1	2		3	1				3	1				1	2	2	500.00	3							1	10101111			0	50			50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H4909	014	0	1	04	01	H4909_014_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4909	014	0	1	04	01	H4909_014_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4909	015	0	1	04	01	H4909_015_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4909	015	0	1	04	01	H4909_015_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4909	016	0	1	04	01	H4909_016_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4909	016	0	1	04	01	H4909_016_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4909	020	0	1	04	01	H4909_020_0	5	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4909	020	0	1	04	01	H4909_020_0	5	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4909	021	0	1	04	01	H4909_021_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4909	021	0	1	04	01	H4909_021_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4909	023	0	1	04	01	H4909_023_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4909	023	0	1	04	01	H4909_023_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4909	026	0	1	04	01	H4909_026_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H4909	026	0	1	04	01	H4909_026_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H4937	001	0	1	04	01	H4937_001_0	6	2	1	1011111						3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											1	10011111					0	20	20	50	50	50	50	50	50	50	20	50	2		2																		2	2	001
H4937	002	0	1	04	01	H4937_002_0	6	2	1	1011111						3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2											1	10011111					0	20	20	50	50	50	50	50	50	50	20	50	2		2																		2	2	001
H4961	001	0	1	04	01	H4961_001_0	13		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	2	001
H4961	003	0	1	04	01	H4961_003_0	13		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	2	001
H4961	006	0	1	04	01	H4961_006_0	12		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	2	001
H4961	007	0	1	04	01	H4961_007_0	12	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							2																		2		2																		1	2	001
H4961	008	0	1	04	01	H4961_008_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							2																		2		2																		1	2	001
H5050	001	0	1	01	01	H5050_001_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10101111			20	50			20	50	20	20	20	20	20	20	50	50	1	100.00	1	00010000					0.00	0.00											2	2	001
H5050	004	0	1	01	01	H5050_004_0	12	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10101111			20	50			20	50	20	20	20	20	20	20	50	50	1	100.00	1	00010000					0.00	0.00											2	2	001
H5050	009	0	1	01	01	H5050_009_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10101111			20	50			20	50	20	20	20	20	20	20	50	50	1	100.00	1	00010000					0.00	0.00											2	2	001
H5050	013	0	1	01	01	H5050_013_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10101111			20	50			20	50	20	20	20	20	20	20	50	50	1	100.00	1	00010000					0.00	0.00											2	2	001
H5050	017	0	1	01	01	H5050_017_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10101111			20	50			20	50	20	20	20	20	20	20	50	50	1	100.00	1	00010000					0.00	0.00											2	2	001
H5050	019	0	1	01	01	H5050_019_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10101111			20	50			20	50	20	20	20	20	20	20	50	50	1	100.00	1	00010000					0.00	0.00											2	2	001
H5050	021	0	1	01	01	H5050_021_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10101111			20	50			20	50	20	20	20	20	20	20	50	50	1	100.00	1	00010000					0.00	0.00											2	2	001
H5050	022	0	1	01	01	H5050_022_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10101111			20	50			20	50	20	20	20	20	20	20	50	50	1	100.00	1	00010000					0.00	0.00											2	2	001
H5050	023	0	1	01	01	H5050_023_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10101111			20	50			20	50	20	20	20	20	20	20	50	50	1	100.00	1	00010000					0.00	0.00											2	2	001
H5211	001	0	1	02	01	H5211_001_0	3		1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10011111					20	50	50	50	50	50	50	50	50	50	50	50	1	100.00	2																		2	2	001
H5211	002	0	1	02	01	H5211_002_0	5		1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10011111					20	50	50	50	50	50	50	50	50	50	50	50	1	100.00	2																		2	2	001
H5211	003	0	1	02	01	H5211_003_0	3		1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10011111					20	50	50	50	50	50	50	50	50	50	50	50	1	100.00	2																		2	2	001
H5211	004	0	1	02	01	H5211_004_0	4		1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10011111					20	50	50	50	50	50	50	50	50	50	50	50	1	100.00	2																		2	2	001
H5211	010	0	1	01	01	H5211_010_0	5		1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10011111					20	50	50	50	50	50	0	50	50	50	50	50	1	100.00	2																		2	2	001
H5211	012	0	1	02	01	H5211_012_0	4		1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10011111					20	50	50	50	50	50	50	50	50	50	50	50	1	100.00	2																		2	2	001
H5211	013	0	1	02	01	H5211_013_0	4		1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10011111					20	50	50	50	50	50	50	50	50	50	50	50	1	100.00	2																		2	2	001
H5215	001	0	1	04	01	H5215_001_0	7	2	1	1001111											3	1				3	1				3	1				3	1				3	1				2											1	10001111							50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H5215	002	0	1	04	01	H5215_002_0	5		1	1001111											3	1				3	1				3	1				3	1				3	1				2											1	10001111							50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H5215	005	0	1	04	01	H5215_005_0	5	2	1	1001111											3	1				3	1				3	1				3	1				3	1				2											1	10001111							50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H5215	006	0	1	04	01	H5215_006_0	7	2	1	1001111											3	1				3	1				3	1				3	1				3	1				2											1	10001111							50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H5215	008	0	1	04	01	H5215_008_0	5	2	1	1001111											3	1				3	1				3	1				3	1				3	1				2											1	10001111							50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H5215	009	0	1	04	01	H5215_009_0	5	2	1	1001111											3	1				3	1				3	1				3	1				3	1				2											1	10001111							50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H5215	012	0	1	04	01	H5215_012_0	8	2	1	1001111											3	1				3	1				3	1				3	1				3	1				2											1	10001111							50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H5216	001	0	1	04	01	H5216_001_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	011	0	1	04	01	H5216_011_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	017	0	1	04	01	H5216_017_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	019	0	1	04	01	H5216_019_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling $25 up to unlimited per year, bridge/crown recementation  $25 up to 1 every 5 years, crown and other restorative services 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges-crown up to 2/5 yrs, bridges-pontic up to 1/5 yrs, occlusal adjustment up to 1/3 yrs, oral surgery up to 2 per yr.	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	019	0	1	04	01	H5216_019_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling 0% up to unlimited per year, bridge/crown recementation $25 up to 1/5 yrs, crown and other restorative services 50% up to 1 per tooth per lifetime.	3	2	2	3		3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year.	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	019	0	1	04	01	H5216_019_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	023	0	1	04	01	H5216_023_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling unlimited/year.Bridge Recementation, crown recementation 1/5 years.Crown/other restorative services-core buildup and prefabricated post and core 1/tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	023	0	1	04	01	H5216_023_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Restorative services include amalgam and/or composite filling up to unlimited per year, bridge recementation and crown recementation up to 1 every 5 years, crown and other restorative services	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Adjts. to dentures, denture rebase/reline/repair and tissue conditioning 1/yr, bridges-crown 2/5 yrs, bridges-pontic, complete+partial dentures 1/5 years, occlusal Adjts. 1/3 yrs, oral surgery 2/year.	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	023	0	1	04	01	H5216_023_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	024	0	1	04	01	H5216_024_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	024	0	1	04	01	H5216_024_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year. Bridges-crown 2/5 years. Bridges-pontic, complete and partial dentures 1/5 years. Occlusal adj. 1/3 years. Oral surgery 2/year.	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	024	0	1	04	01	H5216_024_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	027	0	1	04	01	H5216_027_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	027	0	1	04	01	H5216_027_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	027	0	1	04	01	H5216_027_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		1	2	003
H5216	034	0	1	04	01	H5216_034_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	034	0	1	04	01	H5216_034_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	034	0	1	04	01	H5216_034_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	037	0	1	04	01	H5216_037_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	2											1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	001
H5216	037	0	1	04	01	H5216_037_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	002
H5216	039	0	1	04	01	H5216_039_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	044	0	1	04	01	H5216_044_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	047	0	1	04	01	H5216_047_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling unlimited/year.Bridge Recementation, crown recementation 1/5 years.Crown/other restorative services-core buildup and prefabricated post and core 1/tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	047	0	1	04	01	H5216_047_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative services include amalgam and/or composite filling 0% up to unlimited per year, bridge recementation and crown recementation $25 up to 1 every 5 years, crown and other restorative services	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services services include adjustments to dentures, denture rebase, denture reline, denture repair and tissue conditioning up to 1 per year, brid	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	047	0	1	04	01	H5216_047_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	048	0	1	04	01	H5216_048_0	9	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	053	0	1	04	01	H5216_053_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	057	0	1	04	01	H5216_057_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling $25 unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services-core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	057	0	1	04	01	H5216_057_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative srvc: amalgam and/or composite filling 0% unlimited/year, bridge/crown recementation $25 up to 1 every 5 years, crown. Core buildup, prefab post, core 50% up to 1/ tooth/ lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	057	0	1	04	01	H5216_057_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	058	0	1	04	01	H5216_058_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling $25 unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services-core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	root canal/ root canal retreatment - 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	058	0	1	04	01	H5216_058_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative srvc: amalgam and/or composite filling 0% unlimited/year, bridge/crown recementation $25 up to 1 every 5 years, crown. Core buildup, prefab post, core 50% up to 1/ tooth/ lifetime.	3	2	2	6	root canal/ root canal retreatment - 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	058	0	1	04	01	H5216_058_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	059	0	1	04	01	H5216_059_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	063	0	1	04	01	H5216_063_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	063	0	1	04	01	H5216_063_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year. Bridges-crown 2/5 years. Bridges-pontic, complete and partial dentures 1/5 years. Occlusal adj. 1/3 years. Oral surgery 2/year.	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	063	0	1	04	01	H5216_063_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	064	0	1	04	01	H5216_064_0	5	2	1	1101111	3	2	2	3							3	2	4	6	fillings $25 up to unlimited, recementation of crown $25 up to 1 every 5 years, recementation of dentures $25 up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	5	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges up to 1 every 5 years, oral surgery up to 2 per year, tissue conditioning up to 1 per year, occlusal adjustments up to 1 every 3 years.	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	064	0	1	04	01	H5216_064_0	5	2	1	1101111	3	2	2	3							3	2	3	6	Restorative services include fillings 0% up to unlimited per year, recementation of crown and recementation of dentures $25 copayment up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	11	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures and complete dentures 50% up to 1 every 5 years, denture adjustment and denture reline and denture repair and denture rebase and tissue conditioning 50% up to 1 per year, oral surgery 50% up to 2 per year,  occlusal adjustments 50% up to 1 every 3 years, bridges 50% up to 1 every 5 years.	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	064	0	1	04	01	H5216_064_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	073	0	1	04	01	H5216_073_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	073	0	1	04	01	H5216_073_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	073	0	1	04	01	H5216_073_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	078	1	1	04	01	H5216_078_1	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	078	1	1	04	01	H5216_078_1	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	078	1	1	04	01	H5216_078_1	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	078	2	1	04	01	H5216_078_2	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	088	0	1	04	01	H5216_088_0	7	2	1	1101111	3	2	2	3							3	2	3	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	088	0	1	04	01	H5216_088_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	088	0	1	04	01	H5216_088_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2	003
H5216	089	0	1	04	01	H5216_089_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per toothme.	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Includes bridges up to 1 every 5 years, oral surgery up to 2 per year, tissue conditioning up to 1 per year, occlusal adjustments up to 1 every 3 years.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	089	0	1	04	01	H5216_089_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Restorative services include fillings 0% up to unlimited per year, recementation of crown and recementation of dentures $25 copayment up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	089	0	1	04	01	H5216_089_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	092	0	1	04	01	H5216_092_0	6		1	1101111	3	2	2	3							3	2	5	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	1	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planning (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			20.00	20.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	092	0	1	04	01	H5216_092_0	6		1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	1	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	5	6	periodontics services include scaling and root planning (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	092	0	1	04	01	H5216_092_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	097	0	1	04	01	H5216_097_0	9	2	1	1101111	3	2	2	3							3	2	4	6	amalgam and/or composite filling -$25.00 Unlimitedbridge recementation $25.00 1 every 5 yearscrown 50%1 per tooth per lifetimecrown recementation $25.00 1 every 5 yearsother restorative services	3	2	2	6	root canal 50% 1 per tooth per lifetimeroot canal retreatment50% 1 per tooth per lifetime	3	2	2	6	scaling and root planing (deep cleaning) $25.00 1 per quadrant every 3 yearsscaling for moderate inflammation $25.00 1 every 3 years	3	1				3	2	6	6	bridges-crown 50% 2 every 5 years, bridges-pontic 50%1 every 5 years,occlusal adjustment,50% 1 every 3 years, oral surgery50% 2 per year	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	097	0	1	04	01	H5216_097_0	9	2	1	1101111	3	2	2	3							3	2	4	6	Restorative svc include amalgam and/or composite filling/unlimited/yr. Crown/ Core buildup and Prefab post and core up to 1 / tooth / lifetime, crown recementation 1/5 years.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Adjustments to dentures, rebase, reline, repair and tissue conditioning 1/yr, complete dentures and partial dentures, bridges-crown/ponitc 1/5 yr, occlusal adjustment 1 /3 years, oral surgery 2/yr	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	097	0	1	04	01	H5216_097_0	9	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	099	0	1	04	01	H5216_099_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	100	0	1	04	01	H5216_100_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	100	0	1	04	01	H5216_100_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year. Bridges-crown 2/5 years. Bridges-pontic, complete and partial dentures 1/5 years. Occlusal adj. 1/3 years. Oral surgery 2/year.	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	100	0	1	04	01	H5216_100_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	105	0	1	04	01	H5216_105_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Restorative services include fillings 0% up to unlimited per year, recementation of bridge/crown $25 copayment up to 1/5 yrs, crown and other restorative services 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	2											1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	001
H5216	105	0	1	04	01	H5216_105_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	002
H5216	106	0	1	04	01	H5216_106_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	107	0	1	04	01	H5216_107_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling $25 unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services-core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	107	0	1	04	01	H5216_107_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling 0% unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services - core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair and tissue conditioning 1/year, bridge-pontic, complete/partial dentures 1/5 years, bridge-crown 2/5 years, occlusal adj. 1/3 years, oral surgery 2/year.	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	107	0	1	04	01	H5216_107_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	112	0	1	04	01	H5216_112_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	116	0	1	04	01	H5216_116_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	2											1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	001
H5216	116	0	1	04	01	H5216_116_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	002
H5216	120	0	1	04	01	H5216_120_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	root canal, root canal retreatment 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	2											1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	120	0	1	04	01	H5216_120_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative srvc: amalgam and/or composite filling 0% unlimited/year, bridge/crown recementation $25 up to 1 every 5 years, crown. Core buildup, prefab post, core 50% up to 1/ tooth/ lifetime.	3	2	2	6	root canal, root canal retreatment 1 per tooth per lifetime	3	2	2	1		3	1				3	2	13	6	denture adjust, rebase, reline, repair, tissue condit 1/year; bridges-crown 2/ 5 year; bridges-pontic, complete dentures, partial dentures 1/ 5 years, occlusal adjust 1/3 years, oral surgery 2/ year.	2											1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	120	0	1	04	01	H5216_120_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	124	0	1	04	01	H5216_124_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	2											1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	124	0	1	04	01	H5216_124_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year. Bridges-crown 2/5 years. Bridges-pontic, complete and partial dentures 1/5 years. Occlusal adj. 1/3 years. Oral surgery 2/year.	2											1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	124	0	1	04	01	H5216_124_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	131	0	1	04	01	H5216_131_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	132	0	1	04	01	H5216_132_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	136	0	1	04	01	H5216_136_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Include amalgam and/or composite filling $25 up to unlimited/ year, bridge recementation and crown recementation $25 - 1 every 5 years, crown and other restorative services-50% - 1 per tooth/lifetime	3	2	2	6	1 per tooth per lifetime	3	2	2	1		3	1				3	2	6	6	services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	136	0	1	04	01	H5216_136_0	5	2	1	1101111	3	2	2	3							3	2	4	6	amalgam and/or composite filling 0% -unlimited per year, bridge recementation and crown recementation- 1 every 5 years, crown and other restorative services -1 per tooth per lifetime	3	2	2	6	1 per tooth per lifetime	3	2	2	1		3	1				3	2	13	6	adj. to dentures, rebase, reline, repair and tissue conditioning - 1/yr., bridges-crown - 2/5 yrs., bridges-pontic, complete/partial dentures -1/5 yrs,, occlusal adjustment- 1/3 yrs., oral surg.2/yr	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	136	0	1	04	01	H5216_136_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	137	0	1	04	01	H5216_137_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	137	0	1	04	01	H5216_137_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	137	0	1	04	01	H5216_137_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	138	0	1	04	01	H5216_138_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling $25 unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services-core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	138	0	1	04	01	H5216_138_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling 0% unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services - core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	3		3	2	2	1		3	1				3	2	13	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	138	0	1	04	01	H5216_138_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	141	0	1	04	01	H5216_141_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	141	0	1	04	01	H5216_141_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	141	0	1	04	01	H5216_141_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	142	1	1	04	01	H5216_142_1	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	142	1	1	04	01	H5216_142_1	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year. Bridges-crown 2/5 years. Bridges-pontic, complete and partial dentures 1/5 years. Occlusal adj. 1/3 years. Oral surgery 2/year.	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	142	1	1	04	01	H5216_142_1	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	142	2	1	04	01	H5216_142_2	7	2	1	1101111	3	2	2	2							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	142	2	1	04	01	H5216_142_2	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1/year.Bridges-crown 2/5 years.Bridges-pontic, complete/part. dentures 1/5 years.Occlusal adjustment 1/3 years.Oral surgery 2/year.	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	142	2	1	04	01	H5216_142_2	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	144	0	1	04	01	H5216_144_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	144	0	1	04	01	H5216_144_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	144	0	1	04	01	H5216_144_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	152	0	1	04	01	H5216_152_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling unlimited/year.Bridge Recementation, crown recementation 1/5 years.Crown/other restorative services-core buildup and prefabricated post and core 1/tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	152	0	1	04	01	H5216_152_0	5	2	1	1101111	3	2	2	3							3	2	4	6	amalgam and/or composite filling 0% unlimited/year, bridge/crown recementation $25 up to 1 every 5 years, crown. Core buildup, prefab post, core 50% up to 1/ tooth/ lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	denture adjust, rebase, reline, repair, tissue condit 1/year; bridges-crown 2/ 5 year; bridges-pontic, complete dentures, partial dentures 1/ 5 years, occlusal adjust 1/3 years, oral surgery 2/ year.	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	152	0	1	04	01	H5216_152_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		1	2	003
H5216	154	0	1	04	01	H5216_154_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling $25 unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services-core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	154	0	1	04	01	H5216_154_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling 0% unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services - core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	154	0	1	04	01	H5216_154_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	168	0	1	04	01	H5216_168_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year; bridge and crown recementation $25 1 every 5 years; crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years and scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	168	0	1	04	01	H5216_168_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year; bridge and crown recementation $25 1 every 5 years; crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years; scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year; bridges-crown 2/5 years; bridges-pontic, complete and partial dentures 1/5 years; occlusal adj. 1/3 years; oral surgery 2/year	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	168	0	1	04	01	H5216_168_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	169	0	1	04	01	H5216_169_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling unlimited/year.Bridge Recementation, crown recementation 1/5 years.Crown/other restorative services-core buildup and prefabricated post and core 1/tooth per lifetime.	3	2	2	6	root canal/ root canal retreatment 1 per tooth per lifetime	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	169	0	1	04	01	H5216_169_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	root canal/ root canal retreatment 1 per tooth per lifetime	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	169	0	1	04	01	H5216_169_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	170	0	1	04	01	H5216_170_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	2											1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	170	0	1	04	01	H5216_170_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	2											1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	170	0	1	04	01	H5216_170_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	172	0	1	04	01	H5216_172_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	1	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	172	0	1	04	01	H5216_172_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	1	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	172	0	1	04	01	H5216_172_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	174	0	1	04	01	H5216_174_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	175	0	1	04	01	H5216_175_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	176	0	1	04	01	H5216_176_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	177	0	1	04	01	H5216_177_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	185	0	1	04	01	H5216_185_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	192	0	1	04	01	H5216_192_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative srvc: amalgam and/or composite filling $25 up to unlimited/year, bridge/crown recementation $25 up to 1 every 5 years, Crown/Core buildup, prefab post, core 50% up to 1/ tooth/ lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Prosths, Oral/Maxillo Surgery, bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	500.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	192	0	1	04	01	H5216_192_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative srvc: amalgam and/or composite filling 0% unlimited/year, bridge/crown recementation $25 up to 1 every 5 years, Crown/Core buildup, prefab post, core 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	denture adjust, rebase, reline, repair, tissue condit 1/year; bridges-crown 2/ 5 year; bridges-pontic, complete dentures, partial dentures 1/ 5 years, occlusal adjust 1/3 years, oral surgery 2/ year.	1	2	2	500.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	192	0	1	04	01	H5216_192_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	194	0	1	04	01	H5216_194_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	194	0	1	04	01	H5216_194_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	194	0	1	04	01	H5216_194_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	196	1	1	04	01	H5216_196_1	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	196	2	1	04	01	H5216_196_2	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	196	2	1	04	01	H5216_196_2	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	196	2	1	04	01	H5216_196_2	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	203	1	1	04	01	H5216_203_1	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	203	2	1	04	01	H5216_203_2	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	207	0	1	04	01	H5216_207_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	211	0	1	04	01	H5216_211_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	211	0	1	04	01	H5216_211_0	7	2	1	1101111	3	2	2	6	Non-routine Services services include emergency treatment for pain up to 2 per year.						3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		1									1	10001111							50	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	211	0	1	04	01	H5216_211_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2	003
H5216	213	0	1	04	01	H5216_213_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	215	0	1	04	01	H5216_215_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	216	0	1	04	01	H5216_216_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	223	0	1	04	01	H5216_223_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	224	0	1	04	01	H5216_224_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	226	0	1	04	01	H5216_226_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	229	0	1	04	01	H5216_229_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	232	1	1	04	01	H5216_232_1	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	500.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	232	1	1	04	01	H5216_232_1	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	500.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	232	1	1	04	01	H5216_232_1	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	232	2	1	04	01	H5216_232_2	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	500.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	232	2	1	04	01	H5216_232_2	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	500.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	232	2	1	04	01	H5216_232_2	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	233	1	1	04	01	H5216_233_1	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	2											1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	233	1	1	04	01	H5216_233_1	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	2											1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	233	1	1	04	01	H5216_233_1	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	233	2	1	04	01	H5216_233_2	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	2											1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	233	2	1	04	01	H5216_233_2	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	2											1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	233	2	1	04	01	H5216_233_2	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	234	0	1	04	01	H5216_234_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	500.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	234	0	1	04	01	H5216_234_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	500.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	234	0	1	04	01	H5216_234_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	235	0	1	04	01	H5216_235_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	244	0	1	04	01	H5216_244_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		2																		1	2	001
H5216	246	0	1	04	01	H5216_246_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	247	0	1	04	01	H5216_247_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	249	0	1	04	01	H5216_249_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	249	0	1	04	01	H5216_249_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	249	0	1	04	01	H5216_249_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	252	0	1	04	01	H5216_252_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	260	0	1	04	01	H5216_260_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	261	0	1	04	01	H5216_261_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	263	0	1	04	01	H5216_263_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	264	0	1	04	01	H5216_264_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	265	0	1	04	01	H5216_265_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	266	0	1	04	01	H5216_266_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	269	0	1	04	01	H5216_269_0	12	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2	001
H5216	273	0	1	04	01	H5216_273_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	274	0	1	04	01	H5216_274_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2	001
H5216	279	0	1	04	01	H5216_279_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	285	0	1	04	01	H5216_285_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	286	0	1	04	01	H5216_286_0	6	2	1	1101111	3	2	2	3							3	2	3	6	Restorative services include fillings 0% up to unlimited per year, recementation of crown and recementation of dentures $25 copayment up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	11	6	Part./comp. dentures 1 every 5 yrs. Denture adjustment, reline, repair, and rebase, and tissue conditioning 1 per yr. Oral surgery 2 per yr. Occlusal adjustments 1 every 3 yrs. Bridges 1 every 5 yrs.	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	001
H5216	289	0	1	04	01	H5216_289_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	289	0	1	04	01	H5216_289_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	289	0	1	04	01	H5216_289_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	306	0	1	04	01	H5216_306_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	308	0	1	04	01	H5216_308_0	6	2	1	1101111	3	2	2	3							3	2	3	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	308	0	1	04	01	H5216_308_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	308	0	1	04	01	H5216_308_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		1	2	003
H5216	309	0	1	04	01	H5216_309_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	312	0	1	04	01	H5216_312_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	314	0	1	04	01	H5216_314_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	316	3	1	04	01	H5216_316_3	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2	001
H5216	317	0	1	04	01	H5216_317_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	319	0	1	04	01	H5216_319_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	319	0	1	04	01	H5216_319_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	319	0	1	04	01	H5216_319_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	320	0	1	04	01	H5216_320_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	322	0	1	04	01	H5216_322_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	324	0	1	04	01	H5216_324_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	327	0	1	04	01	H5216_327_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	328	0	1	04	01	H5216_328_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	337	1	1	04	01	H5216_337_1	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	337	2	1	04	01	H5216_337_2	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	338	0	1	04	01	H5216_338_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	339	0	1	04	01	H5216_339_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	341	0	1	04	01	H5216_341_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	345	0	1	04	01	H5216_345_0	5	2	1	1101111	3	2	2	3							3	2	3	6	Restorative services include fillings $25 up to unlimited per year, recementation of crown $25 up to 1 every 5 years, recementation of dentures $25 up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	5	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges up to 1 every 5 years, oral surgery up to 2 per year, tissue conditioning up to 1 per year, occlusal adjustments up to 1 every 3 years.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	345	0	1	04	01	H5216_345_0	5	2	1	1101111	3	2	2	3							3	2	3	6	Restorative services include fillings 0% up to unlimited per year, recementation of crown and recementation of dentures $25 copayment up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	11	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures and complete dentures 50% up to 1 every 5 years, denture adjustment and denture reline and denture repair and denture rebase and tissue conditioning 50% up to 1 per year, oral surgery 50% up to 2 per year,  occlusal adjustments 50% up to 1 every 3 years, bridges 50% up to 1 every 5 years.	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	345	0	1	04	01	H5216_345_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	346	0	1	04	01	H5216_346_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics - Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	346	0	1	04	01	H5216_346_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	346	0	1	04	01	H5216_346_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		1	2	003
H5216	347	0	1	04	01	H5216_347_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	348	0	1	04	01	H5216_348_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Srvc incl amalgam and/or composite filling 0% unlimited/ yr, bridge/crown recementation $25 1/ 5 yrs, crown and other restorative services - core buildup and prefab post and core 50% 1/tooth/ lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Srvc incl adj to dentures, denture rebase/reline/repair, tissue conditioning 1/yr, bridges-crown 2/ 5 yrs, bridges-pontic, complete/prtl dentures 1/ 5 yrs, occlusal adj 1/ 3 yrs, oral surgery 2/ yr	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	001
H5216	348	0	1	04	01	H5216_348_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	002
H5216	349	0	1	04	01	H5216_349_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	350	0	1	04	01	H5216_350_0	6	2	1	1101101	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, crown and bridge recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	1	6	Per tooth, per lifetime						3	1				3	2	6	6	Bridges - 3 every 5 yearsOcclusal Adjustment - 1 every 3 yearsOral Surgery - 2 per year	2											1	10001100							50	50	50	50					50	50	2		1	00101001			25.00	25.00			25.00	25.00					25.00	25.00			1	2	001
H5216	350	0	1	04	01	H5216_350_0	6	2	1	0001000											3	2	4	6	Fillings 0% unlimited per year, crown and bridge recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime																					2											1	00001000							0	50									2		1	00001000							25.00	25.00									1	2	002
H5216	350	0	1	04	01	H5216_350_0	6	2	1	0011000						3	1				3	1																								2											1	00011000					0	0	0	0									2		2																		1	2	003
H5216	353	0	1	04	01	H5216_353_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	354	0	1	04	01	H5216_354_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	355	0	1	04	01	H5216_355_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	359	0	1	04	01	H5216_359_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Restorative services include amalgam and/or composite filling 0% up to unlimited per year, bridge recementation and crown recementation $25 up to 1 every 5 years, crown and other restorative service	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Complete and partial dentures include bridges up to 1 every 5 years, oral surgery up to 2 per year, tissue conditioning up to 1 per year, occlusal adjustments up to 1 every 3 years.	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	359	0	1	04	01	H5216_359_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Restorative services include fillings 0% up to unlimited per year, recementation of crown and recementation of dentures $25 copayment up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Services include partial and complete dentures 1 per 5 yrs, denture adj, reline repair rebase and tissue conditioning 1 per yr, oral surgery 2 per yr, occlusal adj 1 every 3 yrs, bridges 1 per 5 yrs.	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	359	0	1	04	01	H5216_359_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	360	0	1	04	01	H5216_360_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	368	0	1	04	01	H5216_368_0	5	2	1	1101111	3	2	2	3							3	2	3	6	Restorative svcs incl amalgam and/or composite filling $25 @unlim/yr,  Bridge & crown recementation $25 @1/5 yrs, crown & other restorative svcs-core buildup & prefab post & core 50% @1/tooth/lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	368	0	1	04	01	H5216_368_0	5	2	1	1101111	3	2	2	3							3	2	3	6	Restorative svcs incl amalgam and/or composite filling 0% @unlim/yr, bridge & crown recementation $25 @ 1/5yr, crown & other restorative svcs- core buildup & prefab post & core 50% @ 1/tooth/lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Scaling and root cleaning 1 per quadrant every 3 years	3	1				3	2	13	6	Denture adjustments, rebase, reline, and repair, & tissue conditioning 1/yr. Bridges-crown 2/5 yrs. Bridges-pontic, complete/partial dentures 1/5 yrs. Occlusal adjustment 1/3 yrs. Oral surgery 2/yr.	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	368	0	1	04	01	H5216_368_0	5	2	1	0010001						3	1																			3	1									1		1									1	00010001					0	0							0	0			2		2																		1	2	003
H5216	372	0	1	04	01	H5216_372_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	375	0	1	04	01	H5216_375_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	378	0	1	04	01	H5216_378_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	001
H5216	378	0	1	04	01	H5216_378_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	002
H5216	380	0	1	04	01	H5216_380_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	380	0	1	04	01	H5216_380_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	380	0	1	04	01	H5216_380_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	383	0	1	04	01	H5216_383_0	5	2	1	1101111	3	2	2	3							3	2	4	6	amalgam and/or composite filling unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and core buildup and prefabricated post and core up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	383	0	1	04	01	H5216_383_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling up to unlimited per year, bridge and crown recementation up to 1 every 5 years, core buildup and prefabricated post and core up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	denture adjust, rebase, reline, repair, tissue condit 1/year; bridges-crown 2/ 5 year; bridges-pontic, complete dentures, partial dentures 1/ 5 years, occlusal adjust 1/3 years, oral surgery 2/ year.	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	383	0	1	04	01	H5216_383_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	384	0	1	04	01	H5216_384_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	387	1	1	04	01	H5216_387_1	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	387	2	1	04	01	H5216_387_2	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	389	0	1	04	01	H5216_389_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	389	0	1	04	01	H5216_389_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year.	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	389	0	1	04	01	H5216_389_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	391	0	1	04	01	H5216_391_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5216	395	0	1	04	01	H5216_395_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5216	395	0	1	04	01	H5216_395_0	6	2	1	1101111	3	2	2	3							3	2	4	6	$25 amalgam and/or composite filling/unlimited/ yr.  $25 bridge and crown recementation 1/ 5 yr, 50% crown /core buildup and prefabricated post and core  1/ tooth/lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5216	395	0	1	04	01	H5216_395_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5216	396	0	1	04	01	H5216_396_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5244	001	0	1	01	01	H5244_001_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	2	2	001
H5244	002	0	1	01	01	H5244_002_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	2	2	001
H5244	003	0	1	01	01	H5244_003_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	2	2	001
H5253	072	0	1	02	01	H5253_072_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H5253	097	0	1	02	01	H5253_097_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H5253	105	0	1	02	01	H5253_105_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H5253	110	0	1	02	01	H5253_110_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H5253	119	0	1	02	01	H5253_119_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H5253	121	0	1	02	01	H5253_121_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H5253	127	0	1	02	01	H5253_127_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H5253	135	0	1	02	01	H5253_135_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H5262	001	0	1	01	01	H5262_001_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	003	0	1	01	01	H5262_003_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	004	0	1	01	01	H5262_004_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	005	0	1	01	01	H5262_005_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	007	0	1	01	01	H5262_007_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	008	0	1	01	01	H5262_008_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	009	0	1	01	01	H5262_009_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	010	0	1	01	01	H5262_010_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	011	0	1	01	01	H5262_011_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	012	0	1	01	01	H5262_012_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	013	0	1	01	01	H5262_013_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	018	0	1	01	01	H5262_018_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	019	0	1	01	01	H5262_019_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	020	0	1	01	01	H5262_020_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	021	0	1	01	01	H5262_021_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	023	0	1	01	01	H5262_023_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	024	0	1	01	01	H5262_024_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	025	0	1	01	01	H5262_025_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	026	0	1	01	01	H5262_026_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5262	027	0	1	01	01	H5262_027_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H5296	006	0	1	01	01	H5296_006_0	10		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H5296	008	0	1	01	01	H5296_008_0	13		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H5322	039	0	1	02	01	H5322_039_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H5386	003	0	1	01	01	H5386_003_0	5		1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10011111					0.00	5.00	20.00	425.00	0.00	475.00	0.00	450.00	35.00	150.00	20.00	495.00	2	2	001
H5386	003	0	1	01	01	H5386_003_0	5		1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							2																		2		1	10011111					0.00	5.00	20.00	425.00	0.00	475.00	0.00	450.00	35.00	150.00	20.00	495.00	2	2	002
H5386	004	0	1	01	01	H5386_004_0	5	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							2																		2		1	10011111					0.00	5.00	20.00	425.00	0.00	475.00	0.00	450.00	35.00	150.00	20.00	495.00	2	2	001
H5386	005	0	1	01	01	H5386_005_0	5	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							2																		2		1	10011111					0.00	5.00	20.00	425.00	0.00	475.00	0.00	450.00	35.00	150.00	20.00	495.00	2	2	001
H5422	011	0	1	01	01	H5422_011_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H5422	011	0	1	01	01	H5422_011_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H5422	014	0	1	01	01	H5422_014_0	5	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H5422	014	0	1	01	01	H5422_014_0	5	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H5422	015	0	1	01	01	H5422_015_0	5	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H5422	015	0	1	01	01	H5422_015_0	5	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H5425	001	0	1	01	01	H5425_001_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	2	2	001
H5425	004	0	1	01	01	H5425_004_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	2	2	001
H5425	005	0	1	01	01	H5425_005_0	8		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	180.00	34.00	595.00	35.00	615.00	0.00	648.00	0.00	362.00	29.00	803.00	1	1	001
H5425	005	0	1	01	01	H5425_005_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	1	1	002
H5425	006	0	1	01	01	H5425_006_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	007	0	1	01	01	H5425_007_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	008	0	1	01	01	H5425_008_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	009	0	1	01	01	H5425_009_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	019	0	1	01	01	H5425_019_0	8		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	180.00	34.00	595.00	35.00	615.00	0.00	648.00	0.00	362.00	29.00	803.00	1	1	001
H5425	019	0	1	01	01	H5425_019_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	1	1	002
H5425	020	0	1	01	01	H5425_020_0	6		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	180.00	34.00	595.00	35.00	615.00	0.00	648.00	0.00	362.00	29.00	803.00	1	1	001
H5425	020	0	1	01	01	H5425_020_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	1	1	002
H5425	028	0	1	01	01	H5425_028_0	9	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	033	0	1	01	01	H5425_033_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	034	0	1	01	01	H5425_034_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	055	0	1	01	01	H5425_055_0	8		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	180.00	34.00	595.00	35.00	615.00	0.00	648.00	0.00	362.00	29.00	803.00	1	1	001
H5425	055	0	1	01	01	H5425_055_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	1	1	002
H5425	065	0	1	01	01	H5425_065_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	066	0	1	01	01	H5425_066_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	067	0	1	01	01	H5425_067_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	068	0	1	01	01	H5425_068_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	073	0	1	01	01	H5425_073_0	6		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	180.00	34.00	595.00	35.00	615.00	0.00	648.00	0.00	362.00	29.00	803.00	1	1	001
H5425	073	0	1	01	01	H5425_073_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	1	1	002
H5425	075	0	1	01	01	H5425_075_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	2	2	001
H5425	076	0	1	01	01	H5425_076_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	2	2	001
H5425	077	0	1	01	01	H5425_077_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	2	2	001
H5425	078	0	1	01	01	H5425_078_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	2	2	001
H5425	082	0	1	01	01	H5425_082_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	2	2	001
H5425	086	0	1	01	01	H5425_086_0	9	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	087	0	1	01	01	H5425_087_0	9	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	091	0	1	01	01	H5425_091_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	092	0	1	01	01	H5425_092_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	096	0	1	01	01	H5425_096_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	2	2	001
H5425	100	0	1	01	01	H5425_100_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	101	0	1	01	01	H5425_101_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	2	2	001
H5425	102	0	1	01	01	H5425_102_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	2	2	001
H5425	103	0	1	01	01	H5425_103_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	2	2	001
H5425	104	0	1	01	01	H5425_104_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	105	0	1	01	01	H5425_105_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	2	2	001
H5425	106	0	1	01	01	H5425_106_0	8		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	180.00	34.00	595.00	35.00	615.00	0.00	648.00	0.00	362.00	29.00	803.00	1	1	001
H5425	106	0	1	01	01	H5425_106_0	8		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	1	1	002
H5425	107	0	1	01	01	H5425_107_0	8		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	180.00	34.00	595.00	35.00	615.00	0.00	648.00	0.00	362.00	29.00	803.00	1	1	001
H5425	107	0	1	01	01	H5425_107_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	1	1	002
H5425	111	0	1	01	01	H5425_111_0	8		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	180.00	34.00	595.00	35.00	615.00	0.00	648.00	0.00	362.00	29.00	803.00	1	1	001
H5425	111	0	1	01	01	H5425_111_0	8		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	1	1	002
H5425	115	0	1	01	01	H5425_115_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5425	116	0	1	01	01	H5425_116_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H5472	003	0	1	02	01	H5472_003_0	12		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
H5521	040	0	1	04	01	H5521_040_0	8		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1	2	2	2000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H5521	076	0	1	04	01	H5521_076_0	7	2	1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1	2	2	2000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H5521	120	0	1	04	01	H5521_120_0	7		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1	2	2	2000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H5521	121	0	1	04	01	H5521_121_0	7		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1	2	2	2000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H5521	123	0	1	04	01	H5521_123_0	8		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1	2	2	1000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H5521	124	0	1	04	01	H5521_124_0	8		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1	2	2	1000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H5521	277	0	1	04	01	H5521_277_0	9		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1	2	2	1000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H5521	278	0	1	04	01	H5521_278_0	8		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1	2	2	1000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H5521	313	0	1	04	01	H5521_313_0	8		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1	2	2	1000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H5521	318	0	1	04	01	H5521_318_0	7		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1	2	2	2000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H5521	341	0	1	04	01	H5521_341_0	8		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1	2	2	1000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H5521	390	0	1	04	01	H5521_390_0	8		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1	2	2	1000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H5521	391	0	1	04	01	H5521_391_0	8		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1	2	2	1000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
H5525	004	0	1	04	01	H5525_004_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling $25 unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services-core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5525	004	0	1	04	01	H5525_004_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative services include fillings 0% up to unlimited per year, recementation of crown and recementation of dentures $25 copayment up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	11	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5525	004	0	1	04	01	H5525_004_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2	003
H5525	005	0	1	04	01	H5525_005_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5525	005	0	1	04	01	H5525_005_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year.	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5525	005	0	1	04	01	H5525_005_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5525	006	0	1	04	01	H5525_006_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative services include fillings $25 up to unlimited per year, recementation of crown $25 up to 1 every 5 years, recementation of dentures $25 up to 1 every 5 years, crown 50% up to 1 per tooth p	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Include bridges up to 1 every 5 years, oral surgery up to 2 per year, tissue conditioning up to 1 per year, occlusal adjustments up to 1 every 3 years.	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5525	006	0	1	04	01	H5525_006_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative services include fillings 0% up to unlimited per year, recementation of crown and recementation of dentures $25 copayment up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures and complete dentures 50% up to 1 every 5 years, denture adjustment and denture reline and denture repair and	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5525	006	0	1	04	01	H5525_006_0	5	2	1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1	2	2	2000.00	3							1	10101111			0	0			0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5525	008	0	1	04	01	H5525_008_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative services-amalgam and/or composite filling up to unlimited per year, bridge and crown recementationup to 1 every 5 years, crown and other restorative service up to  1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	1000.00	3							1	10000100									50	50					50	50	2		1	00100011			25.00	25.00							25.00	25.00	25.00	25.00			1	2	001
H5525	008	0	1	04	01	H5525_008_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative service-amalgam and/or composite filling up to unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services up to 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Adjs.to dentures, denture rebase, reline, repair and tissue conditioning 1/yr, bridges-crown 2/5 yrs, bridges-pontic, complete and partial dentures 1/5 yrs, occlusal adjs 1/3 yrs, oral surgery 2/year.	1	2	2	1000.00	3							1	10001111							0	50	50	50	50	50	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5525	008	0	1	04	01	H5525_008_0	5	2	1	1110111	3	1				3	1									3	1				3	1				3	1				3	1				1		1									1	10110111			0	0	0	0			0	0	0	0	0	0	0	0	2		2																		1	2	003
H5525	024	0	1	04	01	H5525_024_0	7		1	1101101	3	2	2	3							3	1				3	2	2	3							3	1				3	2	6	6	Prosths, Oral/Maxillo Surgery, bridges-crown up to 2 every 5 years, bridges-pontic up to 1every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101001			25.00	25.00			25.00	25.00					25.00	25.00			1	2	001
H5525	024	0	1	04	01	H5525_024_0	7		1	1101101	3	2	2	3							3	2	4	6	restorative srvc: amalgam and/or composite filling 0% unlimited/year, bridge/crown recementation $25 up to 1 every 5 years, crown. Core buildup, prefab post, core 50% up to 1/ tooth/ lifetime.	3	2	2	3							3	1				3	2	13	6	denture adjust, rebase, reline, repair, tissue condit 1/year; bridges-crown 2/ 5 year; bridges-pontic, complete dentures, partial dentures 1/ 5 years, occlusal adjust 1/3 years, oral surgery 2/ year.	1	2	2	2000.00	3							1	10001101							0	50	50	50			0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5525	026	0	1	04	01	H5525_026_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling unlimited/yr; bridge recementation and crown Recementation 1/5 yrs; crown and other restorative services-core buildup and prefabricated post and core 1/tooth/lifetime.	3	2	2	3		3	2	2	3		3	1				3	2	6	3		1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5525	026	0	1	04	01	H5525_026_0	5	2	1	1101111	3	2	2	3							3	2	4	3		3	2	2	3		3	2	2	3		3	1				3	2	13	3		1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5525	026	0	1	04	01	H5525_026_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5525	027	0	1	04	01	H5525_027_0	5	2	1	1101111	3	2	2	3							3	2	4	6	srvc incl amalgam/composite filling $25/ unlimited per yr, bridge/crown recementation $25 up to 1/ 5 yrs, crown/other restorative srvc - core buildup, prefab post and core 50% up to 1/ tooth/ lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Prosths, Oral/Maxillo Surgery, bridges-crown up to 2 every 5 years, bridges-pontic up to 1every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5525	027	0	1	04	01	H5525_027_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative srvc: amalgam and/or composite filling 0% unlimited/year, bridge/crown recementation $25 up to 1 every 5 years, crown. Core buildup, prefab post, core 50% up to 1/ tooth/ lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	denture adjust, rebase, reline, repair, tissue condit 1/year; bridges-crown 2/ 5 year; bridges-pontic, complete dentures, partial dentures 1/ 5 years, occlusal adjust 1/3 years, oral surgery 2/ year	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5525	027	0	1	04	01	H5525_027_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5525	030	0	1	04	01	H5525_030_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Restorative Srv include amalgam and/or composite filling $25 unlimited per yr, bridge/crown recementation $25 up to 1/5 yrs, crown/core buildup and prefabricated post/core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges-crown up to 2/5 yrs, bridges-pontic up to 1/5 yrs, occlusal adjustment up to 1/3 yrs, oral surgery up to 2 per yr.	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5525	030	0	1	04	01	H5525_030_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Restorative srv include amalgam and/or composite filling 0% unlimited per yr, bridge/crown recementation $25 1/5 yrs, crown/core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Prosthodontics adj to denture/rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adj 1/3 yrs, oral surgery 2 per yr.	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5525	030	0	1	04	01	H5525_030_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5525	034	0	1	04	01	H5525_034_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5525	035	0	1	04	01	H5525_035_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5525	042	0	1	04	01	H5525_042_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00100011			25.00	25.00							25.00	25.00	25.00	25.00			1	2	001
H5525	042	0	1	04	01	H5525_042_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5525	042	0	1	04	01	H5525_042_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5525	049	0	1	04	01	H5525_049_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5525	050	0	1	04	01	H5525_050_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5525	051	1	1	04	01	H5525_051_1	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5525	051	1	1	04	01	H5525_051_1	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5525	051	1	1	04	01	H5525_051_1	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5525	051	2	1	04	01	H5525_051_2	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5525	051	2	1	04	01	H5525_051_2	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5525	051	2	1	04	01	H5525_051_2	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5525	052	0	1	04	01	H5525_052_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	001
H5525	052	0	1	04	01	H5525_052_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	002
H5525	054	0	1	04	01	H5525_054_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5525	055	0	1	04	01	H5525_055_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5525	056	0	1	04	01	H5525_056_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5525	057	0	1	04	01	H5525_057_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5525	058	0	1	04	01	H5525_058_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5525	058	0	1	04	01	H5525_058_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5525	058	0	1	04	01	H5525_058_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5525	061	0	1	04	01	H5525_061_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	2											1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5525	061	0	1	04	01	H5525_061_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year. Bridges-crown 2/5 years. Bridges-pontic, complete and partial dentures 1/5 years. Occlusal adj. 1/3 years. Oral surgery 2/year.	2											1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5525	061	0	1	04	01	H5525_061_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5525	062	0	1	04	01	H5525_062_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling $25 unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services-core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	2											1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5525	062	0	1	04	01	H5525_062_0	5	2	1	1101111	3	2	2	3							3	2	3	6	Amalgam and/or composite filling 0% unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services - core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	2											1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5525	062	0	1	04	01	H5525_062_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5525	063	0	1	04	01	H5525_063_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5525	064	0	1	04	01	H5525_064_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5525	067	0	1	04	01	H5525_067_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5525	068	0	1	04	01	H5525_068_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5525	071	0	1	04	01	H5525_071_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5525	074	0	1	04	01	H5525_074_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5525	075	0	1	04	01	H5525_075_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5525	076	0	1	04	01	H5525_076_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5525	077	0	1	04	01	H5525_077_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5619	001	0	1	01	01	H5619_001_0	5	2	1	1101111	3	2	2	3							3	2	3	6	Amalgam and/or composite filling $25 unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services-core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1	001
H5619	001	0	1	01	01	H5619_001_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling 0% unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services - core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	002
H5619	001	0	1	01	01	H5619_001_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5619	012	0	1	01	01	H5619_012_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H5619	015	0	1	01	01	H5619_015_0	5	2	1	1101111	3	2	2	3							3	2	3	6	Services include fillings $25 up to unlimited per year, recementation of crown $25 up to 1 every 5 years, recementation of dentures $25 up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	5	6	Services include bridges up to 1 every 5 years, oral surgery up to 2 per year, tissue conditioning up to 1 per year, occlusal adjustments up to 1 every 3 years.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1	001
H5619	015	0	1	01	01	H5619_015_0	5	2	1	1101111	3	2	2	3							3	2	3	6	Restorative services include fillings 0% up to unlimited per year, recementation of crown and recementation of dentures $25 copayment up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	11	6	Complete/partial dentures 50% 1/5 yrs, adjust, reline, repair, rebase, tissue conditioning 50% up to 1/year, oral surg 50% 2/yr, occlusal adjustments 50% 1/3 yrs, bridges 50% 1/5 yrs	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	002
H5619	015	0	1	01	01	H5619_015_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	003
H5619	026	0	1	01	01	H5619_026_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1	001
H5619	026	0	1	01	01	H5619_026_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	3		3	2	2	3		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	002
H5619	026	0	1	01	01	H5619_026_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	003
H5619	029	0	1	01	01	H5619_029_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam/composite filling unlimited per year, bridge+crown recementation 1/5 years, crown and other restorative services - core buildup and prefabricated post and core 1/tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001110							50	50	50	50	50	50			50	50	2		1	00101001			25.00	25.00			25.00	25.00					25.00	25.00			1	1	001
H5619	029	0	1	01	01	H5619_029_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling unlimited per year, bridge+crown recementation 1/5 years, crown and other restorative services - core buildup and prefabricated post and core 1 tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj, denture rebase,reline,repair,tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete/partial dentures 1/5 years, occlusal adjustment 1/3 years, oral surgery 2/year.	1		2	2000.00	3							1	10001110							0	50	50	50	0	0			50	50	2		1	00101001			25.00	25.00			25.00	25.00					0.00	0.00			1	1	002
H5619	029	0	1	01	01	H5619_029_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	003
H5619	032	0	1	01	01	H5619_032_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1	001
H5619	032	0	1	01	01	H5619_032_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	002
H5619	032	0	1	01	01	H5619_032_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	003
H5619	039	1	1	01	01	H5619_039_1	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H5619	039	2	1	01	01	H5619_039_2	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H5619	046	0	1	01	01	H5619_046_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		1	2	001
H5619	047	0	1	01	01	H5619_047_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5619	053	0	1	02	01	H5619_053_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5619	055	0	1	01	01	H5619_055_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling $25 unlimited/year, bridge/crown recementation $25 up to 1 every 5 years, crown/other restorative services 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Prosths, Oral/Maxillo Surgery, bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5619	055	0	1	01	01	H5619_055_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling 0% up to unlimited per year, bridge/crown recementation  $25 up to 1/5 yrs, crown and other restorative services 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adjust, rebase, reline, repair, tissue condit 1/year; bridges-crown 2/ 5 year; bridges-pontic, complete dentures, partial dentures 1/ 5 years, occlusal adjust 1/3 years, oral surgery 2/ year.	1		2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5619	055	0	1	01	01	H5619_055_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		1	10001000							0.00	0.00							0.00	0.00	1	2	003
H5619	056	0	1	01	01	H5619_056_0	5	2	1	1101111	3	2	2	3							3	1				3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1	001
H5619	056	0	1	01	01	H5619_056_0	5	2	1	1101111	3	2	2	3							3	1				3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj, rebase, reline, repair, tissue conditioning, 1/year, bridges-crown, bridges-pontic, complete, partial dentures,1/5 years, occlusal adj, 1/3 years, oral surgery, 2/year	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	002
H5619	056	0	1	01	01	H5619_056_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2	003
H5619	057	0	1	01	01	H5619_057_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H5619	059	0	1	01	01	H5619_059_0	5	2	1	1101111	3	2	2	3							3	2	4	6	amalgam/composite filling 0% unlimited/year, bridge/crown recementation $25 1/5 yrs, crown/other restorative services - core buildup and prefabricated post and core 50% up to 1/tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	denture adj,rebase,reline,repair and tissue conditioning 1/yr, bridges-crown up to 2/5 yrs, bridges-pontic, complete/partial dentures 1/5 yrs, occlusal adj 1/3 years, oral surgery 2/yr	1		2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	001
H5619	059	0	1	01	01	H5619_059_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	002
H5619	060	0	1	01	01	H5619_060_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10000100									50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1	001
H5619	060	0	1	01	01	H5619_060_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling 0% unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services - core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	002
H5619	060	0	1	01	01	H5619_060_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	003
H5619	061	0	1	01	01	H5619_061_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative srvc: amalgam and/or composite filling 0% unlimited/year, bridge/crown recementation $25 up to 1 every 5 years, crown. Core buildup, prefab post, core 50% up to 1/ tooth/ lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adjust, rebase, reline, repair, tissue condit 1/year; bridges-crown 2/ 5 year; bridges-pontic, complete dentures, partial dentures 1/ 5 years, occlusal adjust 1/3 years, oral surgery 2/ year.	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	001
H5619	061	0	1	01	01	H5619_061_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	002
H5619	063	0	1	01	01	H5619_063_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling $25 unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services-core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1	001
H5619	063	0	1	01	01	H5619_063_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling 0% unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services - core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	002
H5619	063	0	1	01	01	H5619_063_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	003
H5619	066	0	1	01	01	H5619_066_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5619	066	0	1	01	01	H5619_066_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year.	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5619	066	0	1	01	01	H5619_066_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5619	069	0	1	02	01	H5619_069_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5619	077	0	1	01	01	H5619_077_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling unlimited/year.Bridge Recementation, crown recementation 1/5 years.Crown/other restorative services-core buildup and prefabricated post and core 1/tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5619	077	0	1	01	01	H5619_077_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative srvc: amalgam and/or composite filling 0% unlimited/year, bridge/crown recementation $25 up to 1 every 5 years, crown. Core buildup, prefab post, core 50% up to 1/ tooth/ lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1/year.Bridges-crown 2/5 years.Bridges-pontic, complete/part. dentures 1/5 years.Occlusal adjustment 1/3 years.Oral surgery 2/year.	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5619	077	0	1	01	01	H5619_077_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5619	083	0	1	01	01	H5619_083_0	7	2	1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				2											1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5619	083	0	1	01	01	H5619_083_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2 per year	2											1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5619	083	0	1	01	01	H5619_083_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		2																		1	2	003
H5619	089	0	1	01	01	H5619_089_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5619	100	0	1	01	01	H5619_100_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1	001
H5619	100	0	1	01	01	H5619_100_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	002
H5619	100	0	1	01	01	H5619_100_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	003
H5619	113	0	1	02	01	H5619_113_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5619	114	0	1	01	01	H5619_114_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H5619	116	0	1	01	01	H5619_116_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H5619	119	0	1	01	01	H5619_119_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Per tooth per lifetime	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5619	119	0	1	01	01	H5619_119_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Per tooth per lifetime	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5619	119	0	1	01	01	H5619_119_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5619	121	0	1	01	01	H5619_121_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H5619	122	0	1	01	01	H5619_122_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5619	122	0	1	01	01	H5619_122_0	6	2	1	1101111	3	2	2	3							3	2	4	6	amalgam/composite filling 0% unlimited /year, bridge+crown recementation $25 1/5 years, crown and other restorative services - core buildup and prefab post and core 50% up to 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	denture adjust,rebase,reline,repair, tissue cond 1/ year, bridges-crown 2/ 5 years, bridges-pontic, complete+partial dentures 1/ 5 years, occlusal adj 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5619	122	0	1	01	01	H5619_122_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5619	128	0	1	01	01	H5619_128_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling $25 up to unlimited per year, bridge/crown recementation  $25 up to 1 every 5 years, crown and other restorative services 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5619	128	0	1	01	01	H5619_128_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling 0% up to unlimited per year, bridge/crown recementation $25 up to 1 every 5 years, crown and other restorative services 50% up to 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj, rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5619	128	0	1	01	01	H5619_128_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5619	130	1	1	01	01	H5619_130_1	6	2	1	1101111	3	2	2	3							3	2	4	6	Include amalgam and/or composite filling $25 unlimited / year, bridge and crown recementation $25 1 every 5 years, crown, restorative core buildup, prefab post and core 50% 1 per tooth/lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			2	2	001
H5619	130	1	1	01	01	H5619_130_1	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									2	2	002
H5619	130	1	1	01	01	H5619_130_1	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2	003
H5619	130	2	1	01	01	H5619_130_2	5	2	1	1101111	3	2	2	3							3	2	4	6	Include amalgam and/or composite filling $25 unlimited / year, bridge and crown recementation $25 1 every 5 years, crown, restorative core buildup, prefab post and core 50% 1 per tooth/lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			2	2	001
H5619	130	2	1	01	01	H5619_130_2	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									2	2	002
H5619	130	2	1	01	01	H5619_130_2	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2	003
H5619	133	0	1	01	01	H5619_133_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5619	135	0	1	01	01	H5619_135_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5619	135	0	1	01	01	H5619_135_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		2	1000.00	3							1	10001100							0	50	50	50					50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5619	135	0	1	01	01	H5619_135_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		1	2	003
H5619	137	0	1	01	01	H5619_137_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5619	137	0	1	01	01	H5619_137_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year.	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5619	137	0	1	01	01	H5619_137_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5619	138	0	1	01	01	H5619_138_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Include amalgam and/or composite filling $25 unlimited / year, bridge and crown recementation $25 1 every 5 years, crown, restorative core buildup, prefab post and core 50% 1 per tooth/lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			2	2	001
H5619	138	0	1	01	01	H5619_138_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									2	2	002
H5619	138	0	1	01	01	H5619_138_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2	003
H5619	143	0	1	01	01	H5619_143_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H5619	146	0	1	01	01	H5619_146_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H5619	147	0	1	01	01	H5619_147_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H5619	148	0	1	01	01	H5619_148_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H5619	150	0	1	01	01	H5619_150_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H5619	151	0	1	01	01	H5619_151_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5619	152	0	1	01	01	H5619_152_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5619	157	0	1	01	01	H5619_157_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5619	161	0	1	01	01	H5619_161_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5652	002	0	1	02	01	H5652_002_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H5652	004	0	1	02	01	H5652_004_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H5828	008	0	1	01	01	H5828_008_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H5828	008	0	1	01	01	H5828_008_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H5828	012	1	1	02	01	H5828_012_1	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H5828	012	1	1	02	01	H5828_012_1	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H5828	012	2	1	02	01	H5828_012_2	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H5828	012	2	1	02	01	H5828_012_2	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H5828	012	3	1	02	01	H5828_012_3	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H5828	012	3	1	02	01	H5828_012_3	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H5843	002	0	1	01	01	H5843_002_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			50	50	50	50	20	50	50	50	50	50	20	50	20	50	2		2																		1	1	001
H5854	009	0	1	01	01	H5854_009_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H5854	009	0	1	01	01	H5854_009_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H5854	010	0	1	01	01	H5854_010_0	5	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H5854	010	0	1	01	01	H5854_010_0	5	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H5854	011	0	1	01	01	H5854_011_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H5854	011	0	1	01	01	H5854_011_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H5883	001	1	1	02	01	H5883_001_1	3	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	001	2	1	02	01	H5883_001_2	3	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	001	3	1	02	01	H5883_001_3	3	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	001	4	1	02	01	H5883_001_4	3	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	001	5	1	02	01	H5883_001_5	3	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	002	1	1	02	01	H5883_002_1	5	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	002	2	1	02	01	H5883_002_2	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	002	3	1	02	01	H5883_002_3	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	002	4	1	02	01	H5883_002_4	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	002	7	1	02	01	H5883_002_7	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	003	1	1	02	01	H5883_003_1	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia.	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	003	2	1	02	01	H5883_003_2	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia.	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	003	3	1	02	01	H5883_003_3	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia.	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	003	4	1	02	01	H5883_003_4	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia.	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	003	5	1	02	01	H5883_003_5	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia.	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	007	0	1	01	01	H5883_007_0	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	012	1	1	02	01	H5883_012_1	5	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia.	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	012	2	1	02	01	H5883_012_2	5	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia.	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	014	1	1	02	01	H5883_014_1	5	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia.	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	014	2	1	02	01	H5883_014_2	5	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia.	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	014	3	1	02	01	H5883_014_3	5	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia.	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	014	4	1	02	01	H5883_014_4	5	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia.	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	014	5	1	02	01	H5883_014_5	5	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia.	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5883	015	0	1	01	01	H5883_015_0	6	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia.	1		2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H5945	001	0	1	01	01	H5945_001_0	7	1	2																																																																																								001
H5945	002	0	1	01	01	H5945_002_0	7	1	2																																																																																								001
H5945	008	0	1	01	01	H5945_008_0	7	1	2																																																																																								001
H5945	016	0	1	01	01	H5945_016_0	6	1	2																																																																																								001
H5945	020	0	1	01	01	H5945_020_0	5	1	2																																																																																								001
H5945	021	0	1	01	01	H5945_021_0	5	1	2																																																																																								001
H5945	027	0	1	01	01	H5945_027_0	6	1	2																																																																																								001
H5970	001	0	1	04	01	H5970_001_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	2000.00	3							1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5970	015	0	1	04	01	H5970_015_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5970	016	0	1	04	01	H5970_016_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5970	018	0	1	04	01	H5970_018_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5970	018	0	1	04	01	H5970_018_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling 0% unlimited per yr, bridge/crown recementation $25 1 every 5 yrs, crown/other restorative services - core buildup/prefab post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5970	018	0	1	04	01	H5970_018_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5970	024	1	1	04	01	H5970_024_1	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5970	024	1	1	04	01	H5970_024_1	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5970	024	1	1	04	01	H5970_024_1	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5970	024	2	1	04	01	H5970_024_2	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5970	024	2	1	04	01	H5970_024_2	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5970	024	2	1	04	01	H5970_024_2	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H5970	025	0	1	04	01	H5970_025_0	9	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H5970	027	0	1	04	01	H5970_027_0	9	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H5970	027	0	1	04	01	H5970_027_0	9	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year. Bridges-crown 2/5 years. Bridges-pontic, complete and partial dentures 1/5 years. Occlusal adj. 1/3 years. Oral surgery 2/year.	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H5970	027	0	1	04	01	H5970_027_0	9	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H6322	001	0	1	01	01	H6322_001_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10011111					50	50	75	75	50	50	50	50	50	50	50	75	2		2																		2	2	001
H6322	001	0	1	01	01	H6322_001_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10011111					20	20	50	50	20	20	20	20	20	20	20	50	2		2																		2	2	002
H6322	002	0	1	01	01	H6322_002_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10011111					50	50	75	75	50	50	50	50	50	50	50	75	2		2																		2	2	001
H6322	002	0	1	01	01	H6322_002_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10011111					20	20	50	50	20	20	20	20	20	20	20	50	2		2																		2	2	002
H6322	003	1	1	02	01	H6322_003_1	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				2											1	10011111					50	50	75	75	50	50	50	50	50	50	50	75	2		2																		2	2	001
H6322	003	1	1	02	01	H6322_003_1	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				2											1	10011111					20	20	50	50	20	20	20	20	20	20	20	50	2		2																		2	2	002
H6322	003	2	1	02	01	H6322_003_2	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				2											1	10011111					50	50	75	75	50	50	50	50	50	50	50	75	2		2																		2	2	001
H6322	003	2	1	02	01	H6322_003_2	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				2											1	10011111					20	20	50	50	20	20	20	20	20	20	20	50	2		2																		2	2	002
H6408	001	0	1	01	01	H6408_001_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H6408	001	0	1	01	01	H6408_001_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H6408	003	0	1	01	01	H6408_003_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H6408	003	0	1	01	01	H6408_003_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H6502	003	0	1	04	01	H6502_003_0	4	2	1	0111111	3	1				3	1				3	1				3	1				3	1				3	1									1		1									1	00111111			20	20	20	20	20	50	50	50	50	50	20	20			2		2																		1	2	001
H6502	004	0	1	04	01	H6502_004_0	7	2	1	0111111	3	1				3	1				3	1				3	1				3	1				3	1									1		1									1	00111111			20	20	20	20	20	50	50	50	50	50	20	20			2		2																		2	2	001
H6526	001	0	1	02	01	H6526_001_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H6526	002	0	1	02	01	H6526_002_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H6622	001	0	1	01	01	H6622_001_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H6622	007	0	1	01	01	H6622_007_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H6622	010	0	1	02	01	H6622_010_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H6622	013	0	1	02	01	H6622_013_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H6622	014	0	1	02	01	H6622_014_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H6622	017	0	1	01	01	H6622_017_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative svc include amalgam and/or composite filling/unlimited/yr. Crown/ Core buildup and Prefab post and core up to 1 / tooth / lifetime, Bridge/crown recementation 1/5 years.	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year	1		2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H6622	017	0	1	01	01	H6622_017_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative svc include amalgam and/or composite filling/unlimited/yr. Crown/ Core buildup and Prefab post and core up to 1 / tooth / lifetime, Bridge/crown recementation 1/5 years.	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Adjust to dentures/rebase/reline/repair/tissue conditioning 1/yr, complete dentures/partial dentures, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs, occlusal adjustment 1 /3 yrs, oral surgery 2/ yr.	1		2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H6622	017	0	1	01	01	H6622_017_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H6622	019	0	1	01	01	H6622_019_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H6622	019	0	1	01	01	H6622_019_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H6622	019	0	1	01	01	H6622_019_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H6622	021	1	1	02	01	H6622_021_1	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H6622	021	2	1	02	01	H6622_021_2	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H6622	022	0	1	02	01	H6622_022_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H6622	028	0	1	01	01	H6622_028_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1	001
H6622	028	0	1	01	01	H6622_028_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	002
H6622	028	0	1	01	01	H6622_028_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	003
H6622	029	0	1	01	01	H6622_029_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H6622	030	0	1	01	01	H6622_030_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1	001
H6622	030	0	1	01	01	H6622_030_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	002
H6622	030	0	1	01	01	H6622_030_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	003
H6622	032	0	1	01	01	H6622_032_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H6622	033	0	1	01	01	H6622_033_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H6622	052	0	1	01	01	H6622_052_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H6622	055	0	1	01	01	H6622_055_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Restorative services include amalgam and/or composite filling 0% up to unlimited per year, bridge recementation and crown recementation $25 up to 1 every 5 years, crown and other restorative services	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	001
H6622	055	0	1	01	01	H6622_055_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	002
H6622	063	0	1	01	01	H6622_063_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H6622	063	0	1	01	01	H6622_063_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H6622	063	0	1	01	01	H6622_063_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
H6622	066	0	1	01	01	H6622_066_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H6622	075	0	1	01	01	H6622_075_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H6622	082	0	1	01	01	H6622_082_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	001
H6706	001	0	1	02	01	H6706_001_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H6723	001	1	1	01	01	H6723_001_1	12	1	1	0100000	3	1																																		1		2	1000.00	3							1	00100000			30	30													2		2																		2	2	001
H6723	001	2	1	01	01	H6723_001_2	12	2	1	0111111	3	1				3	1				3	1				3	1				3	1				3	1									1		2	1000.00	3							1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		2																		2	2	001
H6723	001	3	1	01	01	H6723_001_3	12	1	1	0100000	3	1																																		1		2	1000.00	3							1	00100000			30	30													2		2																		2	2	001
H6723	002	1	1	01	01	H6723_002_1	12		1	0111111	3	1				3	1				3	1				3	1				3	1				3	1									1		2	1000.00	3							1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		2																		2	2	001
H6723	002	2	1	01	01	H6723_002_2	12	2	1	0111111	3	1				3	1				3	1				3	1				3	1				3	1									1		2	1000.00	3							1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		2																		2	2	001
H6723	002	3	1	01	01	H6723_002_3	12		1	0111111	3	1				3	1				3	1				3	1				3	1				3	1									1		2	1000.00	3							1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		2																		2	2	001
H6723	003	1	1	01	01	H6723_003_1	12	1	1	0000001																										3	1									1		2	1000.00	3							1	00000001													30	30			2		2																		2	2	001
H6723	003	2	1	01	01	H6723_003_2	12	2	1	0111111	3	1				3	1				3	1				3	1				3	1				3	1									1		2	1000.00	3							1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		2																		2	2	001
H6723	003	3	1	01	01	H6723_003_3	12	2	1	0111111	3	1				3	1				3	1				3	1				3	1				3	1									1		2	1000.00	3							1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		2																		2	2	001
H6723	005	1	1	01	01	H6723_005_1	10	2	1	0111111	3	1				3	1				3	1				3	1				3	1				3	1									1		2	1000.00	3							1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		2																		2	2	001
H6723	005	2	1	01	01	H6723_005_2	10	1	1	0100000	3	1																																		1		2	1000.00	3							1	00100000			30	30													2		2																		2	2	001
H6723	006	6	1	01	01	H6723_006_6	12	1	1	0000001																										3	1									1		2	1000.00	3							1	00000001													30	30			2		2																		2	2	001
H6723	006	7	1	01	01	H6723_006_7	12	1	1	0000001																										3	1									1		2	1000.00	3							1	00000001													30	30			2		2																		2	2	001
H6874	001	0	1	04	01	H6874_001_0	13	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			30	60	30	30	60	60	30	30	0	30	30	30	30	60	2		2																		2	2	001
H6874	003	0	1	04	01	H6874_003_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			30	60	30	30	60	60	30	30	0	30	30	30	30	60	2		2																		2	2	001
H6910	001	0	1	01	01	H6910_001_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H6910	001	0	1	01	01	H6910_001_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H6910	004	0	1	01	01	H6910_004_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H6910	004	0	1	01	01	H6910_004_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H7063	001	0	1	04	01	H7063_001_0	7	2	1	1001111											3	2	1	3		3	2	1	3		3	2	1	3		3	2	1	3		3	2	1	3		1	2	2	1000.00	3							1	10001111							50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H7063	007	0	1	04	01	H7063_007_0	7	2	1	1001111											3	2	1	3		3	2	1	3		3	2	1	3		3	2	1	3		3	2	1	3		2											1	10001111							50	50	50	50	50	50	50	50	50	50	2		2																		2	2	001
H7074	001	0	1	04	01	H7074_001_0	11	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	350.00	4							2																		2		2																		1	1	001
H7093	001	0	1	04	01	H7093_001_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H7093	001	0	1	04	01	H7093_001_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H7093	002	0	1	04	01	H7093_002_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H7093	002	0	1	04	01	H7093_002_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H7220	002	0	1	01	01	H7220_002_0	2	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	001
H7220	002	0	1	01	01	H7220_002_0	2	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	002
H7220	004	0	1	02	01	H7220_004_0	4	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	001
H7220	004	0	1	02	01	H7220_004_0	4	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	002
H7220	009	1	1	01	01	H7220_009_1	3	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	001
H7220	009	1	1	01	01	H7220_009_1	3	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	002
H7220	009	2	1	01	01	H7220_009_2	3	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	001
H7220	009	2	1	01	01	H7220_009_2	3	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	002
H7220	009	3	1	01	01	H7220_009_3	3	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	001
H7220	009	3	1	01	01	H7220_009_3	3	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	002
H7220	010	0	1	01	01	H7220_010_0	3	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	001
H7220	010	0	1	01	01	H7220_010_0	3	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	002
H7220	011	0	1	02	01	H7220_011_0	3	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	001
H7220	011	0	1	02	01	H7220_011_0	3	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	002
H7220	012	0	1	01	01	H7220_012_0	3	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	001
H7220	012	0	1	01	01	H7220_012_0	3	2	1	1001110											3	1				3	1				3	1									3	1				2											1	10001110							50	50	50	50	50	50			50	50	2		2																		2	2	002
H7273	001	0	1	04	01	H7273_001_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10111111			50	50	50	50	20	50	50	50	50	50	20	50	20	50	2		2																		1	1	001
H7273	002	0	1	04	01	H7273_002_0	9	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10111111			50	50	50	50	20	50	50	50	50	50	20	50	20	50	2		2																		1	1	001
H7273	005	0	1	04	01	H7273_005_0	9	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10111111			50	50	50	50	20	50	50	50	50	50	20	50	20	50	2		2																		1	1	001
H7404	005	0	1	04	01	H7404_005_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H7404	011	0	1	04	01	H7404_011_0	4	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H7404	012	0	1	04	01	H7404_012_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H7404	020	0	1	04	01	H7404_020_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H7404	024	0	1	04	01	H7404_024_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H7621	002	0	1	01	01	H7621_002_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Restorative srvc include amalgam and/or composite filling unlimited/year, bridge/crown recementation 1/5 years, crown+other restorative services - core buildup, prefab post and core 1/tooth/lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Prosths, Oral/Maxillo Surgery, bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1	001
H7621	002	0	1	01	01	H7621_002_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	002
H7621	002	0	1	01	01	H7621_002_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	003
H7621	003	0	1	01	01	H7621_003_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1	001
H7621	003	0	1	01	01	H7621_003_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	1	002
H7621	003	0	1	01	01	H7621_003_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	1	003
H7680	001	0	1	01	01	H7680_001_0	7	1	2																																																																																								001
H7680	002	0	1	01	01	H7680_002_0	8	1	2																																																																																								001
H7680	011	0	1	01	01	H7680_011_0	6	1	2																																																																																								001
H7680	012	0	1	01	01	H7680_012_0	6	1	2																																																																																								001
H7680	014	0	1	01	01	H7680_014_0	7	1	2																																																																																								001
H7746	001	0	1	01	01	H7746_001_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10011111					50	50	75	75	50	50	50	50	50	50	50	75	2		2																		2	2	001
H7746	001	0	1	01	01	H7746_001_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10011111					20	20	50	50	20	20	20	20	20	20	20	50	2		2																		2	2	002
H7746	002	0	1	01	01	H7746_002_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10011111					50	50	75	75	50	50	50	50	50	50	50	75	2		2																		2	2	001
H7746	002	0	1	01	01	H7746_002_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10011111					20	20	50	50	20	20	20	20	20	20	20	50	2		2																		2	2	002
H7746	003	0	1	02	01	H7746_003_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				2											1	10011111					50	50	75	75	50	50	50	50	50	50	50	75	2		2																		2	2	001
H7746	003	0	1	02	01	H7746_003_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				2											1	10011111					20	20	50	50	20	20	20	20	20	20	20	50	2		2																		2	2	002
H8133	005	0	1	01	01	H8133_005_0	6		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H8145	032	0	1	09	04	H8145_032_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																				001
H8145	042	0	1	09	04	H8145_042_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																				001
H8145	052	0	1	09	04	H8145_052_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00					001
H8145	052	0	1	09	04	H8145_052_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00											002
H8145	052	0	1	09	04	H8145_052_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																				003
H8145	055	0	1	09	04	H8145_055_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filing 0% unlimitedBridge recementation $25 1 every 5 yearsCrown 50% 1 tooth per lifetimeCrown recementation $25 1 every 5 yearsOther service- 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal, and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	2											1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00											001
H8145	055	0	1	09	04	H8145_055_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																				002
H8145	069	0	1	09	04	H8145_069_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																				001
H8145	084	0	1	09	04	H8145_084_0	11		1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00					001
H8145	084	0	1	09	04	H8145_084_0	11		1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	12	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00											002
H8145	091	0	1	09	04	H8145_091_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																				001
H8145	123	0	1	09	04	H8145_123_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00					001
H8145	123	0	1	09	04	H8145_123_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00											002
H8145	123	0	1	09	04	H8145_123_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																				003
H8145	126	0	1	09	04	H8145_126_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																				001
H8145	163	0	1	09	04	H8145_163_0	3	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling unlimited/yr; bridge recementation and crown Recementation 1/5 yrs; crown and other restorative services-core buildup and prefabricated post and core 1/tooth/lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00					001
H8145	163	0	1	09	04	H8145_163_0	3	2	1	1101111	3	2	2	3							3	2	4	6	Amalgam and/or composite filling unlimited/yr; bridge recementation and crown recementation 1/5 yrs; crown and other restorative services-core buildup and prefabricated post and core 1/tooth/lifetime	3	2	2	6	Endodontics include root canal, and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00											002
H8145	163	0	1	09	04	H8145_163_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																				003
H8211	006	0	1	04	01	H8211_006_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H8244	002	0	1	04	01	H8244_002_0	15		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	500.00	4							2																		2		2																		1	2	001
H8432	009	0	1	01	01	H8432_009_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8432	009	0	1	01	01	H8432_009_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8432	010	0	1	01	01	H8432_010_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8432	010	0	1	01	01	H8432_010_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8432	011	0	1	01	01	H8432_011_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8432	011	0	1	01	01	H8432_011_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8432	036	0	1	01	01	H8432_036_0	3	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8432	036	0	1	01	01	H8432_036_0	3	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8432	037	1	1	01	01	H8432_037_1	4	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8432	037	1	1	01	01	H8432_037_1	4	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8432	037	2	1	01	01	H8432_037_2	4	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8432	037	2	1	01	01	H8432_037_2	4	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8432	038	1	1	01	01	H8432_038_1	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8432	038	1	1	01	01	H8432_038_1	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8432	038	2	1	01	01	H8432_038_2	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8432	038	2	1	01	01	H8432_038_2	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8432	040	0	1	01	01	H8432_040_0	5	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8432	040	0	1	01	01	H8432_040_0	5	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8552	020	0	1	04	01	H8552_020_0	7		1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8552	020	0	1	04	01	H8552_020_0	7		1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8552	029	0	1	04	01	H8552_029_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8552	029	0	1	04	01	H8552_029_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8554	004	0	1	01	01	H8554_004_0	6		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H8604	010	0	1	04	01	H8604_010_0	14		1	1001111											3	2	1	6	Restorative Services: Fillings- 20% - 50% coinsurance for Fillings-1 per tooth every 3 years, 20% - 75% coinsurance for Crowns -1 per tooth every 5 years	3	1				3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3	2	1	6	Extractions: 1 service per tooth per lifetime, excision of lesion - unlimited.	3	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1	2	2	1500.00	3							1	10001111							20	75	50	50	50	50	50	50	50	50	2		2																		2	2	001
H8604	011	0	1	04	01	H8604_011_0	14		1	1001111											3	2	1	6	Restorative Services: Fillings- 20% - 50% coinsurance for Fillings-1 per tooth every 3 years, 20% - 75% coinsurance for Crowns -1 per tooth every 5 years	3	1				3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3	2	1	6	Extractions: 1 service per tooth per lifetime, excision of lesion - unlimited.	3	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1	2	2	1500.00	3							1	10001111							20	75	50	50	50	50	50	50	50	50	2		2																		2	2	001
H8604	013	0	1	04	01	H8604_013_0	14		1	1001111											3	2	1	6	Restorative Services: Fillings- 20% - 50% coinsurance for Fillings-1 per tooth every 3 years, 20% - 75% coinsurance for Crowns -1 per tooth every 5 years	3	1				3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3	2	1	6	Extractions: 1 service per tooth per lifetime, excision of lesion - unlimited.	3	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1	2	2	1500.00	3							1	10001111							20	75	50	50	50	50	50	50	50	50	2		2																		2	2	001
H8604	014	1	1	04	01	H8604_014_1	17	2	1	1001111											3	2	1	6	Restorative Services: Fillings- 20% - 50% coinsurance. for Fillings-1 per tooth every 3 years, 50% - 75% coinsurance for Crowns -1 per tooth every 5 years	3	2	1	6	Endodontics: Unlimited.	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3	2	1	6	Extractions: 1 service per tooth per lifetime, excision of lesion - unlimited.	3	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1	2	2	1500.00	3							1	10001111							20	75	50	50	50	50	50	50	50	50	2		2																		1	2	001
H8604	014	2	1	04	01	H8604_014_2	16	2	1	1001111											3	2	1	6	Restorative Services: Fillings- 20% - 50% coinsurance for Fillings-1 per tooth every 3 years, 50% - 75% coinsurance for Crowns -1 per tooth every 5 years	3	2	1	6	Endodontics: Unlimited.	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3	2	1	6	Extractions: 1 service per tooth per lifetime, excision of lesion - unlimited.	3	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1	2	2	1500.00	3							1	10001111							20	75	50	50	50	50	50	50	50	50	2		2																		1	2	001
H8634	003	0	1	04	01	H8634_003_0	7		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H8634	008	0	1	04	01	H8634_008_0	7		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H8634	010	0	1	04	01	H8634_010_0	6		1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10101111			20	20			20	20	20	20	20	20	20	20	20	20	2		2																		2	2	001
H8634	012	0	1	04	01	H8634_012_0	7		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H8634	014	0	1	04	01	H8634_014_0	7		1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10101111			20	20			20	20	20	20	20	20	20	20	20	20	2		2																		2	2	001
H8634	015	0	1	04	01	H8634_015_0	6		1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10101111			20	20			20	20	20	20	20	20	20	20	20	20	2		2																		2	2	001
H8634	017	0	1	04	01	H8634_017_0	7		1	1101111	3	1									3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10101111			20	20			20	20	20	20	20	20	20	20	20	20	2		2																		2	2	001
H8634	019	0	1	04	01	H8634_019_0	5		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H8634	020	0	1	04	01	H8634_020_0	6		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H8764	001	0	1	01	01	H8764_001_0	7		1	1001111											3	1				3	1				3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	3	1				3	2	1	6	Oral surgery services are covered once in a lifetime except removal of cysts and lesions and incision and drainage procedures, which are covered once in the same day.	1		2	1000.00	3							1	10001111							20	50	50	50	50	50	20	50	50	50	2		2																		2	2	001
H8764	002	0	1	02	01	H8764_002_0	7		1	1001111											3	1				3	1				3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	3	1				3	2	1	6	Oral surgery services are covered once in a lifetime except removal of cysts and lesions and incision and drainage procedures, which are covered once in the same day.	1		2	1000.00	3							1	10001111							20	50	50	50	50	50	20	50	50	50	2		2																		2	2	001
H8764	002	0	1	02	01	H8764_002_0	7		1	1001111											3	1				3	1				3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	3	1				3	2	1	6	Oral surgery services are covered once in a lifetime except removal of cysts and lesions and incision and drainage procedures, which are covered once in the same day.	1		2	1000.00	3							1	10001111							20	50	50	50	50	50	20	50	50	50	2		2																		2	2	002
H8764	003	0	1	01	01	H8764_003_0	7		1	1001111											3	1				3	1				3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	3	1				3	2	1	6	Oral surgery services are covered once in a lifetime except removal of cysts and lesions and incision and drainage procedures, which are covered once in the same day.	1		2	1000.00	3							1	10001111							20	50	50	50	50	50	20	50	50	50	2		2																		2	2	001
H8764	003	0	1	01	01	H8764_003_0	7		1	1001111											3	1				3	1				3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	3	1				3	2	1	6	Oral surgery services are covered once in a lifetime except removal of cysts and lesions and incision and drainage procedures, which are covered once in the same day.	1		2	1000.00	3							1	10001111							20	50	50	50	50	50	20	50	50	50	2		2																		2	2	002
H8764	004	0	1	01	01	H8764_004_0	7		1	1001111											3	1				3	1				3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	3	1				3	2	1	6	Oral surgery services are covered once in a lifetime except removal of cysts and lesions and incision and drainage procedures, which are covered once in the same day.	1		2	1000.00	3							1	10001111							20	50	50	50	50	50	20	50	50	50	2		2																		2	2	001
H8764	004	0	1	01	01	H8764_004_0	7		1	1001111											3	1				3	1				3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	3	1				3	2	1	6	Oral surgery services are covered once in a lifetime except removal of cysts and lesions and incision and drainage procedures, which are covered once in the same day.	1		2	1000.00	3							1	10001111							20	50	50	50	50	50	20	50	50	50	2		2																		2	2	002
H8768	014	0	1	04	01	H8768_014_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H8768	016	0	1	04	01	H8768_016_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H8768	017	1	1	04	01	H8768_017_1	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H8768	017	2	1	04	01	H8768_017_2	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H8768	022	0	1	04	01	H8768_022_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H8768	032	0	1	04	01	H8768_032_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H8768	037	1	1	04	01	H8768_037_1	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H8768	037	2	1	04	01	H8768_037_2	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H8768	038	1	1	04	01	H8768_038_1	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H8768	040	0	1	04	01	H8768_040_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H8768	043	0	1	04	01	H8768_043_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H8768	049	0	1	04	01	H8768_049_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H8768	051	0	1	04	01	H8768_051_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
H8783	001	0	1	04	01	H8783_001_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			30	60	30	30	60	60	30	30	0	30	30	30	30	60	2		2																		2	2	001
H8783	002	0	1	04	01	H8783_002_0	9	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			30	60	30	30	60	60	30	30	0	30	30	30	30	60	2		2																		2	2	001
H8849	001	0	1	01	01	H8849_001_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8849	001	0	1	01	01	H8849_001_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8849	003	0	1	01	01	H8849_003_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8849	003	0	1	01	01	H8849_003_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8849	005	0	1	01	01	H8849_005_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8849	005	0	1	01	01	H8849_005_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8849	006	0	1	01	01	H8849_006_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8849	006	0	1	01	01	H8849_006_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8849	009	0	1	01	01	H8849_009_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8849	009	0	1	01	01	H8849_009_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8849	013	0	1	01	01	H8849_013_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H8849	013	0	1	01	01	H8849_013_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H8902	001	0	1	01	01	H8902_001_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H8902	002	0	1	01	01	H8902_002_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H8902	003	0	1	01	01	H8902_003_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H8902	005	0	1	01	01	H8902_005_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H8902	006	0	1	01	01	H8902_006_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H8902	007	0	1	01	01	H8902_007_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	2	2	001
H8908	001	0	1	02	01	H8908_001_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
H8908	002	0	1	01	01	H8908_002_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
H8908	002	0	1	01	01	H8908_002_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		2	1000.00	3							1	10001111							50	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
H8908	002	0	1	01	01	H8908_002_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2	003
H8998	001	0	1	04	01	H8998_001_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1	2	2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H8998	001	0	1	04	01	H8998_001_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H9003	001	0	1	02	01	H9003_001_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							50	50	50	50	50	50	50	50	10	50	1	50.00	1	10110000			0.00	0.00	0.00	0.00									0.00	25.00	1	2	001
H9003	006	0	1	02	01	H9003_006_0	10	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							50	50	50	50	50	50	50	50	10	50	1	50.00	1	10110000			0.00	0.00	0.00	0.00									0.00	25.00	1	2	001
H9003	008	0	1	02	01	H9003_008_0	11		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							50	50	50	50	50	50	50	50	10	50	1	50.00	1	10110000			0.00	0.00	0.00	0.00									0.00	25.00	1	2	001
H9003	009	0	1	02	01	H9003_009_0	10		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							50	50	50	50	50	50	50	50	10	50	1	50.00	1	10110000			0.00	0.00	0.00	0.00									0.00	25.00	1	2	001
H9047	013	0	2	01	01	H9047_013_0	6		1	1111001	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1														3	1				3	1				2											1	10111001			50	60	0	20	30	60					50	60	0	60	2		2																		2	2	001
H9047	013	0	2	01	01	H9047_013_0	6		1	1111111	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1				3	1				3	1				3	1				3	1				2											1	10111111			50	60	0	20	30	60	50	60	50	60	50	60	0	60	2		2																		2	2	002
H9047	033	0	1	01	01	H9047_033_0	4	2	1	1111001	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1														3	1				3	1				2											1	10111001			50	60	0	20	30	60					50	60	0	60	2		2																		2	2	001
H9047	033	0	1	01	01	H9047_033_0	4		1	1111111	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1				3	1				3	1				3	1				3	1				2											1	10111111			50	60	0	20	30	60	50	60	50	60	50	60	0	60	2		2																		2	2	002
H9047	035	0	1	02	01	H9047_035_0	6	2	1	1111001	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1														3	1				3	1				2											1	10111001			50	60	0	20	30	60					50	60	0	60	2		2																		2	2	001
H9047	035	0	1	02	01	H9047_035_0	6	2	1	1111111	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1				3	1				3	1				3	1				3	1				2											1	10111111			50	60	0	20	30	60	50	60	50	60	50	60	0	60	2		2																		2	2	002
H9047	037	0	1	01	01	H9047_037_0	8		1	1111001	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1														3	1				3	1				2											1	10111001			50	60	0	20	30	60					50	60	0	60	2		2																		2	2	001
H9047	037	0	1	01	01	H9047_037_0	8		1	1111111	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1				3	1				3	1				3	1				3	1				2											1	10111111			50	60	0	20	30	60	50	60	50	60	50	60	0	60	2		2																		2	2	002
H9047	054	0	1	01	01	H9047_054_0	8	2	1	1111001	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1														3	1				3	1				2											1	10111001			50	60	0	20	30	60					50	60	0	60	2		2																		2	2	001
H9047	054	0	1	01	01	H9047_054_0	8	2	1	1111111	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1				3	1				3	1				3	1				3	1				2											1	10111111			50	60	0	20	30	60	50	60	50	60	50	60	0	60	2		2																		2	2	002
H9047	059	0	1	02	01	H9047_059_0	10	2	1	1111001	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1														3	1				3	1				2											1	10111001			50	60	0	20	30	60					50	60	0	60	2		2																		2	2	001
H9047	059	0	1	02	01	H9047_059_0	10	2	1	1111111	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1				3	1				3	1				3	1				3	1				2											1	10111111			50	60	0	20	30	60	50	60	50	60	50	60	0	60	2		2																		2	2	002
H9047	062	0	1	02	01	H9047_062_0	11	2	1	1111001	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1														3	1				3	1				2											1	10111001			50	60	0	20	30	60					50	60	0	60	2		2																		2	2	001
H9047	062	0	1	02	01	H9047_062_0	11	2	1	1111111	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1				3	1				3	1				3	1				3	1				2											1	10111111			50	60	0	20	30	60	50	60	50	60	50	60	0	60	2		2																		2	2	002
H9047	063	0	1	01	01	H9047_063_0	11	2	1	1111001	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1														3	1				3	1				2											1	10111001			50	60	0	20	30	60					50	60	0	60	2		2																		2	2	001
H9047	063	0	1	01	01	H9047_063_0	11	2	1	1111111	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1				3	1				3	1				3	1				3	1				2											1	10111111			50	60	0	20	30	60	50	60	50	60	50	60	0	60	2		2																		2	2	002
H9047	064	0	1	01	01	H9047_064_0	8		1	1111001	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1														3	1				3	1				2											1	10111001			50	60	0	20	30	60					50	60	0	60	2		2																		2	2	001
H9047	064	0	1	01	01	H9047_064_0	8		1	1111111	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1				3	1				3	1				3	1				3	1				2											1	10111111			50	60	0	20	30	60	50	60	50	60	50	60	0	60	2		2																		2	2	002
H9047	065	0	1	02	01	H9047_065_0	10	2	1	1111001	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1														3	1				3	1				2											1	10111001			50	60	0	20	30	60					50	60	0	60	2		2																		2	2	001
H9047	065	0	1	02	01	H9047_065_0	10		1	1111111	3	1				3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3	1				3	1				3	1				3	1				3	1				2											1	10111111			50	60	0	20	30	60	50	60	50	60	50	60	0	60	2		2																		2	2	002
H9104	006	0	1	01	01	H9104_006_0	7		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	180.00	34.00	595.00	35.00	615.00	0.00	648.00	0.00	362.00	29.00	803.00	1	1	001
H9104	006	0	1	01	01	H9104_006_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	390.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	440.00	1	1	002
H9179	001	0	1	01	01	H9179_001_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H9179	001	0	1	01	01	H9179_001_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H9179	003	0	1	01	01	H9179_003_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H9179	003	0	1	01	01	H9179_003_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H9219	001	0	1	04	01	H9219_001_0	9	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H9219	001	0	1	04	01	H9219_001_0	9	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H9219	002	0	1	04	01	H9219_002_0	8		1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H9219	002	0	1	04	01	H9219_002_0	8		1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H9525	004	0	1	01	01	H9525_004_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H9525	004	0	1	01	01	H9525_004_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H9525	006	0	1	01	01	H9525_006_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H9525	006	0	1	01	01	H9525_006_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H9525	011	0	1	01	01	H9525_011_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H9525	011	0	1	01	01	H9525_011_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H9525	013	1	1	01	01	H9525_013_1	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H9525	013	1	1	01	01	H9525_013_1	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H9525	013	2	1	01	01	H9525_013_2	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H9525	013	2	1	01	01	H9525_013_2	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H9525	013	3	1	01	01	H9525_013_3	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H9525	013	3	1	01	01	H9525_013_3	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H9525	013	4	1	01	01	H9525_013_4	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H9525	013	4	1	01	01	H9525_013_4	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H9525	015	0	1	01	01	H9525_015_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H9525	015	0	1	01	01	H9525_015_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H9525	017	0	1	01	01	H9525_017_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
H9525	017	0	1	01	01	H9525_017_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
H9572	001	1	1	04	01	H9572_001_1	5	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	001	2	1	04	01	H9572_001_2	5	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	001	3	1	04	01	H9572_001_3	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	001	4	1	04	01	H9572_001_4	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	001	6	1	04	01	H9572_001_6	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	002	1	1	04	01	H9572_002_1	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	002	2	1	04	01	H9572_002_2	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	002	3	1	04	01	H9572_002_3	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	002	4	1	04	01	H9572_002_4	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	002	6	1	04	01	H9572_002_6	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	003	1	1	04	01	H9572_003_1	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	003	2	1	04	01	H9572_003_2	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	003	3	1	04	01	H9572_003_3	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	003	4	1	04	01	H9572_003_4	5	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	003	6	1	04	01	H9572_003_6	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	004	1	1	04	01	H9572_004_1	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	004	2	1	04	01	H9572_004_2	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	004	3	1	04	01	H9572_004_3	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	004	4	1	04	01	H9572_004_4	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	004	6	1	04	01	H9572_004_6	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	006	1	1	04	01	H9572_006_1	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	006	2	1	04	01	H9572_006_2	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	006	3	1	04	01	H9572_006_3	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	006	4	1	04	01	H9572_006_4	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	006	6	1	04	01	H9572_006_6	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	007	1	1	04	01	H9572_007_1	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	007	2	1	04	01	H9572_007_2	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	007	3	1	04	01	H9572_007_3	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	007	4	1	04	01	H9572_007_4	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9572	007	6	1	04	01	H9572_007_6	4	2	1	1001010											3	2	1	6	Onlays - once per tooth per 84 months						3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change						3	2	1	6	Dentures (Adjustment, repairs, reline, rebase), bridges (repairs), implants (maintenance and repair), anesthesia	1	2	2	1500.00	3							1	10001010							25	25			25	25			25	25	2		2																		2	2	001
H9614	001	0	1	04	01	H9614_001_0	12	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	2000.00	3							1	10001111							50	70	70	70	0	70	50	70	70	70	2		2																		1	2	001
H9706	008	0	1	01	01	H9706_008_0	6		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H9706	009	0	1	01	01	H9706_009_0	6		1	1000110																3	1				3	1									3	1				1	2	2	1000.00	3							1	10000110									20	20	20	20			20	20	2		2																		2	2	001
H9827	001	0	1	01	01	H9827_001_0	9	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H9827	001	0	1	01	01	H9827_001_0	9	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H9827	002	0	1	01	01	H9827_002_0	9	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H9827	002	0	1	01	01	H9827_002_0	9	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H9827	003	0	1	01	01	H9827_003_0	6	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		2	500.00	3							1	00001111							0	50	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	001
H9827	003	0	1	01	01	H9827_003_0	6	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		2	1000.00	3							1	10001111							0	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	002
H9834	001	0	1	01	01	H9834_001_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H9834	003	0	1	01	01	H9834_003_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H9834	004	0	1	01	01	H9834_004_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H9834	005	0	1	01	01	H9834_005_0	3	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H9834	006	0	1	01	01	H9834_006_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		2	2	001
H9943	005	0	1	02	01	H9943_005_0	13		1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		2	1500.00	3							1	10001111							50	50	50	50	0	50	50	50	50	50	2		2																		1	1	001
R0865	001	0	1	31	11	R0865_001_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
R0865	003	0	1	31	11	R0865_003_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Restorative services include fillings $25 up to unlimited per year, bridge and crown recementation $25 up to 1/5 yrs, crown and other restorative services up to 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges-crown up to 2/5 yrs, bridges-pontic up to 1/5 yrs, occlusal adjustment up to 1/3 yrs, oral surgery up to 2 per year	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
R0865	003	0	1	31	11	R0865_003_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
R0865	003	0	1	31	11	R0865_003_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
R0923	002	0	1	31	11	R0923_002_0	18	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
R0923	002	0	1	31	11	R0923_002_0	18	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime.	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj, rebase, reline, repair, tissue conditioning, 1/year, bridges-crown, bridges-pontic, complete, partial dentures,1/5 years, occlusal adj, 1/3 years, oral surgery, 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
R0923	002	0	1	31	11	R0923_002_0	18	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
R1390	001	0	1	31	11	R1390_001_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
R1390	001	0	1	31	11	R1390_001_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
R1390	001	0	1	31	11	R1390_001_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
R1390	002	0	1	31	11	R1390_002_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
R1390	002	0	1	31	11	R1390_002_0	7	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
R1390	002	0	1	31	11	R1390_002_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
R2604	001	0	1	31	11	R2604_001_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
R2604	003	0	1	31	11	R2604_003_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
R3392	001	0	1	31	11	R3392_001_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									2																		2		2																		1	2	001
R3392	002	0	1	31	11	R3392_002_0	9	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, crown and bridge recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	1000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
R3392	002	0	1	31	11	R3392_002_0	9	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, crown and bridge recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
R3392	002	0	1	31	11	R3392_002_0	9	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
R3444	009	0	1	31	11	R3444_009_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
R3444	012	0	1	31	11	R3444_012_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
R3887	001	0	1	31	11	R3887_001_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
R3887	002	0	1	31	11	R3887_002_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				2											1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
R4487	001	0	1	31	11	R4487_001_0	12	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
R4487	001	0	1	31	11	R4487_001_0	12	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
R4845	001	0	1	31	11	R4845_001_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Srvc include amalgam/composite filling 0% unlimited/ yr, bridge/crown recementation $25 1/ 5 years, crown + other restorative services - core buildup and prefab post and core 50% 1/tooth/lifetime.	3	2	2	6	Endodontics include root canal and root canal retreatment 50% up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	denture adjust, rebase, reline, repair, tissue cond 1/year, bridges-crown 2/5 years, bridges-pontic, complete/partial dentures up to 1/5 years, occlusal adj up to 1/3 years, oral surgery up to 2/year	1	2	2	1000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	001
R4845	001	0	1	31	11	R4845_001_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	002
R4845	002	0	1	31	11	R4845_002_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
R4845	002	0	1	31	11	R4845_002_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
R4845	002	0	1	31	11	R4845_002_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
R5329	001	0	1	31	11	R5329_001_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
R5342	001	0	1	31	11	R5342_001_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
R5342	002	0	1	31	11	R5342_002_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
R5342	005	0	1	31	11	R5342_005_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
R5342	006	0	1	31	11	R5342_006_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
R5361	001	0	1	31	11	R5361_001_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
R5361	002	0	1	31	11	R5361_002_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1									1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
R5361	002	0	1	31	11	R5361_002_0	5	2	1	1101111	3	2	2	3							3	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	3	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		1									1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
R5361	002	0	1	31	11	R5361_002_0	5	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
R5495	001	0	1	31	11	R5495_001_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
R5495	002	0	1	31	11	R5495_002_0	7	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
R5941	013	0	1	31	11	R5941_013_0	7	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
R5941	013	0	1	31	11	R5941_013_0	7	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
R5941	014	0	1	31	11	R5941_014_0	8	2	1	0011111						3	1				3	1				3	1				3	1				3	1									1		1									1	00001111							20	20	50	50	50	50	50	50			2		1	00010000					0.00	0.00											2	2	002
R5941	014	0	1	31	11	R5941_014_0	8	2	1	1011111						3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10001111							20	50	50	50	50	50	50	50	50	50	2		1	00010000					0.00	0.00											2	2	003
R6694	006	0	1	31	11	R6694_006_0	9		1	1111111	3	1				3	2	1	6	see note	3	2	4	6	see note	3	2	2	6	see note	3	2	4	6	see note	3	2	1	6	see note	3	2	6	6	see note	1	2	2	1000.00	3							1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	00010000					0.00	0.00											1	2	001
R6801	009	0	1	31	11	R6801_009_0	5	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
R6801	012	0	1	31	11	R6801_012_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
R7220	001	0	1	31	11	R7220_001_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	001
R7220	001	0	1	31	11	R7220_001_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	002
R7220	002	0	1	31	11	R7220_002_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
R7220	002	0	1	31	11	R7220_002_0	4	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
R7220	002	0	1	31	11	R7220_002_0	4	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
R7315	001	0	1	31	11	R7315_001_0	8	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1	2	2	2000.00	3							1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	001
R7315	002	0	1	31	11	R7315_002_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3							1	10001100							50	50	50	50					50	50	2		1	00101011			25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2	001
R7315	002	0	1	31	11	R7315_002_0	6	2	1	1101111	3	2	2	3							3	2	4	6	Fillings 0% unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	3	2	2	6	Endodontics include root canal and root canal retreatment up to 1 per tooth per lifetime.	3	2	2	1		3	1				3	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1	2	2	2000.00	3							1	10001111							0	50	50	50	0	0	0	0	50	50	2		1	00101000			25.00	25.00			25.00	25.00									1	2	002
R7315	002	0	1	31	11	R7315_002_0	6	2	1	1111111	3	1				3	1				3	1				3	1				3	1				3	1				3	1				1		1									1	10111111			0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2	003
R7444	001	0	1	31	11	R7444_001_0	6	2	1	1111111	3	1				3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	3	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1									1	10000000															0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2	001
