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_b16a_bendesc_yn	pbp_b16a_bendesc_ehc	pbp_b16a_bendesc_amo_oe	pbp_b16a_bendesc_lim_oe	pbp_b16a_bendesc_numv_oe	pbp_b16a_bendesc_per_oe	pbp_b16a_bendesc_per_oe_d	pbp_b16a_bendesc_amo_pc	pbp_b16a_bendesc_lim_pc	pbp_b16a_bendesc_numv_pc	pbp_b16a_bendesc_per_pc	pbp_b16a_bendesc_per_pc_d	pbp_b16a_bendesc_amo_ft	pbp_b16a_bendesc_lim_ft	pbp_b16a_bendesc_numv_ft	pbp_b16a_bendesc_per_ft	pbp_b16a_bendesc_per_ft_d	pbp_b16a_bendesc_amo_dx	pbp_b16a_bendesc_lim_dx	pbp_b16a_bendesc_numv_dx	pbp_b16a_bendesc_per_dx	pbp_b16a_bendesc_per_dx_d	pbp_b16a_maxplan_yn	pbp_b16a_maxplan_in_oon	pbp_b16a_maxplan_amt	pbp_b16a_maxplan_per	pbp_b16a_maxplan_per_desc	pbp_b16a_maxenr_yn	pbp_b16a_maxenr_amt	pbp_b16a_maxenr_per	pbp_b16a_maxenr_per_desc	pbp_b16a_coins_yn	pbp_b16a_coins_ehc	pbp_b16a_coins_cserv_sc_pov_yn	pbp_b16a_coins_cserv_sc_pov	pbp_b16a_coins_pct_minov	pbp_b16a_coins_pct_maxov	pbp_b16a_coins_pct_oe	pbp_b16a_coins_pct_maxoe	pbp_b16a_coins_pct_pc	pbp_b16a_coins_pct_maxpc	pbp_b16a_coins_pct_ft	pbp_b16a_coins_pct_maxft	pbp_b16a_coins_pct_dx	pbp_b16a_coins_pct_maxdx	pbp_b16a_ded_yn	pbp_b16a_ded_amt	pbp_b16a_copay_yn	pbp_b16a_copay_ehc	pbp_b16a_copay_cserv_sc_pov_yn	pbp_b16a_copay_cserv_sc_pov	pbp_b16a_copay_amt_ovmin	pbp_b16a_copay_amt_ovmax	pbp_b16a_copay_amt_oemin	pbp_b16a_copay_amt_oemax	pbp_b16a_copay_amt_pcmin	pbp_b16a_copay_amt_pcmax	pbp_b16a_copay_amt_ftmin	pbp_b16a_copay_amt_ftmax	pbp_b16a_copay_amt_dxmin	pbp_b16a_copay_amt_dxmax	pbp_b16a_auth_yn	pbp_b16a_refer_yn	pbp_d_opt_identifier
H0028	016	0	1	02	01	H0028_016_0	8	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H0028	017	0	1	01	01	H0028_017_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H0028	021	0	1	01	01	H0028_021_0	6	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H0028	023	0	1	01	01	H0028_023_0	7	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H0028	027	0	1	01	01	H0028_027_0	7	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H0028	028	0	1	01	01	H0028_028_0	6	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H0028	041	0	1	01	01	H0028_041_0	7	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H0028	043	2	1	01	01	H0028_043_2	8	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H0028	047	0	1	01	01	H0028_047_0	7	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H0028	048	2	1	01	01	H0028_048_2	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H0028	053	1	1	01	01	H0028_053_1	7	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H0028	053	3	1	01	01	H0028_053_3	7	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H0028	053	4	1	01	01	H0028_053_4	6	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H0028	057	0	1	01	01	H0028_057_0	6	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H0028	062	0	1	01	01	H0028_062_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H0107	006	0	1	04	01	H0107_006_0	6		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	001
H0292	001	0	1	01	01	H0292_001_0	8	2	1	1111	3	1				3	1				3	1				3	1				1		500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H0292	002	0	1	01	01	H0292_002_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H0292	003	0	1	01	01	H0292_003_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H0294	004	0	1	04	01	H0294_004_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	011	0	1	04	01	H0294_011_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	023	0	1	04	01	H0294_023_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	026	0	1	04	01	H0294_026_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	030	0	1	04	01	H0294_030_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	031	0	1	04	01	H0294_031_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	032	0	1	04	01	H0294_032_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	033	0	1	04	01	H0294_033_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	037	0	1	04	01	H0294_037_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	038	0	1	04	01	H0294_038_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	039	0	1	04	01	H0294_039_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	040	0	1	04	01	H0294_040_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	041	0	1	04	01	H0294_041_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	042	0	1	04	01	H0294_042_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	043	0	1	04	01	H0294_043_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	044	0	1	04	01	H0294_044_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	046	0	1	04	01	H0294_046_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0294	047	0	1	04	01	H0294_047_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0473	004	0	1	04	01	H0473_004_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H0504	015	0	1	01	01	H0504_015_0	5	2	1	1111	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	4		3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				2		2												2		1	0110	2				0.00	5.00	5.00	5.00					2	2	001
H0504	015	0	1	01	01	H0504_015_0	5	2	1	1111	3	2	2	3		3	2	1	4		3	2	2	3		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				1	1111	2				0	20	0	20	0	20	0	20	2		2		2												2	2	002
H0504	017	0	1	01	01	H0504_017_0	5	2	1	1111	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	4		3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				2		2												2		1	0110	2				0.00	5.00	5.00	5.00					2	2	001
H0504	017	0	1	01	01	H0504_017_0	5	2	1	1111	3	2	2	3		3	2	1	4		3	2	2	3		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				1	1111	2				0	20	0	20	0	20	0	20	2		2		2												2	2	002
H0504	021	0	1	01	01	H0504_021_0	5	2	1	1111	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	4		3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				2		2												2		1	0110	2				0.00	5.00	5.00	5.00					2	2	001
H0504	021	0	1	01	01	H0504_021_0	5	2	1	1111	3	2	2	3		3	2	1	4		3	2	2	3		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				1	1111	2				0	20	0	20	0	20	0	20	2		2		2												2	2	002
H0504	026	0	1	01	01	H0504_026_0	6	2	1	1111	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	4		3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				2		2												2		1	0110	2				0.00	5.00	5.00	5.00					2	2	001
H0504	026	0	1	01	01	H0504_026_0	6	2	1	1111	3	2	2	3		3	2	1	4		3	2	2	3		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				1	1111	2				0	20	0	20	0	20	0	20	2		2		2												2	2	002
H0504	028	0	1	01	01	H0504_028_0	5	2	1	1111	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	4		3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				2		2												2		1	0110	2				0.00	5.00	5.00	5.00					2	2	001
H0504	028	0	1	01	01	H0504_028_0	5	2	1	1111	3	2	2	3		3	2	1	4		3	2	2	3		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				1	1111	2				0	20	0	20	0	20	0	20	2		2		2												2	2	002
H0504	038	0	1	01	01	H0504_038_0	5		1	1111	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	4		3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				2		2												2		1	0110	2				0.00	5.00	5.00	5.00					2	2	001
H0504	038	0	1	01	01	H0504_038_0	5		1	1111	3	2	2	3		3	2	1	4		3	2	2	3		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				1	1111	2				0	20	0	20	0	20	0	20	2		2		2												2	2	002
H0504	039	0	1	01	01	H0504_039_0	5	2	1	1111	3	2	2	3		3	2	1	4		3	2	2	3		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				1	1111	2				0	20	0	20	0	20	0	20	2		2		2												2	2	001
H0504	040	0	1	01	01	H0504_040_0	5	2	1	1111	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	4		3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				2		2												2		1	0110	2				0.00	5.00	5.00	5.00					2	2	001
H0504	040	0	1	01	01	H0504_040_0	5	2	1	1111	3	2	2	3		3	2	1	4		3	2	2	3		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				1	1111	2				0	20	0	20	0	20	0	20	2		2		2												2	2	002
H0504	041	0	1	01	01	H0504_041_0	7	2	1	1111	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	4		3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				2		2												2		1	0110	2				0.00	5.00	5.00	5.00					2	2	001
H0504	041	0	1	01	01	H0504_041_0	7	2	1	1111	3	2	2	3		3	2	1	4		3	2	2	3		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				1	1111	2				0	20	0	20	0	20	0	20	2		2		2												2	2	002
H0504	043	0	1	01	01	H0504_043_0	6	2	1	1111	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	4		3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				2		2												2		1	0110	2				0.00	5.00	5.00	5.00					2	2	001
H0504	043	0	1	01	01	H0504_043_0	6	2	1	1111	3	2	2	3		3	2	1	4		3	2	2	3		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				1	1111	2				0	20	0	20	0	20	0	20	2		2		2												2	2	002
H0504	047	0	1	01	01	H0504_047_0	6	2	1	1111	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3	2	1	4		3	1				3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				2		2												2		1	0110	2				0.00	5.00	5.00	5.00					2	2	001
H0504	047	0	1	01	01	H0504_047_0	6	2	1	1111	3	2	2	3		3	2	1	4		3	2	2	3		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				1	1111	2				0	20	0	20	0	20	0	20	2		2		2												2	2	002
H0504	049	0	1	01	01	H0504_049_0	6	2	1	1111	3	2	2	3		3	2	1	4		3	2	2	3		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				1	1111	2				0	20	0	20	0	20	0	20	2		2		2												2	2	001
H0524	003	0	1	01	01	H0524_003_0	14	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	008	0	1	01	01	H0524_008_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	013	0	1	01	01	H0524_013_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	015	0	1	01	01	H0524_015_0	13	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	031	0	1	01	01	H0524_031_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	032	0	1	01	01	H0524_032_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	033	0	1	01	01	H0524_033_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	034	0	1	01	01	H0524_034_0	10	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	035	0	1	01	01	H0524_035_0	10	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	036	0	1	01	01	H0524_036_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	037	0	1	01	01	H0524_037_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	038	0	1	01	01	H0524_038_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	039	0	1	01	01	H0524_039_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	040	0	1	01	01	H0524_040_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	041	0	1	01	01	H0524_041_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	042	0	1	01	01	H0524_042_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	043	0	1	01	01	H0524_043_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	046	0	1	01	01	H0524_046_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	051	0	1	01	01	H0524_051_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	054	0	1	01	01	H0524_054_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	059	0	1	01	01	H0524_059_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	060	0	1	01	01	H0524_060_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	061	0	1	01	01	H0524_061_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	062	0	1	01	01	H0524_062_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	063	0	1	01	01	H0524_063_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	064	0	1	01	01	H0524_064_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	065	0	1	01	01	H0524_065_0	11	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	078	0	1	01	01	H0524_078_0	10	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	081	0	1	01	01	H0524_081_0	10	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	082	0	1	01	01	H0524_082_0	10	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0524	083	0	1	01	01	H0524_083_0	10	2	1	0010						3	2	1	3												2					2				2		2												2		1	0010	2						0.00	0.00					1	1	001
H0543	013	0	1	02	01	H0543_013_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	019	0	1	02	01	H0543_019_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	028	0	1	02	01	H0543_028_0	8	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	035	0	1	02	01	H0543_035_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	036	0	1	02	01	H0543_036_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	086	0	1	02	01	H0543_086_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	089	0	1	02	01	H0543_089_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	121	0	1	02	01	H0543_121_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	140	0	1	02	01	H0543_140_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	145	0	1	02	01	H0543_145_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	146	0	1	02	01	H0543_146_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	147	0	1	02	01	H0543_147_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	152	0	1	02	01	H0543_152_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	167	0	1	02	01	H0543_167_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	176	0	1	02	01	H0543_176_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	193	0	1	02	01	H0543_193_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	195	0	1	02	01	H0543_195_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	196	0	1	02	01	H0543_196_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	210	0	1	02	01	H0543_210_0	8	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	215	0	1	02	01	H0543_215_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	216	0	1	02	01	H0543_216_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	222	0	1	02	01	H0543_222_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	223	0	1	02	01	H0543_223_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	224	0	1	02	01	H0543_224_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	228	0	1	02	01	H0543_228_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	229	0	1	02	01	H0543_229_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	230	0	1	02	01	H0543_230_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	231	0	1	02	01	H0543_231_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	232	0	1	02	01	H0543_232_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	234	0	1	02	01	H0543_234_0	8	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	235	0	1	02	01	H0543_235_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	236	0	1	02	01	H0543_236_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	237	0	1	02	01	H0543_237_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0543	238	0	1	02	01	H0543_238_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	002	0	1	01	01	H0544_002_0	13	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	002	0	1	01	01	H0544_002_0	13	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	002	0	1	01	01	H0544_002_0	13	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	004	0	1	01	01	H0544_004_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	004	0	1	01	01	H0544_004_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	004	0	1	01	01	H0544_004_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	005	0	1	01	01	H0544_005_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	005	0	1	01	01	H0544_005_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	005	0	1	01	01	H0544_005_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	007	0	1	01	01	H0544_007_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	007	0	1	01	01	H0544_007_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	007	0	1	01	01	H0544_007_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	008	0	1	01	01	H0544_008_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	008	0	1	01	01	H0544_008_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	008	0	1	01	01	H0544_008_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	010	0	1	01	01	H0544_010_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	010	0	1	01	01	H0544_010_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	010	0	1	01	01	H0544_010_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	014	0	1	01	01	H0544_014_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	014	0	1	01	01	H0544_014_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	014	0	1	01	01	H0544_014_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	015	0	1	01	01	H0544_015_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	015	0	1	01	01	H0544_015_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	015	0	1	01	01	H0544_015_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	019	0	1	01	01	H0544_019_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	019	0	1	01	01	H0544_019_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	019	0	1	01	01	H0544_019_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	020	0	1	01	01	H0544_020_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	020	0	1	01	01	H0544_020_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	020	0	1	01	01	H0544_020_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	056	0	1	01	01	H0544_056_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	056	0	1	01	01	H0544_056_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	056	0	1	01	01	H0544_056_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	058	0	1	01	01	H0544_058_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	058	0	1	01	01	H0544_058_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	058	0	1	01	01	H0544_058_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	061	0	1	01	01	H0544_061_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	061	0	1	01	01	H0544_061_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	061	0	1	01	01	H0544_061_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	062	0	1	01	01	H0544_062_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	062	0	1	01	01	H0544_062_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	062	0	1	01	01	H0544_062_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	063	0	1	01	01	H0544_063_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	063	0	1	01	01	H0544_063_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	063	0	1	01	01	H0544_063_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	064	0	1	01	01	H0544_064_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	064	0	1	01	01	H0544_064_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	064	0	1	01	01	H0544_064_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	065	0	1	01	01	H0544_065_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	065	0	1	01	01	H0544_065_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	065	0	1	01	01	H0544_065_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	066	0	1	01	01	H0544_066_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	066	0	1	01	01	H0544_066_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	066	0	1	01	01	H0544_066_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	069	0	1	01	01	H0544_069_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	069	0	1	01	01	H0544_069_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	069	0	1	01	01	H0544_069_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	095	0	1	01	01	H0544_095_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	095	0	1	01	01	H0544_095_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	095	0	1	01	01	H0544_095_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	096	0	1	01	01	H0544_096_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	096	0	1	01	01	H0544_096_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	096	0	1	01	01	H0544_096_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	098	0	1	01	01	H0544_098_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	098	0	1	01	01	H0544_098_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	098	0	1	01	01	H0544_098_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	108	0	1	01	01	H0544_108_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	108	0	1	01	01	H0544_108_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	108	0	1	01	01	H0544_108_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0544	127	0	1	01	01	H0544_127_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0544	127	0	1	01	01	H0544_127_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H0544	127	0	1	01	01	H0544_127_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H0571	007	0	1	01	01	H0571_007_0	7		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H0609	026	0	1	02	01	H0609_026_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0609	054	0	1	02	01	H0609_054_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0609	066	0	1	02	01	H0609_066_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0609	067	0	1	02	01	H0609_067_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0609	068	0	1	02	01	H0609_068_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0755	030	0	1	02	01	H0755_030_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0755	031	0	1	02	01	H0755_031_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0755	032	0	1	02	01	H0755_032_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0755	033	0	1	02	01	H0755_033_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0755	038	0	1	02	01	H0755_038_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0755	044	0	1	02	01	H0755_044_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0755	045	0	1	02	01	H0755_045_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H0783	003	0	1	01	01	H0783_003_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H0783	004	0	1	01	01	H0783_004_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H0978	001	0	1	01	01	H0978_001_0	8	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H0978	002	0	1	01	01	H0978_002_0	7	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H0978	003	0	1	01	01	H0978_003_0	7	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H0978	005	0	1	01	01	H0978_005_0	7	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H0978	006	0	1	01	01	H0978_006_0	7	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H0978	007	0	1	01	01	H0978_007_0	7	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H0978	009	0	1	01	01	H0978_009_0	7	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H1036	153	0	1	01	01	H1036_153_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H1036	219	0	1	01	01	H1036_219_0	6	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H1036	308	0	1	01	01	H1036_308_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H1181	001	0		07	02	H1181_001_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	1	3		3	2	1	3		2					2				1	1111	2	1111			0	20	0	20	0	20	0	20	2		2		2												2	2	001
H1278	003	0	1	04	01	H1278_003_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1278	004	0	1	04	01	H1278_004_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1278	007	0	1	04	01	H1278_007_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1278	009	0	1	04	01	H1278_009_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1278	010	0	1	04	01	H1278_010_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1278	014	0	1	04	01	H1278_014_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1278	020	0	1	04	01	H1278_020_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1278	021	0	1	04	01	H1278_021_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1278	022	0	1	04	01	H1278_022_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1278	024	0	1	04	01	H1278_024_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1278	029	0	1	04	01	H1278_029_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1278	030	0	1	04	01	H1278_030_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1350	028	0	1	01	01	H1350_028_0	4		1	1111	3	2	3	6	Two oral exams per calendar yearOne emergency oral exam per calendar year	3	2	2	3		3	2	1	3		3	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every five years	2					2				2		2												2		2		1	1111	20.00	20.00									2	2	001
H1350	029	0	1	01	01	H1350_029_0	5		1	1111	3	2	3	6	Two oral exams per calendar yearOne emergency oral exam per calendar year	3	2	2	3		3	2	1	3		3	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every five years	2					2				2		2												2		2		1	1111	20.00	20.00									2	2	001
H1423	001	0	1	01	01	H1423_001_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1423	001	0	1	01	01	H1423_001_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H1423	001	0	1	01	01	H1423_001_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H1423	002	0	1	01	01	H1423_002_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1423	002	0	1	01	01	H1423_002_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H1423	002	0	1	01	01	H1423_002_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and1 bitewing series per calendar year andUp to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H1423	004	0	1	01	01	H1423_004_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1423	004	0	1	01	01	H1423_004_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H1423	004	0	1	01	01	H1423_004_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H1423	005	0	1	01	01	H1423_005_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1423	005	0	1	01	01	H1423_005_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H1423	005	0	1	01	01	H1423_005_0	7		1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H1423	007	0	1	01	01	H1423_007_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year."	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1423	007	0	1	01	01	H1423_007_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H1423	007	0	1	01	01	H1423_007_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H1423	008	0	1	01	01	H1423_008_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year."	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1423	008	0	1	01	01	H1423_008_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H1423	008	0	1	01	01	H1423_008_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H1423	009	0	1	01	01	H1423_009_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1423	009	0	1	01	01	H1423_009_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H1423	009	0	1	01	01	H1423_009_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H1468	014	0	1	01	01	H1468_014_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H1607	012	0	1	04	01	H1607_012_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1607	012	0	1	04	01	H1607_012_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H1607	012	0	1	04	01	H1607_012_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H1607	015	0	1	04	01	H1607_015_0	13	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1607	015	0	1	04	01	H1607_015_0	13	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H1607	015	0	1	04	01	H1607_015_0	13	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H1666	013	0	1	04	01	H1666_013_0	5		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	001
H1666	018	0	1	04	01	H1666_018_0	5		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	001
H1822	001	0	1	01	01	H1822_001_0	7	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H1822	002	0	1	01	01	H1822_002_0	7	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H1822	003	0	1	01	01	H1822_003_0	10	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H1889	017	0	1	04	01	H1889_017_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1889	021	0	1	04	01	H1889_021_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1894	008	0	1	01	01	H1894_008_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1894	008	0	1	01	01	H1894_008_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H1894	008	0	1	01	01	H1894_008_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H1944	004	0	1	02	01	H1944_004_0	8	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1944	006	0	1	02	01	H1944_006_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1944	017	0	1	02	01	H1944_017_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1944	018	0	1	02	01	H1944_018_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1944	032	0	1	02	01	H1944_032_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H1951	024	0	1	01	01	H1951_024_0	7	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H1951	028	0	1	01	01	H1951_028_0	7	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H1951	039	0	1	01	01	H1951_039_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H1951	048	2	1	01	01	H1951_048_2	6	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H1951	049	1	1	01	01	H1951_049_1	6	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H1951	049	3	1	01	01	H1951_049_3	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H1951	052	0	1	01	01	H1951_052_0	6	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H1951	054	0	1	01	01	H1951_054_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H2001	001	0	1	04	01	H2001_001_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2001	010	0	1	04	01	H2001_010_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2001	018	0	1	04	01	H2001_018_0	7	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2256	001	1	1	01	01	H2256_001_1	7		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	001
H2256	001	2	1	01	01	H2256_001_2	7		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	001
H2256	001	6	1	01	01	H2256_001_6	7		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	001
H2256	015	1	1	01	01	H2256_015_1	7		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	001
H2256	015	2	1	01	01	H2256_015_2	7		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	001
H2256	015	6	1	01	01	H2256_015_6	7		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	001
H2256	016	1	1	01	01	H2256_016_1	5		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	001
H2256	016	2	1	01	01	H2256_016_2	5		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	001
H2256	033	0	1	01	01	H2256_033_0	7		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	001
H2256	039	0	1	01	01	H2256_039_0	5		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	001
H2320	022	1	1	02	01	H2320_022_1	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2320	022	2	1	02	01	H2320_022_2	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2320	022	3	1	02	01	H2320_022_3	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2320	022	4	1	02	01	H2320_022_4	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2320	022	5	1	02	01	H2320_022_5	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2320	028	1	1	02	01	H2320_028_1	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2320	028	2	1	02	01	H2320_028_2	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2320	028	3	1	02	01	H2320_028_3	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2320	028	4	1	02	01	H2320_028_4	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2320	028	5	1	02	01	H2320_028_5	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2320	029	1	1	02	01	H2320_029_1	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2320	029	2	1	02	01	H2320_029_2	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2320	029	3	1	02	01	H2320_029_3	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2320	029	4	1	02	01	H2320_029_4	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2320	029	5	1	02	01	H2320_029_5	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2320	030	1	1	02	01	H2320_030_1	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2320	030	2	1	02	01	H2320_030_2	6		1	0001											3	2	1	3							1		2500.00	3		2				2		2												2		2		2												2	2	001
H2406	039	0	1	04	01	H2406_039_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	040	0	1	04	01	H2406_040_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	041	0	1	04	01	H2406_041_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	060	0	1	04	01	H2406_060_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	070	0	1	04	01	H2406_070_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	071	0	1	04	01	H2406_071_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	076	0	1	04	01	H2406_076_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	083	0	1	04	01	H2406_083_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	087	0	1	04	01	H2406_087_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	095	0	1	04	01	H2406_095_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	096	0	1	04	01	H2406_096_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	097	0	1	04	01	H2406_097_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	101	0	1	04	01	H2406_101_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	103	0	1	04	01	H2406_103_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	104	0	1	04	01	H2406_104_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	105	0	1	04	01	H2406_105_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	106	0	1	04	01	H2406_106_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	112	0	1	04	01	H2406_112_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	113	0	1	04	01	H2406_113_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2406	119	0	1	04	01	H2406_119_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2459	023	1	1	02	01	H2459_023_1	8	2	1	1110	3	2	1	3		3	2	1	3							3	2	1	3		2					2				2		2												2		2		2												2	2	001
H2459	023	2	1	02	01	H2459_023_2	8	2	1	1110	3	2	1	3		3	2	1	3							3	2	1	3		2					2				2		2												2		2		2												2	2	001
H2459	024	0	1	02	01	H2459_024_0	8	2	1	1110	3	2	1	3		3	2	1	3							3	2	1	3		2					2				2		2												2		2		2												2	2	001
H2459	030	0	1	02	01	H2459_030_0	10	2	1	1110	3	2	1	3		3	2	1	3							3	2	1	6	X-rays: Four periapical (Pas) once per calendar year. Full mouth x-rays every five years.	2					2				2		2												2		2		2												2	2	001
H2462	027	0	1	18	06	H2462_027_0	4		1	1111	3	2	2	3		3	2	2	3		3	2	1	3		3	2	1	6	One panoramic or full mouth x-ray covered once every three years. Bitewing x-rays are covered once per year.  Limits combined INN/OON.	2					2				1	0010	2						0	50					2		2		2												2	2	001
H2462	028	0	1	18	06	H2462_028_0	5		1	1111	3	2	2	3		3	2	2	3		3	2	1	3		3	2	1	6	One panoramic or full mouth x-ray covered once every three years. Bitewing x-rays are covered once per year.  Limits combined INN/OON.	2					2				1	0010	2						0	50					2		2		2												2	2	002
H2463	001	0	1	01	01	H2463_001_0	8	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	002
H2486	003	0	1	01	01	H2486_003_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H2486	005	0	1	01	01	H2486_005_0	6	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H2486	006	0	1	01	01	H2486_006_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H2486	007	0	1	01	01	H2486_007_0	7	2	1	1111	3	1				3	1				3	1				3	1				1		500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H2486	009	0	1	01	01	H2486_009_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	002
H2486	010	0	1	01	01	H2486_010_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H2577	001	1	1	04	01	H2577_001_1	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2577	001	2	1	04	01	H2577_001_2	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2577	002	0	1	04	01	H2577_002_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2577	003	1	1	04	01	H2577_003_1	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2577	003	2	1	04	01	H2577_003_2	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2577	004	0	1	04	01	H2577_004_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2577	007	0	1	04	01	H2577_007_0	4	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2577	009	0	1	04	01	H2577_009_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2577	011	0	1	04	01	H2577_011_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2577	013	0	1	04	01	H2577_013_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2577	014	0	1	04	01	H2577_014_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2577	015	0	1	04	01	H2577_015_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2577	016	0	1	04	01	H2577_016_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2577	017	0	1	04	01	H2577_017_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2577	023	0	1	04	01	H2577_023_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2577	027	0	1	04	01	H2577_027_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2577	028	0	1	04	01	H2577_028_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2582	004	0	1	02	01	H2582_004_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2593	001	0	1	01	01	H2593_001_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2593	001	0	1	01	01	H2593_001_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H2593	001	0	1	01	01	H2593_001_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H2593	003	0	1	01	01	H2593_003_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2593	003	0	1	01	01	H2593_003_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H2593	003	0	1	01	01	H2593_003_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H2593	005	0	1	01	01	H2593_005_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2593	005	0	1	01	01	H2593_005_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H2593	005	0	1	01	01	H2593_005_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H2593	006	0	1	01	01	H2593_006_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2593	006	0	1	01	01	H2593_006_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H2593	006	0	1	01	01	H2593_006_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H2593	029	0	1	01	01	H2593_029_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2593	029	0	1	01	01	H2593_029_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H2593	029	0	1	01	01	H2593_029_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H2593	040	0	1	01	01	H2593_040_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2593	040	0	1	01	01	H2593_040_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H2593	040	0	1	01	01	H2593_040_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H2593	043	0	1	01	01	H2593_043_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2593	043	0	1	01	01	H2593_043_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H2593	043	0	1	01	01	H2593_043_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H2802	008	0	1	02	01	H2802_008_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2802	029	0	1	02	01	H2802_029_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2802	048	0	1	02	01	H2802_048_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2802	059	0	1	02	01	H2802_059_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2802	063	0	1	02	01	H2802_063_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2836	005	0	1	04	01	H2836_005_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H2836	005	0	1	04	01	H2836_005_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H2836	005	0	1	04	01	H2836_005_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3307	002	0	1	02	01	H3307_002_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3307	012	0	1	02	01	H3307_012_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3307	015	0	1	02	01	H3307_015_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3307	018	0	1	02	01	H3307_018_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3307	023	0	1	02	01	H3307_023_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3342	023	1	1	04	01	H3342_023_1	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3342	023	1	1	04	01	H3342_023_1	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3342	023	1	1	04	01	H3342_023_1	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3342	023	2	1	04	01	H3342_023_2	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3342	023	2	1	04	01	H3342_023_2	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3342	023	2	1	04	01	H3342_023_2	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3379	001	0	1	02	01	H3379_001_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3379	041	0	1	02	01	H3379_041_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3379	043	0	1	02	01	H3379_043_0	4	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3379	046	0	1	02	01	H3379_046_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3379	050	0	1	02	01	H3379_050_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3379	051	0	1	02	01	H3379_051_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3418	001	0	1	04	01	H3418_001_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3418	002	0	1	04	01	H3418_002_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3418	003	0	1	04	01	H3418_003_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3418	005	0	1	04	01	H3418_005_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3418	006	0	1	04	01	H3418_006_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3418	007	0	1	04	01	H3418_007_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3418	009	0	1	04	01	H3418_009_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3418	010	0	1	04	01	H3418_010_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	001	0	1	01	01	H3447_001_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	001	0	1	01	01	H3447_001_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	001	0	1	01	01	H3447_001_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	003	0	1	01	01	H3447_003_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	003	0	1	01	01	H3447_003_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	003	0	1	01	01	H3447_003_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	004	0	1	01	01	H3447_004_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	2	3		1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	004	0	1	01	01	H3447_004_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	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	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	005	0	1	01	01	H3447_005_0	6		1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	005	0	1	01	01	H3447_005_0	6		1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	005	0	1	01	01	H3447_005_0	6		1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	010	0	1	01	01	H3447_010_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	010	0	1	01	01	H3447_010_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	010	0	1	01	01	H3447_010_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year."	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	013	0	1	01	01	H3447_013_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	013	0	1	01	01	H3447_013_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	013	0	1	01	01	H3447_013_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	024	0	1	01	01	H3447_024_0	11	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	024	0	1	01	01	H3447_024_0	11	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	024	0	1	01	01	H3447_024_0	11	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	025	0	1	01	01	H3447_025_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	025	0	1	01	01	H3447_025_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	025	0	1	01	01	H3447_025_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	033	0	1	01	01	H3447_033_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	033	0	1	01	01	H3447_033_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	033	0	1	01	01	H3447_033_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	037	0	1	01	01	H3447_037_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	037	0	1	01	01	H3447_037_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	037	0	1	01	01	H3447_037_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	038	1	1	01	01	H3447_038_1	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	038	1	1	01	01	H3447_038_1	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	038	1	1	01	01	H3447_038_1	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	038	2	1	01	01	H3447_038_2	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	038	2	1	01	01	H3447_038_2	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	038	2	1	01	01	H3447_038_2	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	039	0	1	01	01	H3447_039_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	039	0	1	01	01	H3447_039_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	039	0	1	01	01	H3447_039_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	042	1	1	01	01	H3447_042_1	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	042	1	1	01	01	H3447_042_1	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	042	1	1	01	01	H3447_042_1	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	042	2	1	01	01	H3447_042_2	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	042	2	1	01	01	H3447_042_2	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	042	2	1	01	01	H3447_042_2	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	042	3	1	01	01	H3447_042_3	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	042	3	1	01	01	H3447_042_3	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	042	3	1	01	01	H3447_042_3	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	042	4	1	01	01	H3447_042_4	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	042	4	1	01	01	H3447_042_4	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	042	4	1	01	01	H3447_042_4	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3447	043	0	1	01	01	H3447_043_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3447	043	0	1	01	01	H3447_043_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3447	043	0	1	01	01	H3447_043_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3528	010	0	1	02	01	H3528_010_0	12		1	1111	3	2	1	4		3	2	1	4		3	2	1	4		3	2	1	6	Standard x-rays; 1 every 6 monthsComplete series x-rays; 1 every 36 months	2					2				2		2												2		2		2												2	2	001
H3528	010	0	1	02	01	H3528_010_0	12		1	1111	3	2	1	4		3	2	1	4		3	2	1	4		3	2	1	6	Standard x-rays; 1 every 6 monthsComplete series x-rays; 1 every 36 months	2					2				2		2												2		2		2												2	2	002
H3528	010	0	1	02	01	H3528_010_0	12		1	1111	3	1				3	1				3	1				3	1				1		3500.00	3		2				1	1111	2				50	50	50	50	50	50	50	50	2		2		2												2	2	003
H3528	015	0	1	02	01	H3528_015_0	10		1	1111	3	2	1	4		3	2	1	4		3	2	1	4		3	2	1	6	Standard x-ray - 1 every 6 monthsComplete series x-ray - 1 every 36 months	2					2				2		2												2		2		2												2	2	001
H3528	015	0	1	02	01	H3528_015_0	10		1	1111	3	2	1	4		3	2	1	4		3	2	1	4		3	2	1	6	Standard x-ray - 1 every 6 monthsComplete series x-ray - 1 every 36 months	2					2				2		2												2		2		2												2	2	002
H3528	015	0	1	02	01	H3528_015_0	10		1	1111	3	1				3	1				3	1				3	1				1		3500.00	3		2				1	1111	2				50	50	50	50	50	50	50	50	2		2		2												2	2	003
H3528	016	0	1	02	01	H3528_016_0	10		1	1111	3	2	1	4		3	2	1	4		3	2	1	4		3	2	1	6	Standard x-rays; 1 every 6 monthsComplete series x-rays; 1 every 36 months	2					2				2		2												2		2		2												2	2	001
H3528	016	0	1	02	01	H3528_016_0	10		1	1111	3	2	1	4		3	2	1	4		3	2	1	4		3	2	1	6	Standard x-rays; 1 every 6 monthsComplete series x-rays; 1 every 36 months	2					2				2		2												2		2		2												2	2	002
H3528	016	0	1	02	01	H3528_016_0	10		1	1111	3	1				3	1				3	1				3	1				1		3500.00	3		2				1	1111	2				50	50	50	50	50	50	50	50	2		2		2												2	2	003
H3533	006	0	1	01	01	H3533_006_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H3533	010	0	1	01	01	H3533_010_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H3533	027	0	1	01	01	H3533_027_0	7	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H3533	033	0	1	01	01	H3533_033_0	6	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H3536	002	0	1	01	01	H3536_002_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3536	002	0	1	01	01	H3536_002_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3536	002	0	1	01	01	H3536_002_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3655	034	0	1	01	01	H3655_034_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3655	034	0	1	01	01	H3655_034_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3655	034	0	1	01	01	H3655_034_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3655	041	0	1	01	01	H3655_041_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3655	041	0	1	01	01	H3655_041_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3655	041	0	1	01	01	H3655_041_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3655	042	0	1	01	01	H3655_042_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3655	042	0	1	01	01	H3655_042_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3655	042	0	1	01	01	H3655_042_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3655	045	1	1	01	01	H3655_045_1	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3655	045	1	1	01	01	H3655_045_1	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3655	045	1	1	01	01	H3655_045_1	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3655	045	2	1	01	01	H3655_045_2	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3655	045	2	1	01	01	H3655_045_2	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3655	045	2	1	01	01	H3655_045_2	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3655	045	3	1	01	01	H3655_045_3	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3655	045	3	1	01	01	H3655_045_3	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3655	045	3	1	01	01	H3655_045_3	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3655	045	4	1	01	01	H3655_045_4	14	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3655	045	4	1	01	01	H3655_045_4	14	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3655	045	4	1	01	01	H3655_045_4	14	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3655	047	0	1	01	01	H3655_047_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3655	047	0	1	01	01	H3655_047_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H3655	047	0	1	01	01	H3655_047_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H3660	028	0	1	02	01	H3660_028_0	7	1	2																																																															001
H3660	029	0	1	02	01	H3660_029_0	7	1	2																																																															001
H3660	044	0	1	01	01	H3660_044_0	7	1	2																																																															001
H3660	050	0	1	01	01	H3660_050_0	9	1	2																																																															001
H3660	052	1	1	01	01	H3660_052_1	7	1	2																																																															001
H3660	052	2	1	01	01	H3660_052_2	7	1	2																																																															001
H3660	053	1	1	01	01	H3660_053_1	9	1	2																																																															001
H3660	053	2	1	01	01	H3660_053_2	9	1	2																																																															001
H3660	056	1	1	01	01	H3660_056_1	9	1	2																																																															001
H3660	056	2	1	01	01	H3660_056_2	10	1	2																																																															001
H3805	015	0	1	02	01	H3805_015_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3805	017	0	1	02	01	H3805_017_0	4	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3805	037	0	1	02	01	H3805_037_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H3810	001	0	1	01	01	H3810_001_0	4		1	1111	3	2	2	3		3	2	2	3		3	1				3	2	2	3		2					2				2		2												2		1	1000	2										0.00	25.00	2	2	001
H3810	003	0	1	01	01	H3810_003_0	11		1	1111	3	2	2	3		3	2	2	3		3	1				3	2	2	3		2					2				2		2												2		1	1000	2										0.00	25.00	2	2	001
H3810	021	0	1	01	01	H3810_021_0	4		1	1111	3	2	2	3		3	2	2	3		3	1				3	2	2	3		2					2				2		2												2		1	1000	2										0.00	25.00	2	2	001
H3810	022	0	1	01	01	H3810_022_0	8		1	1111	3	2	2	3		3	2	2	3		3	1				3	2	2	3		2					2				2		2												2		1	1000	2										0.00	25.00	2	2	001
H3810	024	0	1	01	01	H3810_024_0	7		1	1111	3	2	2	3		3	2	2	3		3	1				3	2	2	3		2					2				2		2												2		1	1000	2										0.00	25.00	2	2	001
H3864	041	0	1	01	01	H3864_041_0	6		1	1111	3	1				3	1				3	1				3	1				2					2				2		2												2		2		2												2	2	001
H3864	041	0	1	01	01	H3864_041_0	6		1	1111	3	1				3	1				3	1				3	1				2					1	2000.00	3		2		2												2		2		2												2	2	002
H3924	059	21	1	04	01	H3924_059_21	5		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		1	2	1000.00	3		2				2		2												2		2		2												2	2	001
H3924	059	22	1	04	01	H3924_059_22	5		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		1	2	1000.00	3		2				2		2												2		2		2												2	2	001
H3924	065	0	1	04	01	H3924_065_0	5		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		1	2	1000.00	3		2				2		2												2		2		2												2	2	001
H4036	008	0	1	04	01	H4036_008_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4036	008	0	1	04	01	H4036_008_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4036	008	0	1	04	01	H4036_008_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4036	017	0	1	04	01	H4036_017_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4036	017	0	1	04	01	H4036_017_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4036	017	0	1	04	01	H4036_017_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4036	020	0	1	04	01	H4036_020_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4036	020	0	1	04	01	H4036_020_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4036	020	0	1	04	01	H4036_020_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4036	022	0	1	04	01	H4036_022_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4036	022	0	1	04	01	H4036_022_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4036	022	0	1	04	01	H4036_022_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4036	024	0	1	04	01	H4036_024_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4036	024	0	1	04	01	H4036_024_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4036	024	0	1	04	01	H4036_024_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4036	025	0	1	04	01	H4036_025_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4036	025	0	1	04	01	H4036_025_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4036	025	0	1	04	01	H4036_025_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4036	026	0	1	04	01	H4036_026_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4036	026	0	1	04	01	H4036_026_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4036	026	0	1	04	01	H4036_026_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4036	028	0	1	04	01	H4036_028_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4036	028	0	1	04	01	H4036_028_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4036	028	0	1	04	01	H4036_028_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4036	029	0	1	04	01	H4036_029_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4036	029	0	1	04	01	H4036_029_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4036	029	0	1	04	01	H4036_029_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4036	030	0	1	04	01	H4036_030_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4036	030	0	1	04	01	H4036_030_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4036	030	0	1	04	01	H4036_030_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4036	031	0	1	04	01	H4036_031_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4036	031	0	1	04	01	H4036_031_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4036	031	0	1	04	01	H4036_031_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4036	033	0	1	04	01	H4036_033_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4036	033	0	1	04	01	H4036_033_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4036	033	0	1	04	01	H4036_033_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4036	034	0	1	04	01	H4036_034_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4036	034	0	1	04	01	H4036_034_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4036	034	0	1	04	01	H4036_034_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4036	035	0	1	04	01	H4036_035_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4036	035	0	1	04	01	H4036_035_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4036	035	0	1	04	01	H4036_035_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4036	036	0	1	04	01	H4036_036_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4036	036	0	1	04	01	H4036_036_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4036	036	0	1	04	01	H4036_036_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4141	015	0	1	01	01	H4141_015_0	10	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H4141	017	3	1	01	01	H4141_017_3	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H4141	017	5	1	01	01	H4141_017_5	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2	1111			0	0	0	0	0	0	0	0	2		2		2												2	2	001
H4161	002	0	1	01	01	H4161_002_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4161	002	0	1	01	01	H4161_002_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4161	002	0	1	01	01	H4161_002_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4161	004	0	1	01	01	H4161_004_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4161	004	0	1	01	01	H4161_004_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4161	004	0	1	01	01	H4161_004_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4161	005	0	1	01	01	H4161_005_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4161	005	0	1	01	01	H4161_005_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4161	005	0	1	01	01	H4161_005_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4161	006	0	1	01	01	H4161_006_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4161	006	0	1	01	01	H4161_006_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4161	006	0	1	01	01	H4161_006_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4161	007	0	1	01	01	H4161_007_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4161	007	0	1	01	01	H4161_007_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4161	007	0	1	01	01	H4161_007_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4161	009	0	1	01	01	H4161_009_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4161	009	0	1	01	01	H4161_009_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4161	009	0	1	01	01	H4161_009_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4161	010	0	1	01	01	H4161_010_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4161	010	0	1	01	01	H4161_010_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4161	010	0	1	01	01	H4161_010_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4161	011	0	1	01	01	H4161_011_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4161	011	0	1	01	01	H4161_011_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4161	011	0	1	01	01	H4161_011_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4161	012	0	1	01	01	H4161_012_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4161	012	0	1	01	01	H4161_012_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4161	012	0	1	01	01	H4161_012_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4161	013	0	1	01	01	H4161_013_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4161	013	0	1	01	01	H4161_013_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4161	013	0	1	01	01	H4161_013_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4346	001	0	1	01	01	H4346_001_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year."	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4346	001	0	1	01	01	H4346_001_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4346	001	0	1	01	01	H4346_001_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4346	005	0	1	01	01	H4346_005_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year."	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4346	005	0	1	01	01	H4346_005_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4346	005	0	1	01	01	H4346_005_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4346	006	0	1	01	01	H4346_006_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year."	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4346	006	0	1	01	01	H4346_006_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4346	006	0	1	01	01	H4346_006_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4346	009	0	1	01	01	H4346_009_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4346	009	0	1	01	01	H4346_009_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4346	009	0	1	01	01	H4346_009_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4346	010	0	1	01	01	H4346_010_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4346	010	0	1	01	01	H4346_010_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4346	010	0	1	01	01	H4346_010_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4346	012	0	1	01	01	H4346_012_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4346	012	0	1	01	01	H4346_012_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4346	012	0	1	01	01	H4346_012_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4346	017	0	1	01	01	H4346_017_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4346	017	0	1	01	01	H4346_017_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4346	017	0	1	01	01	H4346_017_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4346	019	0	1	01	01	H4346_019_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4346	019	0	1	01	01	H4346_019_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4346	019	0	1	01	01	H4346_019_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4346	029	0	1	01	01	H4346_029_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4346	029	0	1	01	01	H4346_029_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4346	029	0	1	01	01	H4346_029_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4461	039	0	1	01	01	H4461_039_0	6	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H4514	007	0	1	02	01	H4514_007_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4527	024	0	1	02	01	H4527_024_0	4	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4527	037	0	1	02	01	H4527_037_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4527	051	0	1	02	01	H4527_051_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4754	004	0	1	04	01	H4754_004_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	001
H4754	017	0	1	04	01	H4754_017_0	5		1	1111	3	1				3	1				3	1				3	1				2					2				2		2												2		2		2												2	2	001
H4754	017	0	1	04	01	H4754_017_0	5		1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	002
H4801	013	0	1	04	01	H4801_013_0	6		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	001
H4801	014	0	1	04	01	H4801_014_0	6		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	001
H4875	016	1	1	04	01	H4875_016_1	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	016	2	1	04	01	H4875_016_2	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	016	3	1	04	01	H4875_016_3	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	016	4	1	04	01	H4875_016_4	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	016	5	1	04	01	H4875_016_5	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	017	1	1	04	01	H4875_017_1	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	017	2	1	04	01	H4875_017_2	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	017	3	1	04	01	H4875_017_3	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	017	4	1	04	01	H4875_017_4	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	017	5	1	04	01	H4875_017_5	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	018	1	1	04	01	H4875_018_1	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	018	2	1	04	01	H4875_018_2	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	018	3	1	04	01	H4875_018_3	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	018	4	1	04	01	H4875_018_4	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	018	5	1	04	01	H4875_018_5	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	020	1	1	04	01	H4875_020_1	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	020	2	1	04	01	H4875_020_2	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	020	3	1	04	01	H4875_020_3	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	021	1	1	04	01	H4875_021_1	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	021	2	1	04	01	H4875_021_2	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	022	1	1	04	01	H4875_022_1	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	022	2	1	04	01	H4875_022_2	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	022	5	1	04	01	H4875_022_5	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4875	023	0	1	04	01	H4875_023_0	6		1	0001											3	2	1	3							1	2	2500.00	3		2				2		2												2		2		2												2	2	001
H4882	003	0	1	04	01	H4882_003_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	1	3		3	2	1	6	One panoramic or full mouth x-ray covered once every three years. Bitewing x-rays are covered once per year.  Limits combined INN/OON.	2					2				1	0010	2						0	50					2		2		2												2	2	001
H4882	009	1	1	04	01	H4882_009_1	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	1	3		3	2	1	6	One panoramic or full mouth x-ray covered once every three years. Bitewing x-rays are covered once per year.  Limits combined INN/OON.	2					2				1	0010	2						0	50					2		2		2												2	2	001
H4882	009	2	1	04	01	H4882_009_2	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	1	3		3	2	1	6	One panoramic or full mouth x-ray covered once every three years. Bitewing x-rays are covered once per year.  Limits combined INN/OON.	2					2				1	0010	2						0	50					2		2		2												2	2	001
H4882	010	2	1	04	01	H4882_010_2	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	1	3		3	2	1	6	One panoramic or full mouth x-ray covered once every three years. Bitewing x-rays are covered once per year.  Limits combined INN/OON.	2					2				1	0010	2						0	50					2		2		2												2	2	001
H4882	011	1	1	04	01	H4882_011_1	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	1	3		3	2	1	6	One panoramic or full mouth x-ray covered once every three years. Bitewing x-rays are covered once per year.  Limits combined INN/OON.	2					2				1	0010	2						0	50					2		2		2												2	2	001
H4882	011	2	1	04	01	H4882_011_2	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	1	3		3	2	1	6	One panoramic or full mouth x-ray covered once every three years. Bitewing x-rays are covered once per year.  Limits combined INN/OON.	2					2				1	0010	2						0	50					2		2		2												2	2	001
H4909	014	0	1	04	01	H4909_014_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4909	014	0	1	04	01	H4909_014_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4909	014	0	1	04	01	H4909_014_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4909	015	0	1	04	01	H4909_015_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4909	015	0	1	04	01	H4909_015_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4909	015	0	1	04	01	H4909_015_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4909	016	0	1	04	01	H4909_016_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4909	016	0	1	04	01	H4909_016_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4909	016	0	1	04	01	H4909_016_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4909	020	0	1	04	01	H4909_020_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4909	020	0	1	04	01	H4909_020_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4909	020	0	1	04	01	H4909_020_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4909	021	0	1	04	01	H4909_021_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4909	021	0	1	04	01	H4909_021_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4909	021	0	1	04	01	H4909_021_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4909	023	0	1	04	01	H4909_023_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4909	023	0	1	04	01	H4909_023_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4909	023	0	1	04	01	H4909_023_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4909	026	0	1	04	01	H4909_026_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H4909	026	0	1	04	01	H4909_026_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H4909	026	0	1	04	01	H4909_026_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H4937	001	0	1	04	01	H4937_001_0	6	1	1	1101	3	2	2	6	Periodicity varies by covered benefit. See Notes for more details.						3	2	1	3		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				2		2												2		2		2												2	2	001
H4937	002	0	1	04	01	H4937_002_0	6	1	1	1101	3	2	2	6	Periodicity varies by covered benefit. See Notes for more details.						3	2	1	3		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				2		2												2		2		2												2	2	001
H5211	001	0	1	02	01	H5211_001_0	3	2	1	1111	3	2	1	3		3	2	1	3		3	2	1	3		3	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2					2				1	0001	2								20	20			2		2		2												2	2	001
H5211	002	0	1	02	01	H5211_002_0	5	2	1	1111	3	2	1	3		3	2	1	3		3	2	1	3		3	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2					2				1	0001	2								20	20			2		2		2												2	2	001
H5211	003	0	1	02	01	H5211_003_0	3	2	1	1111	3	2	1	3		3	2	1	3		3	2	1	3		3	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2					2				1	0001	2								20	20			2		2		2												2	2	001
H5211	004	0	1	02	01	H5211_004_0	4	2	1	1111	3	2	1	3		3	2	1	3		3	2	1	3		3	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2					2				1	0001	2								20	20			2		2		2												2	2	001
H5211	010	0	1	01	01	H5211_010_0	5	2	1	1111	3	2	1	3		3	2	1	3		3	2	1	3		3	2	0	3		2					2				1	1111	2				0	20	0	20	20	50	0	20	2		2		2												2	2	001
H5211	012	0	1	02	01	H5211_012_0	4	2	1	1111	3	2	1	3		3	2	1	3		3	2	1	3		3	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2					2				1	0001	2								20	20			2		2		2												2	2	001
H5211	013	0	1	02	01	H5211_013_0	4	2	1	1111	3	2	1	3		3	2	1	3		3	2	1	3		3	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2					2				1	0001	2								20	20			2		2		2												2	2	001
H5215	001	0	1	04	01	H5215_001_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	1	3		3	2	1	3		2					2				2		2												2		2		2												2	2	001
H5215	002	0	1	04	01	H5215_002_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	1	3		3	2	1	3		2					2				2		2												2		2		2												2	2	001
H5215	005	0	1	04	01	H5215_005_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	1	3		3	2	1	3		2					2				2		2												2		2		2												2	2	001
H5215	006	0	1	04	01	H5215_006_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	1	3		3	2	1	3		2					2				2		2												2		2		2												2	2	001
H5215	008	0	1	04	01	H5215_008_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	1	3		3	2	1	3		2					2				2		2												2		2		2												2	2	001
H5215	009	0	1	04	01	H5215_009_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	1	3		3	2	1	3		2					2				2		2												2		2		2												2	2	001
H5215	012	0	1	04	01	H5215_012_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	1	3		3	2	1	3		2					2				2		2												2		2		2												2	2	001
H5216	001	0	1	04	01	H5216_001_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	011	0	1	04	01	H5216_011_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	017	0	1	04	01	H5216_017_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	1500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	019	0	1	04	01	H5216_019_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	023	0	1	04	01	H5216_023_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	024	0	1	04	01	H5216_024_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	027	0	1	04	01	H5216_027_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				2		2												2		2		2												1	2	003
H5216	034	0	1	04	01	H5216_034_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	037	0	1	04	01	H5216_037_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	002
H5216	039	0	1	04	01	H5216_039_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	044	0	1	04	01	H5216_044_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	047	0	1	04	01	H5216_047_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	048	0	1	04	01	H5216_048_0	9	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	053	0	1	04	01	H5216_053_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	1	1111	0	0	0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	057	0	1	04	01	H5216_057_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	058	0	1	04	01	H5216_058_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	059	0	1	04	01	H5216_059_0	3	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	063	0	1	04	01	H5216_063_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	064	0	1	04	01	H5216_064_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	073	0	1	04	01	H5216_073_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	078	1	1	04	01	H5216_078_1	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	078	2	1	04	01	H5216_078_2	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	088	0	1	04	01	H5216_088_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	089	0	1	04	01	H5216_089_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	092	0	1	04	01	H5216_092_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	097	0	1	04	01	H5216_097_0	9	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	1	1111	0	0	0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	099	0	1	04	01	H5216_099_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	100	0	1	04	01	H5216_100_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	105	0	1	04	01	H5216_105_0	4	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	002
H5216	106	0	1	04	01	H5216_106_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	107	0	1	04	01	H5216_107_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	112	0	1	04	01	H5216_112_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	116	0	1	04	01	H5216_116_0	4	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	002
H5216	120	0	1	04	01	H5216_120_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	1	1111	0	0	0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	124	0	1	04	01	H5216_124_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	131	0	1	04	01	H5216_131_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	132	0	1	04	01	H5216_132_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	136	0	1	04	01	H5216_136_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	137	0	1	04	01	H5216_137_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	138	0	1	04	01	H5216_138_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	141	0	1	04	01	H5216_141_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	142	1	1	04	01	H5216_142_1	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	142	2	1	04	01	H5216_142_2	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	144	0	1	04	01	H5216_144_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	152	0	1	04	01	H5216_152_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	003
H5216	154	0	1	04	01	H5216_154_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	168	0	1	04	01	H5216_168_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	169	0	1	04	01	H5216_169_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	170	0	1	04	01	H5216_170_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	172	0	1	04	01	H5216_172_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	174	0	1	04	01	H5216_174_0	4	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	175	0	1	04	01	H5216_175_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	176	0	1	04	01	H5216_176_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	177	0	1	04	01	H5216_177_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	185	0	1	04	01	H5216_185_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	192	0	1	04	01	H5216_192_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	194	0	1	04	01	H5216_194_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	196	1	1	04	01	H5216_196_1	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	196	2	1	04	01	H5216_196_2	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	203	1	1	04	01	H5216_203_1	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	203	2	1	04	01	H5216_203_2	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	207	0	1	04	01	H5216_207_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	211	0	1	04	01	H5216_211_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	213	0	1	04	01	H5216_213_0	4	2	1	1111	3	1				3	1				3	1				3	1				1	2	0.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	215	0	1	04	01	H5216_215_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	216	0	1	04	01	H5216_216_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	223	0	1	04	01	H5216_223_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	224	0	1	04	01	H5216_224_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	226	0	1	04	01	H5216_226_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	229	0	1	04	01	H5216_229_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	232	1	1	04	01	H5216_232_1	4	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	232	2	1	04	01	H5216_232_2	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	233	1	1	04	01	H5216_233_1	4	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	233	2	1	04	01	H5216_233_2	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	234	0	1	04	01	H5216_234_0	4	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	235	0	1	04	01	H5216_235_0	4	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	244	0	1	04	01	H5216_244_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				2		2												2		2		2												1	2	001
H5216	246	0	1	04	01	H5216_246_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	247	0	1	04	01	H5216_247_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	249	0	1	04	01	H5216_249_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	252	0	1	04	01	H5216_252_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	260	0	1	04	01	H5216_260_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	261	0	1	04	01	H5216_261_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	263	0	1	04	01	H5216_263_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	264	0	1	04	01	H5216_264_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	265	0	1	04	01	H5216_265_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	266	0	1	04	01	H5216_266_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	269	0	1	04	01	H5216_269_0	12	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	273	0	1	04	01	H5216_273_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	274	0	1	04	01	H5216_274_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	279	0	1	04	01	H5216_279_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	1500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	285	0	1	04	01	H5216_285_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	289	0	1	04	01	H5216_289_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	306	0	1	04	01	H5216_306_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	308	0	1	04	01	H5216_308_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	003
H5216	309	0	1	04	01	H5216_309_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	312	0	1	04	01	H5216_312_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	314	0	1	04	01	H5216_314_0	10	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	316	3	1	04	01	H5216_316_3	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	317	0	1	04	01	H5216_317_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	319	0	1	04	01	H5216_319_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	320	0	1	04	01	H5216_320_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	322	0	1	04	01	H5216_322_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	324	0	1	04	01	H5216_324_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	327	0	1	04	01	H5216_327_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	328	0	1	04	01	H5216_328_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	337	1	1	04	01	H5216_337_1	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	337	2	1	04	01	H5216_337_2	8	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	338	0	1	04	01	H5216_338_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	339	0	1	04	01	H5216_339_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	341	0	1	04	01	H5216_341_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	345	0	1	04	01	H5216_345_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	346	0	1	04	01	H5216_346_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	003
H5216	347	0	1	04	01	H5216_347_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	348	0	1	04	01	H5216_348_0	4	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	002
H5216	349	0	1	04	01	H5216_349_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	350	0	1	04	01	H5216_350_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	353	0	1	04	01	H5216_353_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	354	0	1	04	01	H5216_354_0	3	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	355	0	1	04	01	H5216_355_0	3	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	359	0	1	04	01	H5216_359_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	360	0	1	04	01	H5216_360_0	8	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	368	0	1	04	01	H5216_368_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	6	per year	2				1	1111	1	1111	0	0	0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	372	0	1	04	01	H5216_372_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	375	0	1	04	01	H5216_375_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	378	0	1	04	01	H5216_378_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	002
H5216	380	0	1	04	01	H5216_380_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	383	0	1	04	01	H5216_383_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	384	0	1	04	01	H5216_384_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	387	1	1	04	01	H5216_387_1	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	387	2	1	04	01	H5216_387_2	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	389	0	1	04	01	H5216_389_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5216	391	0	1	04	01	H5216_391_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	0.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5216	395	0	1	04	01	H5216_395_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												1	2	003
H5216	396	0	1	04	01	H5216_396_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5244	001	0	1	01	01	H5244_001_0	7	1	2																																																															001
H5244	002	0	1	01	01	H5244_002_0	7	1	2																																																															001
H5244	003	0	1	01	01	H5244_003_0	7	1	2																																																															001
H5253	072	0	1	02	01	H5253_072_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5253	097	0	1	02	01	H5253_097_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5253	105	0	1	02	01	H5253_105_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5253	110	0	1	02	01	H5253_110_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5253	119	0	1	02	01	H5253_119_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5253	121	0	1	02	01	H5253_121_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5253	127	0	1	02	01	H5253_127_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5253	135	0	1	02	01	H5253_135_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5262	001	0	1	01	01	H5262_001_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	003	0	1	01	01	H5262_003_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	004	0	1	01	01	H5262_004_0	3	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	005	0	1	01	01	H5262_005_0	3	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	007	0	1	01	01	H5262_007_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	008	0	1	01	01	H5262_008_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	009	0	1	01	01	H5262_009_0	3	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	010	0	1	01	01	H5262_010_0	3	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	011	0	1	01	01	H5262_011_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	012	0	1	01	01	H5262_012_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	013	0	1	01	01	H5262_013_0	3	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	018	0	1	01	01	H5262_018_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	019	0	1	01	01	H5262_019_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	020	0	1	01	01	H5262_020_0	3	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	021	0	1	01	01	H5262_021_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	023	0	1	01	01	H5262_023_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	024	0	1	01	01	H5262_024_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	025	0	1	01	01	H5262_025_0	3	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	026	0	1	01	01	H5262_026_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5262	027	0	1	01	01	H5262_027_0	3	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H5322	039	0	1	02	01	H5322_039_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5386	003	0	1	01	01	H5386_003_0	5		1	1110	3	1				3	2	1	4							3	2	1	4		2					2				2		2												2		1	0110	2				0.00	0.00	15.00	15.00					2	2	001
H5386	003	0	1	01	01	H5386_003_0	5		1	1110	3	1				3	1									3	1				2					2				2		2												2		1	1110	2				0.00	0.00	15.00	15.00			0.00	0.00	2	2	002
H5386	004	0	1	01	01	H5386_004_0	5	2	1	1110	3	1				3	1									3	1				2					2				2		2												2		1	1110	2				0.00	0.00	15.00	15.00			0.00	0.00	2	2	001
H5386	005	0	1	01	01	H5386_005_0	5	2	1	1110	3	1				3	1									3	1				2					2				2		2												2		1	1110	2				0.00	0.00	15.00	15.00			0.00	0.00	2	2	001
H5422	011	0	1	01	01	H5422_011_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5422	011	0	1	01	01	H5422_011_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H5422	011	0	1	01	01	H5422_011_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H5422	014	0	1	01	01	H5422_014_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5422	014	0	1	01	01	H5422_014_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H5422	014	0	1	01	01	H5422_014_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 periapical images per calendar year	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H5422	015	0	1	01	01	H5422_015_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5422	015	0	1	01	01	H5422_015_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H5422	015	0	1	01	01	H5422_015_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H5425	001	0	1	01	01	H5425_001_0	7	1	2																																																															001
H5425	004	0	1	01	01	H5425_004_0	8	1	2																																																															001
H5425	005	0	1	01	01	H5425_005_0	8		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	005	0	1	01	01	H5425_005_0	8	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	002
H5425	006	0	1	01	01	H5425_006_0	10	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	007	0	1	01	01	H5425_007_0	8	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	008	0	1	01	01	H5425_008_0	7	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	009	0	1	01	01	H5425_009_0	7	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	019	0	1	01	01	H5425_019_0	8		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	019	0	1	01	01	H5425_019_0	8	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	002
H5425	020	0	1	01	01	H5425_020_0	6		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	020	0	1	01	01	H5425_020_0	6	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	002
H5425	028	0	1	01	01	H5425_028_0	9	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	033	0	1	01	01	H5425_033_0	7	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	034	0	1	01	01	H5425_034_0	8	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	055	0	1	01	01	H5425_055_0	8	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	055	0	1	01	01	H5425_055_0	8	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	002
H5425	065	0	1	01	01	H5425_065_0	8	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	066	0	1	01	01	H5425_066_0	8	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	067	0	1	01	01	H5425_067_0	8	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	068	0	1	01	01	H5425_068_0	6	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	073	0	1	01	01	H5425_073_0	6		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	073	0	1	01	01	H5425_073_0	6	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	002
H5425	075	0	1	01	01	H5425_075_0	8	1	2																																																															001
H5425	076	0	1	01	01	H5425_076_0	8	1	2																																																															001
H5425	077	0	1	01	01	H5425_077_0	8	1	2																																																															001
H5425	078	0	1	01	01	H5425_078_0	8	1	2																																																															001
H5425	082	0	1	01	01	H5425_082_0	7	1	2																																																															001
H5425	086	0	1	01	01	H5425_086_0	9	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	087	0	1	01	01	H5425_087_0	9	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	091	0	1	01	01	H5425_091_0	8	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	092	0	1	01	01	H5425_092_0	6	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	096	0	1	01	01	H5425_096_0	8	1	2																																																															001
H5425	100	0	1	01	01	H5425_100_0	6	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	101	0	1	01	01	H5425_101_0	8	1	2																																																															001
H5425	102	0	1	01	01	H5425_102_0	8	1	2																																																															001
H5425	103	0	1	01	01	H5425_103_0	8	1	2																																																															001
H5425	104	0	1	01	01	H5425_104_0	8	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	105	0	1	01	01	H5425_105_0	8	1	2																																																															001
H5425	106	0	1	01	01	H5425_106_0	8		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	106	0	1	01	01	H5425_106_0	8		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	002
H5425	107	0	1	01	01	H5425_107_0	8		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	107	0	1	01	01	H5425_107_0	8		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	002
H5425	111	0	1	01	01	H5425_111_0	8		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	111	0	1	01	01	H5425_111_0	8		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	002
H5425	115	0	1	01	01	H5425_115_0	6	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5425	116	0	1	01	01	H5425_116_0	6	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H5525	004	0	1	04	01	H5525_004_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5525	005	0	1	04	01	H5525_005_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5525	006	0	1	04	01	H5525_006_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5525	008	0	1	04	01	H5525_008_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5525	024	0	1	04	01	H5525_024_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	1	1111	0	0	0	0	0	0	0	0	0	0	2		2		2												1	2	003
H5525	026	0	1	04	01	H5525_026_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5525	027	0	1	04	01	H5525_027_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5525	030	0	1	04	01	H5525_030_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5525	034	0	1	04	01	H5525_034_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5525	035	0	1	04	01	H5525_035_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5525	042	0	1	04	01	H5525_042_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5525	049	0	1	04	01	H5525_049_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5525	050	0	1	04	01	H5525_050_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5525	051	1	1	04	01	H5525_051_1	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5525	051	2	1	04	01	H5525_051_2	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5525	052	0	1	04	01	H5525_052_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	002
H5525	054	0	1	04	01	H5525_054_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5525	055	0	1	04	01	H5525_055_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5525	056	0	1	04	01	H5525_056_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5525	057	0	1	04	01	H5525_057_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5525	058	0	1	04	01	H5525_058_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												1	2	003
H5525	061	0	1	04	01	H5525_061_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5525	062	0	1	04	01	H5525_062_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5525	063	0	1	04	01	H5525_063_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1250.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5525	064	0	1	04	01	H5525_064_0	3	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	1	1111	0	0	0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5525	067	0	1	04	01	H5525_067_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5525	068	0	1	04	01	H5525_068_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5525	071	0	1	04	01	H5525_071_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5525	074	0	1	04	01	H5525_074_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5525	075	0	1	04	01	H5525_075_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5525	076	0	1	04	01	H5525_076_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5525	077	0	1	04	01	H5525_077_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	001	0	1	01	01	H5619_001_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	012	0	1	01	01	H5619_012_0	8	2	1	1111	3	1				3	1				3	1				3	1				1		500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	015	0	1	01	01	H5619_015_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	026	0	1	01	01	H5619_026_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	029	0	1	01	01	H5619_029_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	032	0	1	01	01	H5619_032_0	6	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	039	1	1	01	01	H5619_039_1	5	2	1	1111	3	1				3	1				3	1				3	1				1		1500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	039	2	1	01	01	H5619_039_2	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	046	0	1	01	01	H5619_046_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	047	0	1	01	01	H5619_047_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	053	0	1	02	01	H5619_053_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	055	0	1	01	01	H5619_055_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	056	0	1	01	01	H5619_056_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	057	0	1	01	01	H5619_057_0	8	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	059	0	1	01	01	H5619_059_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	002
H5619	060	0	1	01	01	H5619_060_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	061	0	1	01	01	H5619_061_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	002
H5619	063	0	1	01	01	H5619_063_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	066	0	1	01	01	H5619_066_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	069	0	1	02	01	H5619_069_0	6	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	077	0	1	01	01	H5619_077_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	083	0	1	01	01	H5619_083_0	7	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	1	1111	0	0	0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	089	0	1	01	01	H5619_089_0	7	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	100	0	1	01	01	H5619_100_0	7	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	113	0	1	02	01	H5619_113_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	114	0	1	01	01	H5619_114_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	116	0	1	01	01	H5619_116_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	119	0	1	01	01	H5619_119_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	121	0	1	01	01	H5619_121_0	3	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	122	0	1	01	01	H5619_122_0	6	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	128	0	1	01	01	H5619_128_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	130	1	1	01	01	H5619_130_1	6	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	130	2	1	01	01	H5619_130_2	5	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	133	0	1	01	01	H5619_133_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	135	0	1	01	01	H5619_135_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	003
H5619	137	0	1	01	01	H5619_137_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	138	0	1	01	01	H5619_138_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5619	143	0	1	01	01	H5619_143_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	146	0	1	01	01	H5619_146_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	147	0	1	01	01	H5619_147_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	148	0	1	01	01	H5619_148_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	150	0	1	01	01	H5619_150_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1250.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	151	0	1	01	01	H5619_151_0	4	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	152	0	1	01	01	H5619_152_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	157	0	1	01	01	H5619_157_0	6	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5619	161	0	1	01	01	H5619_161_0	6	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	1	1111	0	0	0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5652	002	0	1	02	01	H5652_002_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5652	004	0	1	02	01	H5652_004_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5828	008	0	1	01	01	H5828_008_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5828	008	0	1	01	01	H5828_008_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H5828	008	0	1	01	01	H5828_008_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H5828	012	1	1	02	01	H5828_012_1	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5828	012	1	1	02	01	H5828_012_1	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H5828	012	1	1	02	01	H5828_012_1	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H5828	012	2	1	02	01	H5828_012_2	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5828	012	2	1	02	01	H5828_012_2	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H5828	012	2	1	02	01	H5828_012_2	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H5828	012	3	1	02	01	H5828_012_3	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5828	012	3	1	02	01	H5828_012_3	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H5828	012	3	1	02	01	H5828_012_3	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H5854	009	0	1	01	01	H5854_009_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5854	009	0	1	01	01	H5854_009_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H5854	009	0	1	01	01	H5854_009_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H5854	010	0	1	01	01	H5854_010_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5854	010	0	1	01	01	H5854_010_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H5854	010	0	1	01	01	H5854_010_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H5854	011	0	1	01	01	H5854_011_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H5854	011	0	1	01	01	H5854_011_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H5854	011	0	1	01	01	H5854_011_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
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	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	1	1111	0	0	0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5970	015	0	1	04	01	H5970_015_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5970	016	0	1	04	01	H5970_016_0	3	2	1	1111	3	1				3	1				3	1				3	1				1	2	500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5970	018	0	1	04	01	H5970_018_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5970	024	1	1	04	01	H5970_024_1	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5970	024	2	1	04	01	H5970_024_2	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H5970	025	0	1	04	01	H5970_025_0	9	2	1	1111	3	1				3	1				3	1				3	1				2					1	500.00	3		1	1111	1	1111	0	0	0	0	0	0	0	0	0	0	2		2		2												2	2	001
H5970	027	0	1	04	01	H5970_027_0	9	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H6502	003	0	1	04	01	H6502_003_0	4	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				2		2												2		2		1	1111	0.00	0.00									2	2	001
H6502	004	0	1	04	01	H6502_004_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				2		2												2		2		1	1111	0.00	0.00									2	2	001
H6526	001	0	1	02	01	H6526_001_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H6526	002	0	1	02	01	H6526_002_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H6622	001	0	1	01	01	H6622_001_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H6622	007	0	1	01	01	H6622_007_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H6622	010	0	1	02	01	H6622_010_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H6622	013	0	1	02	01	H6622_013_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H6622	014	0	1	02	01	H6622_014_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H6622	017	0	1	01	01	H6622_017_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H6622	019	0	1	01	01	H6622_019_0	6	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H6622	021	1	1	02	01	H6622_021_1	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H6622	021	2	1	02	01	H6622_021_2	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H6622	022	0	1	02	01	H6622_022_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H6622	028	0	1	01	01	H6622_028_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H6622	029	0	1	01	01	H6622_029_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H6622	030	0	1	01	01	H6622_030_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H6622	032	0	1	01	01	H6622_032_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H6622	033	0	1	01	01	H6622_033_0	6	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H6622	052	0	1	01	01	H6622_052_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H6622	055	0	1	01	01	H6622_055_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	002
H6622	063	0	1	01	01	H6622_063_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H6622	066	0	1	01	01	H6622_066_0	5	2	1	1111	3	1				3	1				3	1				3	1				1		500.00	3		2				1	1111	1	1111	0	0	0	0	0	0	0	0	0	0	2		2		2												2	2	001
H6622	075	0	1	01	01	H6622_075_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H6622	082	0	1	01	01	H6622_082_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H6706	001	0	1	02	01	H6706_001_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H6874	001	0	1	04	01	H6874_001_0	13	2	1	1110	3	2	1	3		3	2	1	3							3	2	1	3		2					2				2		2												2		2		2												2	2	001
H6874	003	0	1	04	01	H6874_003_0	6	2	1	1110	3	2	1	3		3	2	1	3							3	2	1	3		2					2				2		2												2		2		2												2	2	001
H7093	001	0	1	04	01	H7093_001_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H7093	001	0	1	04	01	H7093_001_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H7093	001	0	1	04	01	H7093_001_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H7093	002	0	1	04	01	H7093_002_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H7093	002	0	1	04	01	H7093_002_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H7093	002	0	1	04	01	H7093_002_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H7404	005	0	1	04	01	H7404_005_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H7404	011	0	1	04	01	H7404_011_0	4	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H7404	012	0	1	04	01	H7404_012_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H7404	020	0	1	04	01	H7404_020_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H7404	024	0	1	04	01	H7404_024_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H7621	002	0	1	01	01	H7621_002_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H7621	003	0	1	01	01	H7621_003_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	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
H8145	032	0	1	09	04	H8145_032_0	4	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2														001
H8145	042	0	1	09	04	H8145_042_0	8	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2														001
H8145	052	0	1	09	04	H8145_052_0	4	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2														003
H8145	055	0	1	09	04	H8145_055_0	4	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2														002
H8145	069	0	1	09	04	H8145_069_0	5	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2														001
H8145	091	0	1	09	04	H8145_091_0	4	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	6	Per Year	2				1	1111	1	1111	0	0	0	0	0	0	0	0	0	0	2		2		2														001
H8145	123	0	1	09	04	H8145_123_0	4	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2														003
H8145	126	0	1	09	04	H8145_126_0	4	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2														001
H8145	163	0	1	09	04	H8145_163_0	3	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	1	1111	0	0	0	0	0	0	0	0	0	0	2		2		2														003
H8211	006	0	1	04	01	H8211_006_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8432	009	0	1	01	01	H8432_009_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8432	009	0	1	01	01	H8432_009_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8432	009	0	1	01	01	H8432_009_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8432	010	0	1	01	01	H8432_010_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8432	010	0	1	01	01	H8432_010_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8432	010	0	1	01	01	H8432_010_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8432	011	0	1	01	01	H8432_011_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8432	011	0	1	01	01	H8432_011_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8432	011	0	1	01	01	H8432_011_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8432	036	0	1	01	01	H8432_036_0	3	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8432	036	0	1	01	01	H8432_036_0	3	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8432	036	0	1	01	01	H8432_036_0	3	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8432	037	1	1	01	01	H8432_037_1	4	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8432	037	1	1	01	01	H8432_037_1	4	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8432	037	1	1	01	01	H8432_037_1	4	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8432	037	2	1	01	01	H8432_037_2	4	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8432	037	2	1	01	01	H8432_037_2	4	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8432	037	2	1	01	01	H8432_037_2	4	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8432	038	1	1	01	01	H8432_038_1	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8432	038	1	1	01	01	H8432_038_1	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8432	038	1	1	01	01	H8432_038_1	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8432	038	2	1	01	01	H8432_038_2	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8432	038	2	1	01	01	H8432_038_2	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8432	038	2	1	01	01	H8432_038_2	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8432	040	0	1	01	01	H8432_040_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8432	040	0	1	01	01	H8432_040_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8432	040	0	1	01	01	H8432_040_0	5	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8552	020	0	1	04	01	H8552_020_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8552	020	0	1	04	01	H8552_020_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8552	020	0	1	04	01	H8552_020_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8552	029	0	1	04	01	H8552_029_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8552	029	0	1	04	01	H8552_029_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8552	029	0	1	04	01	H8552_029_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8634	010	0	1	04	01	H8634_010_0	6		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	001
H8634	014	0	1	04	01	H8634_014_0	7		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	001
H8634	015	0	1	04	01	H8634_015_0	6		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	001
H8634	017	0	1	04	01	H8634_017_0	7		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	001
H8764	002	0	1	02	01	H8764_002_0	7		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		2					2				2		2												2		2		2												2	2	001
H8764	002	0	1	02	01	H8764_002_0	7		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		2					2				2		2												2		2		2												2	2	002
H8764	003	0	1	01	01	H8764_003_0	7		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		2					2				2		2												2		2		2												2	2	001
H8764	003	0	1	01	01	H8764_003_0	7		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		2					2				2		2												2		2		2												2	2	002
H8764	004	0	1	01	01	H8764_004_0	7		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		2					2				2		2												2		2		2												2	2	001
H8764	004	0	1	01	01	H8764_004_0	7		1	1110	3	2	2	3		3	2	2	3							3	2	1	3		2					2				2		2												2		2		2												2	2	002
H8768	014	0	1	04	01	H8768_014_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8768	016	0	1	04	01	H8768_016_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8768	017	1	1	04	01	H8768_017_1	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8768	017	2	1	04	01	H8768_017_2	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8768	022	0	1	04	01	H8768_022_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8768	032	0	1	04	01	H8768_032_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8768	037	1	1	04	01	H8768_037_1	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8768	037	2	1	04	01	H8768_037_2	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8768	038	1	1	04	01	H8768_038_1	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8768	040	0	1	04	01	H8768_040_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8768	043	0	1	04	01	H8768_043_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8768	049	0	1	04	01	H8768_049_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8768	051	0	1	04	01	H8768_051_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8783	001	0	1	04	01	H8783_001_0	10	2	1	1110	3	2	1	3		3	2	1	3							3	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	001
H8783	002	0	1	04	01	H8783_002_0	9	2	1	1110	3	2	1	3		3	2	1	3							3	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	001
H8849	001	0	1	01	01	H8849_001_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8849	001	0	1	01	01	H8849_001_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8849	001	0	1	01	01	H8849_001_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8849	003	0	1	01	01	H8849_003_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8849	003	0	1	01	01	H8849_003_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8849	003	0	1	01	01	H8849_003_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8849	005	0	1	01	01	H8849_005_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8849	005	0	1	01	01	H8849_005_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8849	005	0	1	01	01	H8849_005_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8849	006	0	1	01	01	H8849_006_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8849	006	0	1	01	01	H8849_006_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8849	006	0	1	01	01	H8849_006_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8849	009	0	1	01	01	H8849_009_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8849	009	0	1	01	01	H8849_009_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8849	009	0	1	01	01	H8849_009_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8849	013	0	1	01	01	H8849_013_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H8849	013	0	1	01	01	H8849_013_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H8849	013	0	1	01	01	H8849_013_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H8902	001	0	1	01	01	H8902_001_0	7	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H8902	002	0	1	01	01	H8902_002_0	6	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H8902	003	0	1	01	01	H8902_003_0	6	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H8902	005	0	1	01	01	H8902_005_0	7	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H8902	006	0	1	01	01	H8902_006_0	6	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H8902	007	0	1	01	01	H8902_007_0	7	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H8908	001	0	1	02	01	H8908_001_0	7	2	1	1111	3	1				3	1				3	1				3	1				1		500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
H8908	002	0	1	01	01	H8908_002_0	7	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
H9003	001	0	1	02	01	H9003_001_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	1				3	1				1		1250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H9003	006	0	1	02	01	H9003_006_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	1				3	1				1		1250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H9003	008	0	1	02	01	H9003_008_0	11		1	1111	3	2	2	3		3	2	2	3		3	1				3	1				1		1250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H9003	009	0	1	02	01	H9003_009_0	10	2	1	1111	3	2	2	3		3	2	2	3		3	1				3	1				1		1250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H9047	013	0	2	01	01	H9047_013_0	6	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	001
H9047	013	0	2	01	01	H9047_013_0	6	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	002
H9047	033	0	1	01	01	H9047_033_0	4	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	001
H9047	033	0	1	01	01	H9047_033_0	4	2	1	1000																3	2	12	6	PHP	2					2				1	1000	2										0	20	2		2		2												2	2	002
H9047	035	0	1	02	01	H9047_035_0	6	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	001
H9047	035	0	1	02	01	H9047_035_0	6	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	002
H9047	037	0	1	01	01	H9047_037_0	8	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	001
H9047	037	0	1	01	01	H9047_037_0	8	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	002
H9047	054	0	1	01	01	H9047_054_0	8	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	001
H9047	054	0	1	01	01	H9047_054_0	8	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	002
H9047	059	0	1	02	01	H9047_059_0	10	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	001
H9047	059	0	1	02	01	H9047_059_0	10	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	002
H9047	062	0	1	02	01	H9047_062_0	11	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	001
H9047	062	0	1	02	01	H9047_062_0	11	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	002
H9047	063	0	1	01	01	H9047_063_0	11	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	001
H9047	063	0	1	01	01	H9047_063_0	11	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	002
H9047	064	0	1	01	01	H9047_064_0	8	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	001
H9047	064	0	1	01	01	H9047_064_0	8	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	002
H9047	065	0	1	02	01	H9047_065_0	10	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	001
H9047	065	0	1	02	01	H9047_065_0	10	2	1	1000																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).	2					2				1	1000	2										0	20	2		2		2												2	2	002
H9104	006	0	1	01	01	H9104_006_0	7		1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	001
H9104	006	0	1	01	01	H9104_006_0	7	2	1	1110	3	2	2	3		3	2	2	3							3	2	2	3		2					2				2		2												2		2		2												2	2	002
H9219	001	0	1	04	01	H9219_001_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H9219	001	0	1	04	01	H9219_001_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H9219	001	0	1	04	01	H9219_001_0	9	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H9219	002	0	1	04	01	H9219_002_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H9219	002	0	1	04	01	H9219_002_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H9219	002	0	1	04	01	H9219_002_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H9525	004	0	1	01	01	H9525_004_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H9525	004	0	1	01	01	H9525_004_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H9525	004	0	1	01	01	H9525_004_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H9525	006	0	1	01	01	H9525_006_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H9525	006	0	1	01	01	H9525_006_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H9525	006	0	1	01	01	H9525_006_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H9525	011	0	1	01	01	H9525_011_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H9525	011	0	1	01	01	H9525_011_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H9525	011	0	1	01	01	H9525_011_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H9525	013	1	1	01	01	H9525_013_1	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H9525	013	1	1	01	01	H9525_013_1	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H9525	013	1	1	01	01	H9525_013_1	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H9525	013	2	1	01	01	H9525_013_2	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H9525	013	2	1	01	01	H9525_013_2	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H9525	013	2	1	01	01	H9525_013_2	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H9525	013	3	1	01	01	H9525_013_3	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H9525	013	3	1	01	01	H9525_013_3	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H9525	013	3	1	01	01	H9525_013_3	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H9525	013	4	1	01	01	H9525_013_4	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H9525	013	4	1	01	01	H9525_013_4	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H9525	013	4	1	01	01	H9525_013_4	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H9525	015	0	1	01	01	H9525_015_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H9525	015	0	1	01	01	H9525_015_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H9525	015	0	1	01	01	H9525_015_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H9525	017	0	1	01	01	H9525_017_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
H9525	017	0	1	01	01	H9525_017_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
H9525	017	0	1	01	01	H9525_017_0	6	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	1		2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
H9834	001	0	1	01	01	H9834_001_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H9834	003	0	1	01	01	H9834_003_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H9834	004	0	1	01	01	H9834_004_0	3	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H9834	005	0	1	01	01	H9834_005_0	3	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
H9834	006	0	1	01	01	H9834_006_0	4	2	1	1111	3	1				3	1				3	1				3	1				1		1000.00	3		2				2		2												2		2		2												2	2	001
R0865	001	0	1	31	11	R0865_001_0	8	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
R0865	003	0	1	31	11	R0865_003_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
R0923	002	0	1	31	11	R0923_002_0	18	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
R1390	001	0	1	31	11	R1390_001_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
R1390	002	0	1	31	11	R1390_002_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
R2604	001	0	1	31	11	R2604_001_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
R2604	003	0	1	31	11	R2604_003_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
R3392	001	0	1	31	11	R3392_001_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	001
R3392	002	0	1	31	11	R3392_002_0	9	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
R3444	009	0	1	31	11	R3444_009_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
R3444	012	0	1	31	11	R3444_012_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
R3887	001	0	1	31	11	R3887_001_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
R3887	002	0	1	31	11	R3887_002_0	6	2	1	1111	3	1				3	1				3	1				3	1				2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
R4487	001	0	1	31	11	R4487_001_0	12	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
R4487	001	0	1	31	11	R4487_001_0	12	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
R4487	001	0	1	31	11	R4487_001_0	12	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
R4845	001	0	1	31	11	R4845_001_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	002
R4845	002	0	1	31	11	R4845_002_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
R5329	001	0	1	31	11	R5329_001_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
R5342	001	0	1	31	11	R5342_001_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
R5342	002	0	1	31	11	R5342_002_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
R5342	005	0	1	31	11	R5342_005_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
R5342	006	0	1	31	11	R5342_006_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
R5361	001	0	1	31	11	R5361_001_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
R5361	002	0	1	31	11	R5361_002_0	5	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
R5495	001	0	1	31	11	R5495_001_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
R5495	002	0	1	31	11	R5495_002_0	7	2	1	1111	3	1				3	1				3	1				3	1				1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	001
R5941	013	0	1	31	11	R5941_013_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
R5941	013	0	1	31	11	R5941_013_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
R5941	013	0	1	31	11	R5941_013_0	7	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and -1 bitewing series per calendar year and -Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
R5941	014	0	1	31	11	R5941_014_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
R5941	014	0	1	31	11	R5941_014_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	1000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	002
R5941	014	0	1	31	11	R5941_014_0	8	2	1	1111	3	2	2	3		3	2	2	3		3	2	2	3		3	2	1	6	-1 full-mouth x-ray or panoramic x-ray per year and-1 bitewing series per calendar year and-Up to 7 Periapical images per calendar year.	1	2	2000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	003
R6801	009	0	1	31	11	R6801_009_0	5	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
R6801	012	0	1	31	11	R6801_012_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
R7220	001	0	1	31	11	R7220_001_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	002
R7220	002	0	1	31	11	R7220_002_0	4	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
R7315	001	0	1	31	11	R7315_001_0	8	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	1	1111	0	0	0	0	0	0	0	0	0	0	2		2		2												2	2	001
R7315	002	0	1	31	11	R7315_002_0	6	2	1	1111	3	1				3	1				3	1				3	1				1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	003
R7444	001	0	1	31	11	R7444_001_0	6	2	1	1111	3	2	2	3		3	2	3	3		3	2	2	3		3	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	001
