pbp_a_hnumber	pbp_a_plan_identifier	segment_id	pbp_a_ben_cov	pbp_a_plan_type	orgtype	bid_id	version	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_b16b_bendesc_yn	pbp_b16b_bendesc_ehc	pbp_b16b_bendesc_amo_es	pbp_b16b_bendesc_lim_es	pbp_b16b_bendesc_numv_es	pbp_b16b_bendesc_per_es	pbp_b16b_bendesc_per_es_d	pbp_b16b_bendesc_amo_ds	pbp_b16b_bendesc_lim_ds	pbp_b16b_bendesc_numv_ds	pbp_b16b_bendesc_per_ds	pbp_b16b_bendesc_per_ds_d	pbp_b16b_bendesc_amo_rs	pbp_b16b_bendesc_lim_rs	pbp_b16b_bendesc_numv_rs	pbp_b16b_bendesc_per_rs	pbp_b16b_bendesc_per_rs_d	pbp_b16b_bendesc_amo_end	pbp_b16b_bendesc_lim_end	pbp_b16b_bendesc_num_end	pbp_b16b_bendesc_per_end	pbp_b16b_bendesc_per_end_d	pbp_b16b_bendesc_amo_peri	pbp_b16b_bendesc_lim_peri	pbp_b16b_bendesc_num_peri	pbp_b16b_bendesc_per_peri	pbp_b16b_bendesc_per_peri_d	pbp_b16b_bendesc_amo_ext	pbp_b16b_bendesc_lim_ext	pbp_b16b_bendesc_num_ext	pbp_b16b_bendesc_per_ext	pbp_b16b_bendesc_per_ext_d	pbp_b16b_bendesc_amo_poo	pbp_b16b_bendesc_lim_poo	pbp_b16b_bendesc_numv_poo	pbp_b16b_bendesc_per_poo	pbp_b16b_bendesc_per_poo_d	pbp_b16b_maxplan_yn	pbp_b16b_maxplan_in_oon	pbp_b16b_maxbene_type	pbp_b16b_maxplan_amt	pbp_b16b_maxplan_per	pbp_b16b_maxplan_per_desc	pbp_b16b_maxenr_yn	pbp_b16b_maxenr_type	pbp_b16b_maxenr_amt	pbp_b16b_maxenr_per	pbp_b16b_maxenr_per_desc	pbp_b16b_coins_yn	pbp_b16b_coins_ehc	pbp_b16b_coins_pct_mc_min	pbp_b16b_coins_pct_mc_max	pbp_b16b_coins_pct_es_min	pbp_b16b_coins_pct_es_max	pbp_b16b_coins_pct_ds_min	pbp_b16b_coins_pct_ds_max	pbp_b16b_coins_pct_rs_min	pbp_b16b_coins_pct_rs_max	pbp_b16b_coins_pct_end_min	pbp_b16b_coins_pct_end_max	pbp_b16b_coins_pct_peri_min	pbp_b16b_coins_pct_peri_max	pbp_b16b_coins_pct_ext_min	pbp_b16b_coins_pct_ext_max	pbp_b16b_coins_pct_poo_min	pbp_b16b_coins_pct_poo_max	pbp_b16b_ded_yn	pbp_b16b_ded_amt	pbp_b16b_copay_yn	pbp_b16b_copay_ehc	pbp_b16b_copay_amt_mc_min	pbp_b16b_copay_amt_mc_max	pbp_b16b_copay_amt_es_min	pbp_b16b_copay_amt_es_max	pbp_b16b_copay_amt_ds_min	pbp_b16b_copay_amt_ds_max	pbp_b16b_copay_amt_rs_min	pbp_b16b_copay_amt_rs_max	pbp_b16b_copay_amt_end_min	pbp_b16b_copay_amt_end_max	pbp_b16b_copay_amt_peri_min	pbp_b16b_copay_amt_peri_max	pbp_b16b_copay_amt_ext_min	pbp_b16b_copay_amt_ext_max	pbp_b16b_copay_amt_poo_min	pbp_b16b_copay_amt_poo_max	pbp_b16b_auth_yn	pbp_b16b_refer_yn
H0016	001	0	1	20	08	H0016_001_0	1	2																																																																																																																																																						
H0016	003	0	1	20	08	H0016_003_0	1	2																																																																																																																																																						
H0022	001	0	1	48	05	H0022_001_0	13	1	1111	2	2	1	6	Oral examinations are covered annually for individuals 21 and over and twice annually for those 20 and under.	2	2	1	3		2	2	1	4		2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		2																		2	2
H0028	007	0	1	01	01	H0028_007_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	014	0	1	01	01	H0028_014_0	8	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H0028	015	0	1	02	01	H0028_015_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays inc bitewing x-rays, intraoral x-rays up to 1 set(s)  a year, panoramic film or diagnostic x-rays up to 1 every 5 years. The combined max benefit coverage applies to both IN and OON svc.	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	Denture adj, rebase,reline,repair,tissue cond. 1/year, bridges-crown 2/5 years, bridges-pontic, complete/part dentures 1/5 years, occlusal. adj. 1/3 years, oral surg	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	016	0	1	02	01	H0028_016_0	8	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	017	0	1	01	01	H0028_017_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	35.00	35.00			0.00	0.00	25.00	25.00									1	2
H0028	019	0	1	01	01	H0028_019_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	021	0	1	01	01	H0028_021_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	30.00	30.00			0.00	0.00											1	2
H0028	023	0	1	01	01	H0028_023_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	3		2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H0028	024	0	1	01	01	H0028_024_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	025	1	1	01	01	H0028_025_1	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	025	2	1	01	01	H0028_025_2	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	027	0	1	01	01	H0028_027_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	5		3					3					3					3					3					2						2					2																		2		1	01010000	35.00	35.00			0.00	0.00											1	2
H0028	028	0	1	01	01	H0028_028_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H0028	029	0	1	01	01	H0028_029_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years. Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0028	030	0	1	01	01	H0028_030_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling unlimited per year, bridge and crown recementation 1 every 5 years, crown/other restorative services, core buildup and prefab post and core 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj, rebase,reline,repair,tissue cond. 1/year, bridges-crown 2/5 years, bridges-pontic, complete/part dentures 1/5 years, occlusal. adj. 1/3 years, oral surgery 2/year, implant 1/tooth/life	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0028	031	0	1	01	01	H0028_031_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam/composite filling unlimited per year, bridge+crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1/tooth/lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0028	032	0	1	01	01	H0028_032_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	033	0	1	01	01	H0028_033_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	034	0	1	01	01	H0028_034_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Srvc incl amalgam/composite filling unlimited per year, crown and other restorative services - core buildup and prefab post and core 1 per tooth per lifetime, crown recementation 1 every 5 years	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	5	1		2	1				2	2	10	6	Srvc inc adj to dentures, denture rebase/reline/repair, tissue conditioning up to 1/ yr, complete/partial dentures up to 1/ 5 yrs, occlusal adj up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0028	035	0	1	01	01	H0028_035_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures and complete dentures up to 1 every 5 years,etc	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0028	036	0	1	01	01	H0028_036_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures and complete dentures up to 1 every 5 years, oral surgery up to 2 per year, denture adjustment, etc	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0028	037	0	1	01	01	H0028_037_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Srvc incl amalgam and/or composite filling unlimited/yr, crown and other restorative services - core buildup and prefab post and core up to 1/ tooth per lifetime, crown recementation 1 every 5 years	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	1	1		2	1				2	2	10	6	Srvc incl adj to dentures, denture rebase/reline/repair, tissue conditioning up to 1/ yr, complete/prtl dentures up to 1/ 5 yrs, occlusal adj up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0028	039	0	1	01	01	H0028_039_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures and complete dentures up to 1 every 5 years, oral surgery up to 2 per year, denture adjustment, etc	1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0028	041	0	1	01	01	H0028_041_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	042	0	1	01	01	H0028_042_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	043	1	1	01	01	H0028_043_1	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	amalgam/composite filling unlimited per year, crown and other restorative services - core buildup and prefab post and core 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics include scaling and root planning (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	043	2	1	01	01	H0028_043_2	8	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	amalgam/composite filling unlimited per year, crown and other restorative services - core buildup and prefab post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	4	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	044	0	1	01	01	H0028_044_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0028	045	0	1	01	01	H0028_045_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjust/rebase/reline/repair,tissue cond 1/yr,bridges-crown 2/5 yrs,bridges-pontic, complete+prtl dentures 1/5 yrs, occlusal adj 1/3 yrs, oral surgery 2/yr, restoration implant 1/tooth/lifetime	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0028	046	0	1	01	01	H0028_046_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0028	047	0	1	01	01	H0028_047_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Fillings $25 unlimited per year, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime, crown recementation $25 1 every 5 years.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Denture adjustments, rebase, reline, repair, tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	45.00	45.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H0028	048	1	1	01	01	H0028_048_1	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling unlimited per year, bridge recementation & crown recementation 1 every 5 years, crown & core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	14	6	Dent. Adj.,rebase,reline,repair,and tissue conditioning 1/yr.Bridges-crown 2/5 yrs.Bridges-pontic, comp/part dent. 1/5 yrs.Occlusal adj. 1/3 yrs.Oral surgery 2/yr.Restoration implant 1/tooth/lifetime.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	25.00	25.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1
H0028	048	2	1	01	01	H0028_048_2	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					1	00010000					0	0											2		1	01001010	40.00	40.00					25.00	25.00			25.00	25.00					1	1
H0028	050	0	1	01	01	H0028_050_0	10	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	051	0	1	01	01	H0028_051_0	8	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Partial and complete dentures up to 1 set(s) every 5 years. Denture adjustment, reline, repair, rebase, and tissue conditioning up to 1 per year. Occlusal adjustments up to 1 every 3 years. Oral surge	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	052	0	1	01	01	H0028_052_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	053	1	1	01	01	H0028_053_1	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	amalgam and/or composite filling up to unlimited/yr, crown and other restorative services - core buildup and prefab post and core 1/ tooth/ lifetime, crown recementation up to 1/ 5 yrs	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	053	3	1	01	01	H0028_053_3	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	053	4	1	01	01	H0028_053_4	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H0028	054	1	1	02	01	H0028_054_1	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	054	2	1	02	01	H0028_054_2	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling unlimited per year, bridge/crown recementation 1 every 5 years, crown/other restorative services - core buildup/prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj, rebase, reline, repair, tissue conditioning, 1/yr, bridges-crown, 2/5 yrs, bridges-pontic, complete, partial dentures up to 1/5 yrs, occlusal adjustment, 1/3 yrs, oral surgery, 2/yr	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	055	0	1	02	01	H0028_055_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	056	0	1	02	01	H0028_056_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	057	0	1	01	01	H0028_057_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	058	0	1	01	01	H0028_058_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Complete and partial dentures 1 every 5 years, oral surgery 2 per year, denture adjustment, reline, repair, rebase, and tissue conditioning 1 per year, occlusal adjustments 1 every 3 years	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	059	0	1	01	01	H0028_059_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	060	0	1	01	01	H0028_060_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures and complete dentures up to 1 every 5 years, oral surgery up to 2 per year, denture adjustment, denture reline	1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0028	062	0	1	01	01	H0028_062_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	20.00	20.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
H0028	063	0	1	01	01	H0028_063_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0028	064	0	1	01	01	H0028_064_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0028	801	0	1	01	01	H0028_801_0	10	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0028	802	0	1	01	01	H0028_802_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0028	804	0	1	01	01	H0028_804_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0028	805	0	1	01	01	H0028_805_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0029	801	0	1	01	01	H0029_801_0	12	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0034	001	0	1	01	01	H0034_001_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0034	002	0	1	01	01	H0034_002_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0062	801	0	1	01	01	H0062_801_0	12	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0074	001	0	1	04	01	H0074_001_0	21	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1500.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0074	004	0	1	04	01	H0074_004_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0088	002	0	1	04	01	H0088_002_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H0088	003	0	1	04	01	H0088_003_0	21	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1	2	2	1500.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0104	012	0	1	04	01	H0104_012_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H0104	014	0	1	04	01	H0104_014_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H0104	015	0	1	04	01	H0104_015_0	3	1	1111	2	1				2	1				2	1				2	1				1	2	1300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															2	2
H0104	801	0	1	04	01	H0104_801_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0104	802	0	1	04	01	H0104_802_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0104	804	0	1	04	01	H0104_804_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0104	805	0	1	04	01	H0104_805_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0104	806	0	1	04	01	H0104_806_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0104	807	0	1	04	01	H0104_807_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0104	808	0	1	04	01	H0104_808_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0104	809	0	1	04	01	H0104_809_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0105	001	0	1	20	08	H0105_001_0	1																																																																																																																																																							
H0105	002	0	1	20	08	H0105_002_0	1																																																																																																																																																							
H0107	003	0	1	04	01	H0107_003_0	7	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	45.00	45.00															2	2
H0107	004	0	1	04	01	H0107_004_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	45.00	45.00															2	2
H0107	005	0	1	04	01	H0107_005_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	45.00	45.00															2	2
H0107	006	0	1	04	01	H0107_006_0	6	2		3					3										3																																														2		3										3					3					3					3					3											2					1	01000000	0	0															2		2																		2	2
H0107	007	0	1	04	01	H0107_007_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1	2	2	5000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H0107	010	0	1	04	01	H0107_010_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1	2	2	1000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H0107	011	0	1	04	01	H0107_011_0	5	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H0107	801	0	1	04	01	H0107_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	802	0	1	04	01	H0107_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	803	0	1	04	01	H0107_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	804	0	1	04	01	H0107_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	805	0	1	04	01	H0107_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	806	0	1	04	01	H0107_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	807	0	1	04	01	H0107_807_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	808	0	1	04	01	H0107_808_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	809	0	1	04	01	H0107_809_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	810	0	1	04	01	H0107_810_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	811	0	1	04	01	H0107_811_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	812	0	1	04	01	H0107_812_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	813	0	1	04	01	H0107_813_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	814	0	1	04	01	H0107_814_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	815	0	1	04	01	H0107_815_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	816	0	1	04	01	H0107_816_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	817	0	1	04	01	H0107_817_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	818	0	1	04	01	H0107_818_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	819	0	1	04	01	H0107_819_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0107	820	0	1	04	01	H0107_820_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0111	001	0	1	04	01	H0111_001_0	20	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1500.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0111	004	0	1	04	01	H0111_004_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0112	001	0	1	20	08	H0112_001_0	1																																																																																																																																																							
H0112	002	0	1	20	08	H0112_002_0	1																																																																																																																																																							
H0137	001	0	1	48	05	H0137_001_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	6	Supplemental coverage includes coverage of all dental services described in 130 CMR 420.421 (A) and (C) for all enrollees.	2					2				2		2												2		2		2												1	2	1	1111111	2	2	1	6	Supplemental coverage includes coverage of all dental services described in 130 CMR 420.421 (A) and (C) for all enrollees.	2	1				2	2	1	6	Supplemental coverage includes coverage of all dental services described in 130 CMR 420.421 (A) and (C) for all enrollees.	2	2	1	6	Supplemental coverage includes coverage of all dental services described in 130 CMR 420.421 (A) and (C) for all enrollees.	2	2	1	6	Supplemental coverage includes coverage of all dental services described in 130 CMR 420.421 (A) and (C) for all enrollees.	2	2	1	6	Supplemental coverage includes coverage of all dental services described in 130 CMR 420.421 (A) and (C) for all enrollees.	2	2	1	6	Supplemental coverage includes coverage of all dental services described in 130 CMR 420.421 (A) and (C) for all enrollees.	2						2					2																		2		2																		1	2
H0154	008	0	1	01	01	H0154_008_0	3	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H0154	011	0	1	01	01	H0154_011_0	4	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H0154	012	0	1	01	01	H0154_012_0	4	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H0154	015	1	1	01	01	H0154_015_1	4	1	1111	2	1				2	1				2	1				2	1				1		1175.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H0154	015	2	1	01	01	H0154_015_2	4	1	1111	2	1				2	1				2	1				2	1				1		1175.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H0154	016	0	1	01	01	H0154_016_0	4	1	1111	2	1				2	1				2	1				2	1				1		1200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H0154	017	0	1	01	01	H0154_017_0	4	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H0154	019	0	1	01	01	H0154_019_0	4	1	1111	2	1				2	1				2	1				2	1				1		2350.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H0154	020	0	1	01	01	H0154_020_0	4	1	1111	2	1				2	1				2	1				2	1				1		2200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H0154	801	0	1	01	01	H0154_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0154	802	0	1	01	01	H0154_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0154	803	0	1	01	01	H0154_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0169	001	0	1	02	01	H0169_001_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0169	002	0	1	02	01	H0169_002_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0169	003	0	1	02	01	H0169_003_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0169	004	0	1	02	01	H0169_004_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0169	006	0	1	02	01	H0169_006_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0169	008	0	1	02	01	H0169_008_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0174	002	0	1	01	01	H0174_002_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	40.00	40.00															1	2
H0174	004	0	1	01	01	H0174_004_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	5000.00	3		2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0174	006	0	1	01	01	H0174_006_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 months.Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0174	009	0	1	01	01	H0174_009_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0174	010	0	1	01	01	H0174_010_0	20	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0174	014	0	1	01	01	H0174_014_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0174	015	0	1	01	01	H0174_015_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	30.00	30.00															1	2
H0174	016	0	1	01	01	H0174_016_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0174	017	0	1	01	01	H0174_017_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H0174	018	0	1	01	01	H0174_018_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H0174	019	0	1	01	01	H0174_019_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H0174	020	0	1	01	01	H0174_020_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H0174	021	0	1	01	01	H0174_021_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H0174	022	0	1	01	01	H0174_022_0	20	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0192	001	0	1	48	05	H0192_001_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	6	6	Per lifetime.	2	2	1	6	Every 12months: Bitewing Radiographs Every 3yrs per arch (under age 21): Occlusal Radiograph Every 5yrs (over age 5): Panoramic Radiograph, Full mouth/Complete series everyday, with medical necessity	2					2				2		2												2		2		2												2	2	1	1011011						2	1				2	1									2	2	1	3		2	2	999	6	Everyday, based on medical necessity	2	2	1	6	Prosthodontics(removable)-Once per 5yrs per arch when prognosis of complete/partial denture is at least 5yrs: Complete/partial dentures. Every day per medical need: Other Oral/Maxillofacial Surgery.	2						2					2																		2		2																		2	2
H0216	001	0	1	20	08	H0216_001_0	1																																																																																																																																																							
H0216	002	0	1	20	08	H0216_002_0	1																																																																																																																																																							
H0235	001	0	1	20	08	H0235_001_0	2																																																																																																																																																							
H0235	002	0	1	20	08	H0235_002_0	2																																																																																																																																																							
H0247	001	0	1	20	08	H0247_001_0	1																																																																																																																																																							
H0247	002	0	1	20	08	H0247_002_0	1																																																																																																																																																							
H0251	002	0	1	02	01	H0251_002_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0251	004	0	1	02	01	H0251_004_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0270	001	0	1	04	01	H0270_001_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0270	002	0	1	04	01	H0270_002_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	005	0	1	04	01	H0271_005_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	006	0	1	04	01	H0271_006_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	007	0	1	04	01	H0271_007_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	012	0	1	04	01	H0271_012_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	013	0	1	04	01	H0271_013_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	014	0	1	04	01	H0271_014_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	016	0	1	04	01	H0271_016_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	017	0	1	04	01	H0271_017_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	020	0	1	04	01	H0271_020_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	023	0	1	04	01	H0271_023_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	024	0	1	04	01	H0271_024_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0271	025	0	1	04	01	H0271_025_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	026	0	1	04	01	H0271_026_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	027	0	1	04	01	H0271_027_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	028	0	1	04	01	H0271_028_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	029	0	1	04	01	H0271_029_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	030	0	1	04	01	H0271_030_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	033	0	1	04	01	H0271_033_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	034	0	1	04	01	H0271_034_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	035	0	1	04	01	H0271_035_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	036	0	1	04	01	H0271_036_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	037	0	1	04	01	H0271_037_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	038	0	1	04	01	H0271_038_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	039	0	1	04	01	H0271_039_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0271	042	0	1	04	01	H0271_042_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	043	0	1	04	01	H0271_043_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	044	0	1	04	01	H0271_044_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	045	0	1	04	01	H0271_045_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0271	046	0	1	04	01	H0271_046_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	050	0	1	04	01	H0271_050_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	052	0	1	04	01	H0271_052_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0271	053	0	1	04	01	H0271_053_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	054	0	1	04	01	H0271_054_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	055	0	1	04	01	H0271_055_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	056	0	1	04	01	H0271_056_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0271	057	0	1	04	01	H0271_057_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0271	058	0	1	04	01	H0271_058_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0271	059	0	1	04	01	H0271_059_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	060	1	1	04	01	H0271_060_1	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	060	2	1	04	01	H0271_060_2	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	063	0	1	04	01	H0271_063_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0271	065	0	1	04	01	H0271_065_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2																																											2					1	01000000	20	20															2		2																		1	2
H0292	001	0	1	01	01	H0292_001_0	8	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Amalgam and/or composite filling unlimited per yr, bridge/crown recementation 1 every 5 yrs, crown/other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0292	002	0	1	01	01	H0292_002_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Amalgam and/or composite filling unlimited per yr, bridge/crown recementation 1 every 5 yrs, crown/other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	11	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0292	003	0	1	01	01	H0292_003_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Amalgam and/or composite filling unlimited per yr, bridge/crown recementation 1 every 5 yrs, crown/other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0294	002	0	1	04	01	H0294_002_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	004	0	1	04	01	H0294_004_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0294	010	0	1	04	01	H0294_010_0	10	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	011	0	1	04	01	H0294_011_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	012	0	1	04	01	H0294_012_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	014	0	1	04	01	H0294_014_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	015	0	1	04	01	H0294_015_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	016	0	1	04	01	H0294_016_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	017	0	1	04	01	H0294_017_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	018	0	1	04	01	H0294_018_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	019	0	1	04	01	H0294_019_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	020	0	1	04	01	H0294_020_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	021	0	1	04	01	H0294_021_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	022	0	1	04	01	H0294_022_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	023	0	1	04	01	H0294_023_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0294	024	0	1	04	01	H0294_024_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	025	0	1	04	01	H0294_025_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	026	0	1	04	01	H0294_026_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	027	0	1	04	01	H0294_027_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0294	028	0	1	04	01	H0294_028_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	029	0	1	04	01	H0294_029_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	030	0	1	04	01	H0294_030_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0294	031	0	1	04	01	H0294_031_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0294	032	0	1	04	01	H0294_032_0	6	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0294	033	0	1	04	01	H0294_033_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0294	034	0	1	04	01	H0294_034_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	035	0	1	04	01	H0294_035_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	036	0	1	04	01	H0294_036_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	037	0	1	04	01	H0294_037_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0294	038	0	1	04	01	H0294_038_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0294	039	0	1	04	01	H0294_039_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0294	040	0	1	04	01	H0294_040_0	7	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0294	041	0	1	04	01	H0294_041_0	7	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0294	042	0	1	04	01	H0294_042_0	7	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0294	043	0	1	04	01	H0294_043_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	044	0	1	04	01	H0294_044_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	046	0	1	04	01	H0294_046_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0294	047	0	1	04	01	H0294_047_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0302	001	0	1	01	01	H0302_001_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	Office visit copay applies, per visitBitewing X-rays Two per calendar yearPeriapical X-rays Four films per calendar yearFull Mouth or Panoramic X-rays One per five-year period	2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	1111111	2	2	1	6	Crowns/Inlays/Onlays/Prosthodontics/Implants - Seven-year replacement limitPeriodontics Non Surgical - One per two year period	2	2	1	6	Two oral exams per year, two bitewing x-rays per year, four periapical x-rays per year, one fluoride treatment per year	2	2	1	6	Office visit copay applies, per visitDental visits are covered services until Max Benefit Limit is met .50% coinsurance for covered services up to Max Plan Benefit.See notes below for detail.	2	2	1	6	Office visit copay applies, per visitDental visits are covered services until Max Benefit Limit is met .50% coinsurance for covered services up to Max Plan Benefit.See notes below for detail.	2	2	1	6	Office visit copay applies, per visitDental visits are covered services until Max Benefit Limit is met .50% coinsurance for covered services up to Max Plan Benefit.See notes below for detail.	2	1				2	2	1	6	Office visit copay applies, per visitDental visits are covered services until MaxBenefit Limit is met .50% coinsurance for covered services up to Max Plan Benefit.See notes below for detail.	1		2	3000.00	3		2					1	11111111	20	20	50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	10111111			10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	2	2
H0302	006	0	1	01	01	H0302_006_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	Office visit copay applies, per visitBitewing X-rays Two per calendar yearPeriapical X-rays Four films per calendar yearFull Mouth or Panoramic X-rays One per five-year period	2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	1111111	2	2	1	6	Crowns/Inlays/Onlays/Prosthodontics - Seven-year replacement limitPeriodontics Non Surgical - One per two year period	2	2	1	6	Two oral exams per year, two bitewing x-rays per year, four periapical x-rays per year, one fluoride treatment per year	2	2	1	6	Office visit copay applies, per visitDental visits are covered services until Maximum Benefit Limit is met .50% coinsurance for covered services up to Maximum Plan Benefit.	2	2	1	6	Office visit copay applies, per visitDental visits are covered services until Max Benefit Limit is met .50% coinsurance for covered services up to Max Plan Benefit.	2	2	1	6	Office visit copay applies, per visitDental visits are covered services until Maximum Benefit Limit is met .50% coinsurance for covered services up to Maximum Plan Benefit.	2	1				2	2	1	6	Office visit copay applies, per visitDental visits are covered services until Maximum Benefit Limit is met .50% coinsurance for covered services up to Maximum Plan Benefit.	1		2	2000.00	3		2					1	11111111	20	20	50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	10111111			10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	2	2
H0302	008	0	1	01	01	H0302_008_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0302	801	0	1	01	01	H0302_801_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0321	002	0	1	02	01	H0321_002_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0321	004	0	1	02	01	H0321_004_0	9	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0332	001	0	1	01	01	H0332_001_0	8	1	1110	2	2	1	6	Periodic oral evaluation 1 every 6 monthsAll other oral evaluations 1 every 12 months	2	2	1	4							2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	2	1	6	End therapy 1 per lifetime. All other endodontics unlimited up to the maximum annual benefit.	2	2	1	6	Non-surgical periodontal Service 1 every 12 months; Periodontal maintenance 1 every 60 months	2	1				2	2	1	6	Removable prosthodontics (complete/partial) - 1 every 60 monthsFixed prosthodontics - 1 every 60 months	1		1				2					2																		2		2																		2	2
H0332	002	0	1	01	01	H0332_002_0	12	1	1110	2	2	1	6	Periodic oral evaluation - 1 visit every 6 monthsLimited, comprehensive and extensive oral evaluations - 1 visit every 12 months	2	2	1	4							2	2	1	3		2					2				2		2												2		2		2												2	2	2		3										3					3					3					3					3											2					2																		2		1	01000000	25.00	25.00															2	2
H0332	004	0	1	02	01	H0332_004_0	11	1	1110	2	2	1	6	Periodic oral evaluation 1 every 6 monthsAll other oral evaluations 1 every 12 months	2	2	1	4							2	2	1	3		1		2500.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	2	1	6	End therapy 1 per lifetime; all other endodontics unlimited up to the maximum annual benefit	2	2	1	6	Non-surgical periodontal service 1 every 12 months; periodontal maintenance 1 every 60 months	2	1				2	2	1	6	Removable prosthodontics (complete/ partial) - 1 every 60 months; Fixed prosthodontics - 1 every 60 months; Repairs and adjustments unlimited up to the maximum annual benefit	1		1				2					2																		2		1	01000000	25.00	25.00															2	2
H0332	009	0	1	01	01	H0332_009_0	9	1	1110	2	2	1	6	Periodic oral evaluation 1 every 6 monthsAll other oral evaluations 1 every 12 months	2	2	1	4							2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	2	1	6	End therapy 1 per lifetime. All other endodontics unlimited up to the maximum annual benefit.	2	2	1	6	Non-surgical periodontal Service 1 every 12 months; Periodontal maintenance 1 every 60 months	2	1				2	2	1	6	Removable prosthodontics (complete/partial) - 1 every 60 monthsFixed prosthodontics - 1 every 60 months	1		1				2					2																		2		1	01000000	20.00	20.00															2	2
H0332	010	0	1	01	01	H0332_010_0	8	1	1110	2	2	1	6	Periodic oral evaluation 1 every 6 monthsAll other oral evaluations 1 every 12 months	2	2	1	4							2	2	1	3		1		2500.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	2	1	6	End therapy 1 per lifetime. All other endodontics unlimited up to the maximum annual benefit.	2	2	1	6	Non-surgical periodontal service 1 every 12 months; Periodontal maintenance 1 every 60 months	2	1				2	2	1	6	Removable prosthodontics (complete/partial) - 1 every 60 monthsFixed prosthodontics - 1 every 60 months	1		1				2					2																		2		2																		2	2
H0332	011	0	1	02	01	H0332_011_0	10	1	1110	2	2	1	6	Periodic oral evaluation 1 every 6 monthsAll other oral evaluations 1 every 12 months	2	2	1	4							2	2	1	3		1		3500.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	2	1	6	End therapy 1 per lifetime; all other endodontics unlimited up to the maximum annual benefit	2	2	1	6	Non-surgical periodontal service 1 every 12 months; periodontal maintenance 1 every 60 months	2	1				2	2	1	6	Removable prosthodontics (complete/ partial) - 1 every 60 months; Fixed prosthodontics - 1 every 60 months; Repairs and adjustments unlimited up to the maximum annual benefit	1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H0332	801	0	1	01	01	H0332_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0332	803	0	1	01	01	H0332_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0332	804	0	1	01	01	H0332_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0332	805	0	1	01	01	H0332_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0332	806	0	1	01	01	H0332_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0332	807	0	1	01	01	H0332_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0332	808	0	1	01	01	H0332_808_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0332	809	0	1	01	01	H0332_809_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0332	810	0	1	01	01	H0332_810_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0332	811	0	1	01	01	H0332_811_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0332	812	0	1	01	01	H0332_812_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0332	813	0	1	01	01	H0332_813_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0332	814	0	1	01	01	H0332_814_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0336	001	0	1	48	05	H0336_001_0	2	1	0110	2	2	1	4		2	2	1	4												2					2				2		2												2		2		2												2	2	1	1011111						2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2						2					2																		2		2																		1	1
H0342	001	0	1	04	01	H0342_001_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															2	2
H0342	801	0	1	04	01	H0342_801_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0342	802	0	1	04	01	H0342_802_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0342	803	0	1	04	01	H0342_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0342	804	0	1	04	01	H0342_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0351	038	0	1	01	01	H0351_038_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	15.00	15.00															1	2
H0351	053	0	1	01	01	H0351_053_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0351	054	0	1	01	01	H0351_054_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1500.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	50.00	50.00															1	2
H0351	057	0	1	01	01	H0351_057_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	35.00	35.00															1	2
H0351	061	0	1	01	01	H0351_061_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0351	062	0	1	01	01	H0351_062_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	10.00	10.00															1	2
H0351	063	0	1	01	01	H0351_063_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0351	064	0	1	01	01	H0351_064_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	40.00	40.00															1	2
H0354	001	0	1	01	01	H0354_001_0	9	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101111	25.00	25.00	0.00	260.00			0.00	620.00	0.00	675.00	0.00	575.00	0.00	195.00	0.00	950.00	1	2
H0354	027	0	1	01	01	H0354_027_0	9	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101111	15.00	15.00	0.00	260.00			0.00	620.00	0.00	675.00	0.00	575.00	0.00	195.00	0.00	950.00	1	2
H0354	028	0	1	01	01	H0354_028_0	9	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	5.00	5.00															1	2
H0354	029	0	1	01	01	H0354_029_0	8	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101111	35.00	35.00	0.00	260.00			0.00	620.00	0.00	675.00	0.00	575.00	0.00	195.00	0.00	950.00	1	2
H0354	804	0	1	01	01	H0354_804_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0354	805	0	1	01	01	H0354_805_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0363	001	0	1	01	01	H0363_001_0	9	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H0390	001	0	1	20	08	H0390_001_0	1																																																																																																																																																							
H0390	002	0	1	20	08	H0390_002_0	1																																																																																																																																																							
H0422	001	0	1	02	01	H0422_001_0	7	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			50	70	50	50	70	70	50	50	0	50	50	50	50	70	1	100.00	2																		2	2
H0422	003	0	1	02	01	H0422_003_0	9	1	1111	2	1				2	1				2	1				2	1				1		850.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H0423	001	0	1	01	01	H0423_001_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		1		1000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Diagnostic services limited to below services in notes.	2	2	1	6	Restorative services limited to major restoratives, selected types shown below only at $0 copayment/1 every 60 months per tooth.	2	2	1	6	Endodontics, limited to root canal therapy - selected services shown below only at $0 copayment/1 per lifetime per tooth	2	2	1	6	Periodontics, limited to osseous surgery – including elevation of a full thickness flap and closure at $0 copayment/ 1 every 60 months per quad:	2	2	1	6	Extractions limited to one per lifetime for services shown below in notes.	2	2	1	6	Prosthodontics limited to crowns-single restoration, selected types shown below only at $0 copayment/1 every 60 months per tooth.	1		2	700.00	3		2					1	01000000	20	20															2		2																		1	2
H0423	004	0	1	01	01	H0423_004_0	6	2																																																															2																																											2					2																		2		2																		1	2
H0423	007	0	1	01	01	H0423_007_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		1		1000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6		2	2	1	6	Restorative services limited to major restoratives, selected types shown below only at $0 copayment/1 every 60 months per tooth	2	2	1	6	Endodontics, limited to root canal therapy - selected services shown below only at $0 copayment/1 per lifetime per tooth	2	2	1	6	Periodontics, limited to osseous surgery – including elevation of a full thickness flap and closure at $0 copayment/ 1 every 60 months per quad:	2	2	1	6	Extractions limited to one per lifetime for services shown below in notes.	2	2	1	6	Prosthodontics limited to crowns-single restoration, selected types shown below only at $0 copayment/1 every 60 months per tooth	1		2	700.00	3		2					1	01000000	20	20															2		2																		1	2
H0424	001	0	1	20	08	H0424_001_0	1	2																																																																																																																																																						
H0424	002	0	1	20	08	H0424_002_0	1	2																																																																																																																																																						
H0432	003	0	1	02	01	H0432_003_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0432	004	0	1	02	01	H0432_004_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0432	009	0	1	02	01	H0432_009_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0432	012	0	1	02	01	H0432_012_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0432	013	0	1	02	01	H0432_013_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0432	017	0	1	02	01	H0432_017_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0439	002	0	1	01	01	H0439_002_0	8	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H0439	003	1	1	01	01	H0439_003_1	7	1	1111	2	1				2	1				2	1				2	1				1		600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H0439	003	2	1	01	01	H0439_003_2	7	1	1111	2	1				2	1				2	1				2	1				1		700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H0439	006	0	1	01	01	H0439_006_0	7	1	1111	2	1				2	1				2	1				2	1				1		1300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H0439	007	0	1	01	01	H0439_007_0	7	1	1111	2	1				2	1				2	1				2	1				1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H0439	008	0	1	01	01	H0439_008_0	7	1	1111	2	1				2	1				2	1				2	1				1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	55.00	55.00															1	2
H0439	009	0	1	01	01	H0439_009_0	7	1	1111	2	1				2	1				2	1				2	1				1		1100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H0439	010	0	1	01	01	H0439_010_0	7	1	1111	2	1				2	1				2	1				2	1				1		1200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H0439	011	0	1	01	01	H0439_011_0	7	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H0439	012	0	1	01	01	H0439_012_0	9	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H0439	013	0	1	01	01	H0439_013_0	7	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H0439	801	0	1	01	01	H0439_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0440	001	0	1	20	08	H0440_001_0	1																																																																																																																																																							
H0440	002	0	1	20	08	H0440_002_0	1																																																																																																																																																							
H0473	001	0	1	04	01	H0473_001_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0473	003	0	1	04	01	H0473_003_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0473	004	0	1	04	01	H0473_004_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	amalgam and/or composite filling unlimited/yr, bridge crown recementation 1 per 5 yrs, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0473	005	0	1	04	01	H0473_005_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	amalgam and/or composite filling unlimited per year, bridge and crown recementation 1 per 5 years, crown/other restorative services - core buildup, prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0473	006	0	1	04	01	H0473_006_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0477	001	0	1	20	08	H0477_001_0	1																																																																																																																																																							
H0477	002	0	1	20	08	H0477_002_0	1																																																																																																																																																							
H0480	001	0	1	48	05	H0480_001_0	15	1	1111	2	2	1	4		2	2	1	4		2	2	6	6	Per lifetime	2	2	1	6	Every 12 months: Bitewing Radiographs Every 3yrs per arch (under age 21): Occlusal Radiograph Every 5yrs (over age 5): Panoramic Radiograph, Full mouth/Complete series everyday, with medical necessity	2					2				2		2												2		2		2												2	2	1	1011011						2	1				2	1									2	2	1	3		2	2	999	6	Everyday, based on medical necessity	2	2	1	6	Prosthodontics(removable)-Once per 5yrs per arch when prognosis of complete/partial denture is at least 5yrs: Complete/partial dentures. Every day per medical need: Other Oral/Maxillofacial Surgery.	2						2					2																		2		2																		1	2
H0482	002	0	1	01	01	H0482_002_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 months.Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					1	10111111			30	30	30	30	30	30	30	30	30	30	30	30	30	30	2		1	01000000	25.00	25.00															1	2
H0482	003	0	1	01	01	H0482_003_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H0482	005	0	1	01	01	H0482_005_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 months. Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0504	015	0	1	01	01	H0504_015_0	5	1	1111	4	2	1	6	No frequency limit for limited oral evaluation – problem focused, comprehensive oral evaluation – new or established patient covered once every 36 months from last date of service.	4	2	2	3		4	2	2	3		4	2	1	6	No frequency limit for bitewing – single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2					2				2		2												2		1	1101	2				0.00	16.00			5.00	5.00	0.00	10.00	2	2	1	1011111						4	1				4	2	1	6	No frequency limit for amalgam - 1 surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years from last date of service (exact tooth).	4	2	1	6	No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact teeth).	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	4	2	1	6	No frequency limit for extraction, erupted tooth or exposed root (elevation and/or forceps removal), removal of impacted tooth – soft tissue covered once per lifetime (exact tooth).	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2						2					2																		2		1	10011111					0.00	15.00	19.00	430.00	25.00	373.00	40.00	60.00	23.00	80.00	0.00	525.00	2	1
H0504	017	0	1	01	01	H0504_017_0	5	1	1111	4	2	1	6	No frequency limit for limited oral evaluation – problem focused, comprehensive oral evaluation – new or established patient covered once every 36 months from last date of service were last rendered.	4	2	2	3		4	2	2	3		4	2	1	6	No frequency limit for bitewing – single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2					2				2		2												2		1	1101	2				0.00	16.00			5.00	5.00	0.00	10.00	2	2	1	1011111						4	1				4	2	1	6	No frequency limit for amalgam - 1 surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years from last date of service (exact tooth).	4	2	1	6	No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact teeth).	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	4	2	1	6	No frequency limit for extraction, erupted tooth or exposed root (elevation and/or forceps removal), removal of impacted tooth – soft tissue covered once per lifetime (exact tooth).	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2						2					2																		2		1	10011111					0.00	15.00	19.00	430.00	25.00	373.00	40.00	60.00	23.00	80.00	0.00	525.00	2	1
H0504	021	0	1	01	01	H0504_021_0	5	1	1111	4	2	1	6	No frequency limit for limited oral evaluation – problem focused, comprehensive oral evaluation – new or established patient covered once every 36 months from last date of service were last rendered.	4	2	2	3		4	2	2	3		4	2	1	6	No frequency limit for bitewing – single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2					2				2		2												2		1	1101	2				0.00	16.00			5.00	5.00	0.00	10.00	2	2	1	1011111						4	1				4	2	1	6	No frequency limit for amalgam - 1 surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years from last date of service (exact tooth).	4	2	1	6	No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact teeth).	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	4	2	1	6	No frequency limit for extraction, erupted tooth or exposed root (elevation and/or forceps removal), removal of impacted tooth – soft tissue covered once per lifetime (exact tooth).	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2						2					2																		2		1	11011111	0.00	5.00			0.00	15.00	19.00	430.00	25.00	373.00	40.00	60.00	23.00	80.00	0.00	525.00	2	1
H0504	026	0	1	01	01	H0504_026_0	6	2		3					3					3					3																																														2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	5.00															2	1
H0504	028	0	1	01	01	H0504_028_0	5	1	1111	4	2	1	6	No frequency limit for limited oral evaluation – problem focused, comprehensive oral evaluation – new or established patient covered once every 36 months from last date of service were last rendered.	4	2	2	3		4	2	2	3		4	2	1	6	No frequency limit for bitewing – single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2					2				2		2												2		1	1101	2				0.00	16.00			5.00	5.00	0.00	10.00	2	2	1	1011111						4	1				4	2	1	6	No frequency limit for amalgam - 1 surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years from last date of service (exact tooth).	4	2	1	6	No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact teeth).	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	4	2	1	6	No frequency limit for extraction, erupted tooth or exposed root (elevation and/or forceps removal), removal of impacted tooth – soft tissue covered once per lifetime (exact tooth).	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2						2					2																		2		1	11011111	0.00	30.00			0.00	15.00	19.00	430.00	25.00	373.00	40.00	60.00	23.00	80.00	0.00	525.00	2	1
H0504	038	0	1	01	01	H0504_038_0	5	2		3					3					3					3																																														2							3					3					3					3					3					3											2					2																		2		2																		2	1
H0504	039	0	1	01	01	H0504_039_0	5	1	1111	4	2	1	4		4	2	1	4		4	2	1	4		4	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	2							3					3					3					3					3					3											2					2																		2		2																		2	1
H0504	040	0	1	01	01	H0504_040_0	5	1	1111	4	2	1	6	No frequency limit for limited oral evaluation – problem focused, comprehensive oral evaluation – new or established patient covered once every 36 months from last date of service were last rendered.	4	2	2	3		4	2	2	3		4	2	1	6	No frequency limit for bitewing – single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2					2				2		2												2		1	1101	2				0.00	16.00			5.00	5.00	0.00	10.00	2	2	1	1011111						4	1				4	2	1	6	No frequency limit for amalgam - 1 surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years from last date of service (exact tooth).	4	2	1	6	No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact teeth).	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	4	2	1	6	No frequency limit for extraction, erupted tooth or exposed root (elevation and/or forceps removal), removal of impacted tooth – soft tissue covered once per lifetime (exact tooth).	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2						2					2																		2		1	10011111					0.00	15.00	19.00	430.00	25.00	373.00	40.00	60.00	23.00	80.00	0.00	525.00	2	1
H0504	041	0	1	01	01	H0504_041_0	7	1	1111	4	2	1	4		4	2	1	4		4	2	1	4		4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				2		2												2		2		2												2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	15.00															2	1
H0504	043	0	1	01	01	H0504_043_0	6	1	1111	4	2	1	6	No frequency limit for limited oral evaluation – problem focused, comprehensive oral evaluation – new or established patient covered once every 36 months from last date of service were last rendered.	4	2	2	3		4	2	2	3		4	2	1	6	No frequency limit for bitewing – single radiographic image, panoramic radiographic image covered once every 24 months from last date of service.	2					2				2		2												2		1	1101	2				0.00	16.00			5.00	5.00	0.00	10.00	2	2	1	1011111						4	1				4	2	1	6	No frequency limit for amalgam - 1 surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years from last date of service (exact tooth).	4	2	1	6	No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact teeth).	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	4	2	1	6	No frequency limit for extraction, erupted tooth or exposed root (elevation and/or forceps removal), removal of impacted tooth – soft tissue covered once per lifetime (exact tooth).	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2						2					2																		2		1	10011111					0.00	15.00	19.00	430.00	25.00	373.00	40.00	60.00	23.00	80.00	0.00	525.00	2	1
H0504	047	0	1	01	01	H0504_047_0	6	1	1111	4	2	1	4		4	2	1	4		4	2	1	4		4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				2		2												2		2		2												2	2	2							3					3					3					3					3					3											2					2																		2		2																		2	1
H0504	049	0	1	01	01	H0504_049_0	6	1	1111	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	4	2	1	4		4	1				4	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	1	1011111						4	1				4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	4	2	1	6	No frequency limit for removal of lateral exostosis (maxilla or mandible), removal of impacted tooth soft tissue covered once per lifetime (exact tooth).	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1		2	1000.00	3		2					2																		2		1	10011111					0.00	10.00	0.00	295.00	5.00	425.00	20.00	293.00	10.00	94.00	0.00	310.00	2	1
H0504	803	0	1	01	01	H0504_803_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0504	804	0	1	01	01	H0504_804_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0504	805	0	1	01	01	H0504_805_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0504	806	0	1	01	01	H0504_806_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0523	022	0	1	01	01	H0523_022_0	7	1	1111	2	1				2	1				2	1				2	1				1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	052	0	1	01	01	H0523_052_0	7	1	1111	2	1				2	1				2	1				2	1				1		600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	065	0	1	01	01	H0523_065_0	6	1	1111	2	1				2	1				2	1				2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	067	0	1	01	01	H0523_067_0	6	1	1111	2	1				2	1				2	1				2	1				1		1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	068	0	1	01	01	H0523_068_0	6	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	069	0	1	01	01	H0523_069_0	6	1	1111	2	1				2	1				2	1				2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	070	0	1	01	01	H0523_070_0	6	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	071	0	1	01	01	H0523_071_0	6	1	1111	2	1				2	1				2	1				2	1				1		1150.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	072	0	1	01	01	H0523_072_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	073	0	1	01	01	H0523_073_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	074	0	1	02	01	H0523_074_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	075	0	1	01	01	H0523_075_0	8	1	1111	2	1				2	1				2	1				2	1				1		2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	076	0	1	02	01	H0523_076_0	7	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	077	0	1	02	01	H0523_077_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	078	0	1	02	01	H0523_078_0	8	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	079	0	1	02	01	H0523_079_0	7	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	080	0	1	02	01	H0523_080_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0523	801	0	1	01	01	H0523_801_0	10	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0523	805	0	1	01	01	H0523_805_0	10	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0524	003	0	1	01	01	H0524_003_0	14	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	0.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	008	0	1	01	01	H0524_008_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	5.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	013	0	1	01	01	H0524_013_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	10.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	10.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	015	0	1	01	01	H0524_015_0	13	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	0.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	031	0	1	01	01	H0524_031_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	10.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	5.00	10.00			0.00	0.00					0.00	0.00	5.00	5.00			1	1
H0524	032	0	1	01	01	H0524_032_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	15.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	10.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	033	0	1	01	01	H0524_033_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	10.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	5.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	034	0	1	01	01	H0524_034_0	10	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	0.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	035	0	1	01	01	H0524_035_0	10	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	0.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	036	0	1	01	01	H0524_036_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	5.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	037	0	1	01	01	H0524_037_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	0.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	038	0	1	01	01	H0524_038_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	10.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	5.00	10.00			0.00	0.00					0.00	0.00	5.00	5.00			1	1
H0524	039	0	1	01	01	H0524_039_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	10.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	040	0	1	01	01	H0524_040_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	5.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	5.00	5.00			0.00	0.00					0.00	0.00	5.00	5.00			1	1
H0524	041	0	1	01	01	H0524_041_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	10.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	5.00	10.00			0.00	0.00					0.00	0.00	5.00	5.00			1	1
H0524	042	0	1	01	01	H0524_042_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	0.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	043	0	1	01	01	H0524_043_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	10.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	5.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	046	0	1	01	01	H0524_046_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	20.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	5.00	15.00			0.00	0.00					0.00	0.00	5.00	5.00			1	1
H0524	051	0	1	01	01	H0524_051_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	10.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	10.00	15.00			0.00	0.00					0.00	0.00	10.00	10.00			1	1
H0524	054	0	1	01	01	H0524_054_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	10.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	5.00	10.00			0.00	0.00					0.00	0.00	5.00	5.00			1	1
H0524	059	0	1	01	01	H0524_059_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	10.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	5.00	15.00			0.00	0.00					0.00	0.00	5.00	5.00			1	1
H0524	060	0	1	01	01	H0524_060_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	20.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	10.00	15.00			0.00	0.00					0.00	0.00	10.00	10.00			1	1
H0524	061	0	1	01	01	H0524_061_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	5.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	5.00	15.00			0.00	0.00					0.00	0.00	5.00	5.00			1	1
H0524	062	0	1	01	01	H0524_062_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	10.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	10.00	15.00			0.00	0.00					0.00	0.00	10.00	10.00			1	1
H0524	063	0	1	01	01	H0524_063_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	10.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	5.00	15.00			0.00	0.00					0.00	0.00	5.00	5.00			1	1
H0524	064	0	1	01	01	H0524_064_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	15.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	10.00	20.00			0.00	0.00					0.00	0.00	10.00	10.00			1	1
H0524	065	0	1	01	01	H0524_065_0	11	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	25.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	10.00	25.00			0.00	0.00					0.00	0.00	10.00	10.00			1	1
H0524	078	0	1	01	01	H0524_078_0	10	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	0.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	081	0	1	01	01	H0524_081_0	10	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	0.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	082	0	1	01	01	H0524_082_0	10	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	0.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	083	0	1	01	01	H0524_083_0	10	1	1110	2	2	2	3		4	2	2	3							2	2	1	6	Bitewings are limited to 2 sets per 12 month period. Bitewings for radiographic images 1 series every 6 months.	2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	0010011	3					4	2	2	3		3					3					4	2	1	6	Limited to 4 quadrants during any 12 consecutive months. Periodontal maintenance 1 treatment each 12 month period.	4	1				3					2						2					2																		2		1	01010011	0.00	0.00			0.00	0.00					0.00	0.00	0.00	0.00			1	1
H0524	801	0	1	01	01	H0524_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0524	802	0	1	01	01	H0524_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0524	803	0	2	01	01	H0524_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0524	804	0	2	01	01	H0524_804_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0524	805	0	1	01	01	H0524_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0524	806	0	1	01	01	H0524_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0524	807	0	2	01	01	H0524_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0524	808	0	2	01	01	H0524_808_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0524	809	0	1	01	01	H0524_809_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0524	810	0	1	01	01	H0524_810_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0524	811	0	2	01	01	H0524_811_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0524	812	0	2	01	01	H0524_812_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0542	001	0	1	20	08	H0542_001_0	3																																																																																																																																																							
H0542	002	0	1	20	08	H0542_002_0	3																																																																																																																																																							
H0543	013	0	1	02	01	H0543_013_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	019	0	1	02	01	H0543_019_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	022	0	1	02	01	H0543_022_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	028	0	1	02	01	H0543_028_0	8	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0543	035	0	1	02	01	H0543_035_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	1
H0543	036	0	1	02	01	H0543_036_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0543	060	0	1	02	01	H0543_060_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	086	0	1	02	01	H0543_086_0	7	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0543	089	0	1	02	01	H0543_089_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0543	121	0	1	02	01	H0543_121_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	1
H0543	140	0	1	02	01	H0543_140_0	6	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0543	145	0	1	02	01	H0543_145_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0543	146	0	1	02	01	H0543_146_0	7	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0543	147	0	1	02	01	H0543_147_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0543	151	0	1	02	01	H0543_151_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	152	0	1	02	01	H0543_152_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0543	164	0	1	02	01	H0543_164_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	165	0	1	02	01	H0543_165_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	166	0	1	02	01	H0543_166_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	167	0	1	02	01	H0543_167_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	168	0	1	02	01	H0543_168_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	169	0	1	02	01	H0543_169_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	170	0	1	02	01	H0543_170_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	176	0	1	02	01	H0543_176_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	183	0	1	01	01	H0543_183_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0543	188	0	1	02	01	H0543_188_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	189	0	1	02	01	H0543_189_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	191	0	1	02	01	H0543_191_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	193	0	1	02	01	H0543_193_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	195	0	1	02	01	H0543_195_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0543	196	0	1	02	01	H0543_196_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	204	0	1	02	01	H0543_204_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	209	0	1	02	01	H0543_209_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	210	0	1	02	01	H0543_210_0	8	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	214	0	1	02	01	H0543_214_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	215	0	1	02	01	H0543_215_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	216	0	1	02	01	H0543_216_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	217	0	1	02	01	H0543_217_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	218	0	1	02	01	H0543_218_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	219	0	1	02	01	H0543_219_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	220	0	1	02	01	H0543_220_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	221	0	1	02	01	H0543_221_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	222	0	1	02	01	H0543_222_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	223	0	1	02	01	H0543_223_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	1
H0543	224	0	1	02	01	H0543_224_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	225	0	1	02	01	H0543_225_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	226	0	1	02	01	H0543_226_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	227	0	1	02	01	H0543_227_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	228	0	1	02	01	H0543_228_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0543	229	0	1	02	01	H0543_229_0	7	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0543	230	0	1	02	01	H0543_230_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0543	231	0	1	02	01	H0543_231_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	1
H0543	232	0	1	02	01	H0543_232_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0543	234	0	1	02	01	H0543_234_0	8	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	1
H0543	235	0	1	02	01	H0543_235_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0543	236	0	1	02	01	H0543_236_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	1
H0543	237	0	1	02	01	H0543_237_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	1
H0543	238	0	1	02	01	H0543_238_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	1
H0543	239	0	1	02	01	H0543_239_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2																																											2					1	01000000	20	20															2		2																		1	1
H0543	240	0	1	01	01	H0543_240_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0543	241	0	1	01	01	H0543_241_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0543	242	0	1	01	01	H0543_242_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0543	243	0	1	01	01	H0543_243_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0543	246	0	1	01	01	H0543_246_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0543	247	0	1	01	01	H0543_247_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0543	248	0	1	02	01	H0543_248_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0543	249	0	1	01	01	H0543_249_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0543	802	0	1	01	01	H0543_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0543	805	0	1	01	01	H0543_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0543	806	0	1	01	01	H0543_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0543	809	0	2	01	01	H0543_809_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0544	002	0	1	01	01	H0544_002_0	13	1	1110	4	2	2	3		4	2	2	3		3					4	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	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H0544	004	0	1	01	01	H0544_004_0	8	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0544	005	0	1	01	01	H0544_005_0	9	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0544	007	0	1	01	01	H0544_007_0	8	1	1110	4	2	2	3		4	2	2	3		3					4	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	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	20.00															1	2
H0544	008	0	1	01	01	H0544_008_0	8	1	1110	4	2	2	3		4	2	2	3		3					4	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	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H0544	010	0	1	01	01	H0544_010_0	7	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0544	014	0	1	01	01	H0544_014_0	7	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0544	015	0	1	01	01	H0544_015_0	6	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0544	019	0	1	01	01	H0544_019_0	7	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0544	020	0	1	01	01	H0544_020_0	6	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0544	056	0	1	01	01	H0544_056_0	7	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	15.00	15.00															1	2
H0544	058	0	1	01	01	H0544_058_0	7	1	1111	4	2	2	3		4	2	2	3		4	1				4	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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		2	500.00	3		2					2																		2		1	01000000	0.00	0.00															1	2
H0544	061	0	1	01	01	H0544_061_0	7	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	50.00	50.00															1	2
H0544	062	0	1	01	01	H0544_062_0	7	1	1111	4	2	1	3		4	2	1	3		4	1				4	1				2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		2	500.00	3		2					2																		2		1	01000000	0.00	0.00															1	2
H0544	063	0	1	01	01	H0544_063_0	7	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	15.00	15.00															1	2
H0544	064	0	1	01	01	H0544_064_0	7	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	45.00	45.00															1	2
H0544	065	0	1	01	01	H0544_065_0	7	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	35.00	35.00															1	2
H0544	066	0	1	01	01	H0544_066_0	7	1	1111	4	2	2	3		4	2	2	3		4	1				4	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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		2	500.00	3		2					2																		2		1	01000000	0.00	0.00															1	2
H0544	069	0	1	01	01	H0544_069_0	7	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	20.00	20.00															1	2
H0544	091	0	1	01	01	H0544_091_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0544	095	0	1	01	01	H0544_095_0	7	1	1111	4	2	2	3		4	2	2	3		4	2	1	3		4	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H0544	096	0	1	01	01	H0544_096_0	7	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	25.00	25.00															1	2
H0544	098	0	1	01	01	H0544_098_0	7	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	45.00	45.00															1	2
H0544	108	0	1	01	01	H0544_108_0	7	1	1111	4	2	2	3		4	2	2	3		4	2	1	3		4	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H0544	127	0	1	01	01	H0544_127_0	7	2		3					3					3					3																																														2							3					3					3					3					3					3											2					2																		2		1	01000000	10.00	10.00															1	2
H0544	805	0	1	01	01	H0544_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0544	806	0	1	01	01	H0544_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0544	808	0	2	01	01	H0544_808_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0544	809	0	2	01	01	H0544_809_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0544	810	0	1	01	01	H0544_810_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0544	812	0	2	01	01	H0544_812_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0562	009	0	1	01	01	H0562_009_0	15	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	2	1	6	12 to 36 months	2	1				2	1				2						2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	15.00	0.00	300.00	5.00	275.00	0.00	375.00	15.00	150.00	0.00	2250.00	1	2
H0562	012	0	1	01	01	H0562_012_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	2	1	6	12 to 36 months	2	1				2	1				2						2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	15.00	0.00	300.00	5.00	275.00	0.00	375.00	15.00	150.00	0.00	2250.00	1	2
H0562	039	0	1	01	01	H0562_039_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	2	1	6	12 to 36 months	2	1				2	1				2						2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	15.00	0.00	300.00	5.00	275.00	0.00	375.00	15.00	150.00	0.00	2250.00	1	2
H0562	079	0	1	01	01	H0562_079_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	2	1	6	12 to 36 months	2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	15.00	0.00	300.00	5.00	275.00	0.00	375.00	15.00	150.00	0.00	2250.00	1	2
H0562	092	0	1	01	01	H0562_092_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	2	1	6	12 to 36 months	2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	15.00	0.00	300.00	5.00	275.00	0.00	375.00	15.00	150.00	0.00	2250.00	1	2
H0562	097	0	1	01	01	H0562_097_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	2	1	6	12 to 36 months	2	1				2	1				2						2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	15.00	0.00	300.00	5.00	275.00	0.00	375.00	15.00	150.00	0.00	2250.00	1	2
H0562	125	0	1	01	01	H0562_125_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	2	1	6	12 to 36 months	2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	15.00	0.00	300.00	5.00	275.00	0.00	375.00	15.00	150.00	0.00	2250.00	1	2
H0562	126	0	1	01	01	H0562_126_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	2	1	6	12 to 36 months	2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	15.00	0.00	300.00	5.00	275.00	0.00	375.00	15.00	150.00	0.00	2250.00	1	2
H0562	128	0	1	01	01	H0562_128_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	2	1	6	12 to 36 months	2	1				2	1				2						2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	15.00	0.00	300.00	5.00	275.00	0.00	375.00	15.00	150.00	0.00	2250.00	1	2
H0562	130	1	1	01	01	H0562_130_1	15	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	2	1	6	12 to 36 months	2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	15.00	0.00	300.00	5.00	275.00	0.00	375.00	15.00	150.00	0.00	2250.00	1	2
H0562	130	2	1	01	01	H0562_130_2	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	2	1	6	12 to 36 months	2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	15.00	0.00	300.00	5.00	275.00	0.00	375.00	15.00	150.00	0.00	2250.00	1	2
H0562	801	0	1	01	01	H0562_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0562	803	0	1	01	01	H0562_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0562	804	0	1	01	01	H0562_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0571	001	0	1	01	01	H0571_001_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	0000010						3					3					3					2	2	1	3		3					3					2						2					2																		2		1	01000010	20.00	20.00									0.00	450.00					1	1
H0571	005	0	1	01	01	H0571_005_0	6	1	1110	2	2	2	3		2	2	1	4							2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					2																		2		1	10000000															0.00	1740.00	2	2
H0571	007	0	1	01	01	H0571_007_0	7	2		3					3										3																																														2							3					3					3					3					3					3											2					2																		2		1	01000000	35.00	35.00															1	1
H0609	007	0	1	02	01	H0609_007_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	012	0	1	02	01	H0609_012_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	018	0	1	02	01	H0609_018_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	025	0	1	02	01	H0609_025_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	026	0	1	02	01	H0609_026_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	027	0	1	02	01	H0609_027_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	028	0	1	02	01	H0609_028_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	031	0	1	02	01	H0609_031_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	032	0	1	02	01	H0609_032_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	033	0	1	02	01	H0609_033_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	034	1	1	02	01	H0609_034_1	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	034	2	1	02	01	H0609_034_2	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	036	1	1	02	01	H0609_036_1	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	036	2	1	02	01	H0609_036_2	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	037	0	1	02	01	H0609_037_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	038	0	1	02	01	H0609_038_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	040	0	1	02	01	H0609_040_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	041	0	1	02	01	H0609_041_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	042	0	1	02	01	H0609_042_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	043	0	1	02	01	H0609_043_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	044	0	1	02	01	H0609_044_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	045	0	1	02	01	H0609_045_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	046	0	1	02	01	H0609_046_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	047	0	1	02	01	H0609_047_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	048	0	1	02	01	H0609_048_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	049	0	1	02	01	H0609_049_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	050	0	1	02	01	H0609_050_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	051	0	1	02	01	H0609_051_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	052	0	1	02	01	H0609_052_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0609	053	0	1	02	01	H0609_053_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0609	054	0	1	02	01	H0609_054_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	055	0	1	02	01	H0609_055_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	056	0	1	02	01	H0609_056_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	057	0	1	02	01	H0609_057_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0609	058	0	1	02	01	H0609_058_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	059	0	1	02	01	H0609_059_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	060	0	1	02	01	H0609_060_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0609	061	0	1	02	01	H0609_061_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	062	0	1	02	01	H0609_062_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	063	0	1	02	01	H0609_063_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	064	0	1	02	01	H0609_064_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0609	065	0	1	02	01	H0609_065_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	066	0	1	02	01	H0609_066_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	067	0	1	02	01	H0609_067_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0609	068	0	1	02	01	H0609_068_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H0609	070	0	1	02	01	H0609_070_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	071	0	1	02	01	H0609_071_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H0609	801	0	1	01	01	H0609_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0609	804	0	1	01	01	H0609_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0609	805	0	1	01	01	H0609_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0609	806	0	2	01	01	H0609_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0609	807	0	1	01	01	H0609_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0609	808	0	1	01	01	H0609_808_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0609	809	0	1	01	01	H0609_809_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0609	810	0	1	01	01	H0609_810_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0609	811	0	1	01	01	H0609_811_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0609	812	0	1	01	01	H0609_812_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0609	813	0	1	01	01	H0609_813_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0609	814	0	1	01	01	H0609_814_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0609	815	0	1	01	01	H0609_815_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0609	816	0	1	01	01	H0609_816_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0609	817	0	1	01	01	H0609_817_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0609	818	0	1	01	01	H0609_818_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0609	819	0	1	01	01	H0609_819_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0609	820	0	1	01	01	H0609_820_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0609	821	0	1	01	01	H0609_821_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0609	822	0	1	01	01	H0609_822_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0609	823	0	1	01	01	H0609_823_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0609	824	0	1	01	01	H0609_824_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0609	825	0	2	01	01	H0609_825_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0613	001	0	1	20	08	H0613_001_0	1																																																																																																																																																							
H0613	003	0	1	20	08	H0613_003_0	1																																																																																																																																																							
H0624	001	0	1	02	01	H0624_001_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0628	001	0	1	02	01	H0628_001_0	8	1	1111	2	1				2	1				2	1				2	1				1		1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0628	003	0	1	02	01	H0628_003_0	6	1	1111	2	1				2	1				2	1				2	1				1		2900.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0628	005	0	1	02	01	H0628_005_0	8	1	1111	2	1				2	1				2	1				2	1				1		2900.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0628	006	0	1	02	01	H0628_006_0	7	1	1111	2	1				2	1				2	1				2	1				1		2100.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0628	007	0	1	02	01	H0628_007_0	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0628	008	0	1	02	01	H0628_008_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0628	009	0	1	02	01	H0628_009_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0628	010	0	1	02	01	H0628_010_0	6	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0628	011	0	1	01	01	H0628_011_0	6	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below	2	2	4	6	Varies by procedure, see note below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see note below.	1		2	2000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	0.00	0.00			0.00	0.00											1	2
H0628	012	0	1	01	01	H0628_012_0	7	1	1111	2	1				2	1				2	1				2	1				1		6000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0628	013	0	1	01	01	H0628_013_0	6	1	1111	2	1				2	1				2	1				2	1				1		6000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0628	014	0	1	01	01	H0628_014_0	3	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Plan will cover 1 filling per tooth per year, recement once per tooth per year, crown repair once per tooth per year, and 1 crown per tooth every 5 years.	2	2	2	6	Plan will cover 1 root canal and the retreatment of 1 root canal per tooth per lifetime.	2	2	4	6	Plan will cover scaling and root planing once per quadrant every 2 years and periodontal maintenance 2 times per year.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see notes.	1		2	2000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	0.00	0.00			0.00	0.00											1	2
H0628	015	0	1	01	01	H0628_015_0	3	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Plan will cover 1 filling per tooth per year, recement once per tooth per year, crown repair once per tooth per year, and 1 crown per tooth every 5 years.	2	2	2	6	Plan will cover 1 root canal and the retreatment of 1 root canal per tooth per lifetime.	2	2	4	6	Plan will cover scaling and root planing once per quadrant every 2 years and periodontal maintenance 2 times per year.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see notes.	1		2	2000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	0.00	0.00			0.00	0.00											1	2
H0628	017	0	1	02	01	H0628_017_0	7	1	1111	2	1				2	1				2	1				2	1				1		2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0628	018	0	1	01	01	H0628_018_0	8	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0628	801	0	1	01	01	H0628_801_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0628	802	0	1	01	01	H0628_802_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0630	013	0	1	01	01	H0630_013_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	1		1450.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0011110	3					2	1				4	1				4	1				4	1				3					3					1		1				2					1	00001110							30	30	50	50	50	50					2		1	01010000	15.00	15.00			0.00	0.00											2	2
H0630	014	0	1	01	01	H0630_014_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H0630	015	0	1	02	01	H0630_015_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	1		1650.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				2	1				4	1				4	1				4	1				4	1				4	1				1		1				2					1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		1	01010000	10.00	10.00			0.00	0.00											2	2
H0630	016	0	1	02	01	H0630_016_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	1		1650.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				2	1				4	1				4	1				4	1				4	1				4	1				1		1				2					1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		1	01010000	10.00	10.00			0.00	0.00											2	2
H0630	017	0	1	01	01	H0630_017_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	1		1450.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0011110	3					2	1				4	1				4	1				4	1				3					3					1		1				2					1	00001110							30	30	50	50	50	50					2		1	01010000	25.00	25.00			0.00	0.00											2	2
H0630	020	0	1	01	01	H0630_020_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	1		1450.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0011110	3					2	1				4	1				4	1				4	1				3					3					1		1				2					1	00001110							30	30	50	50	50	50					2		1	01010000	20.00	20.00			0.00	0.00											2	2
H0630	021	0	1	02	01	H0630_021_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	1		1650.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				2	1				4	1				4	1				4	1				4	1				4	1				1		1				2					1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		1	01010000	10.00	10.00			0.00	0.00											2	2
H0630	023	0	1	02	01	H0630_023_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	1		1650.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				2	1				4	1				4	1				4	1				4	1				4	1				1		1				2					1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		1	01010000	20.00	20.00			0.00	0.00											2	2
H0630	024	0	1	01	01	H0630_024_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H0630	025	0	1	02	01	H0630_025_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	1		2350.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				2	1				4	1				4	1				4	1				4	1				4	1				1		1				2					1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											2	2
H0630	026	0	1	02	01	H0630_026_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	1		2350.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				2	1				4	1				4	1				4	1				4	1				4	1				1		1				2					1	10101111			30	50			30	50	50	50	50	50	30	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											2	2
H0630	805	0	2	01	01	H0630_805_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	806	0	2	01	01	H0630_806_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	807	0	1	01	01	H0630_807_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	808	0	1	01	01	H0630_808_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	809	0	2	01	01	H0630_809_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	810	0	1	01	01	H0630_810_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	811	0	2	01	01	H0630_811_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	812	0	2	01	01	H0630_812_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	813	0	1	01	01	H0630_813_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	814	0	1	01	01	H0630_814_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	815	0	2	01	01	H0630_815_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	816	0	1	01	01	H0630_816_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	817	0	2	01	01	H0630_817_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	818	0	2	01	01	H0630_818_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	819	0	1	01	01	H0630_819_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	820	0	1	01	01	H0630_820_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	821	0	2	01	01	H0630_821_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0630	822	0	1	01	01	H0630_822_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0672	001	0	1	01	01	H0672_001_0	8	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	25.00	25.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H0672	003	0	1	01	01	H0672_003_0	8	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	25.00	25.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H0672	004	0	1	01	01	H0672_004_0	9	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	30.00	30.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H0672	005	0	1	01	01	H0672_005_0	9	1	1111	2	1				2	1				2	1				2	1				1		1200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H0672	006	0	1	01	01	H0672_006_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H0672	007	0	1	01	01	H0672_007_0	9	1	1111	2	1				2	1				2	1				2	1				1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H0672	008	0	1	01	01	H0672_008_0	8	1	1111	2	1				2	1				2	1				2	1				1		400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H0672	009	0	1	01	01	H0672_009_0	9	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H0672	010	0	1	01	01	H0672_010_0	10	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H0672	011	0	1	01	01	H0672_011_0	7	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H0672	013	0	1	01	01	H0672_013_0	7	1	1111	2	1				2	1				2	1				2	1				1		3400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H0672	014	0	1	01	01	H0672_014_0	7	1	1111	2	1				2	1				2	1				2	1				1		3400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H0672	015	0	1	01	01	H0672_015_0	8	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H0672	016	0	1	01	01	H0672_016_0	7	1	1111	2	1				2	1				2	1				2	1				1		2100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H0672	017	0	1	01	01	H0672_017_0	7	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H0672	018	0	1	01	01	H0672_018_0	8	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H0672	801	0	1	01	01	H0672_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0710	004	0	1	04	01	H0710_004_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	005	0	1	04	01	H0710_005_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	007	0	1	04	01	H0710_007_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	008	0	1	04	01	H0710_008_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	009	0	1	04	01	H0710_009_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	010	0	1	04	01	H0710_010_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	4500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	012	0	1	04	01	H0710_012_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	013	0	1	04	01	H0710_013_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	016	0	1	04	01	H0710_016_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	017	0	1	04	01	H0710_017_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	020	0	1	04	01	H0710_020_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	4500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	026	0	1	04	01	H0710_026_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	027	0	1	04	01	H0710_027_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	030	0	1	04	01	H0710_030_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	7000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	031	0	1	04	01	H0710_031_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	032	0	1	04	01	H0710_032_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	033	0	1	04	01	H0710_033_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	034	0	1	04	01	H0710_034_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	035	0	1	04	01	H0710_035_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	036	0	1	04	01	H0710_036_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	037	0	1	04	01	H0710_037_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	038	0	1	04	01	H0710_038_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	039	0	1	04	01	H0710_039_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	041	0	1	04	01	H0710_041_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	046	0	1	04	01	H0710_046_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	047	0	1	04	01	H0710_047_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	050	0	1	04	01	H0710_050_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	051	0	1	04	01	H0710_051_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	052	0	1	04	01	H0710_052_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	053	0	1	04	01	H0710_053_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	054	0	1	04	01	H0710_054_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	055	0	1	04	01	H0710_055_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	056	0	1	04	01	H0710_056_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	057	0	1	04	01	H0710_057_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	058	0	1	04	01	H0710_058_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	059	0	1	04	01	H0710_059_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	060	0	1	04	01	H0710_060_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	061	0	1	04	01	H0710_061_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	062	0	1	04	01	H0710_062_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	063	0	1	04	01	H0710_063_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	064	0	1	04	01	H0710_064_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	066	0	1	04	01	H0710_066_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	067	0	1	04	01	H0710_067_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	068	0	1	04	01	H0710_068_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	069	0	1	04	01	H0710_069_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	070	0	1	04	01	H0710_070_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	071	0	1	04	01	H0710_071_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0710	801	0	1	04	01	H0710_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	802	0	1	04	01	H0710_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	803	0	1	04	01	H0710_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	804	0	2	04	01	H0710_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	805	0	2	04	01	H0710_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	806	0	2	04	01	H0710_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	807	0	1	04	01	H0710_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	808	0	1	04	01	H0710_808_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	809	0	1	04	01	H0710_809_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	810	0	1	04	01	H0710_810_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	811	0	1	04	01	H0710_811_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	812	0	2	04	01	H0710_812_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	813	0	2	04	01	H0710_813_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	814	0	2	04	01	H0710_814_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	815	0	1	04	01	H0710_815_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	816	0	1	04	01	H0710_816_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	817	0	1	04	01	H0710_817_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	818	0	1	04	01	H0710_818_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	819	0	1	04	01	H0710_819_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	820	0	1	04	01	H0710_820_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	821	0	1	04	01	H0710_821_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	822	0	1	04	01	H0710_822_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	823	0	1	04	01	H0710_823_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	824	0	2	04	01	H0710_824_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	825	0	1	04	01	H0710_825_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	826	0	1	04	01	H0710_826_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	827	0	1	04	01	H0710_827_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	829	0	1	04	01	H0710_829_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	830	0	1	04	01	H0710_830_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0710	831	0	1	04	01	H0710_831_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0712	005	0	1	01	01	H0712_005_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0712	019	0	1	01	01	H0712_019_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1500.00	3		2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0712	020	0	1	01	01	H0712_020_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1500.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0712	023	0	1	01	01	H0712_023_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0712	025	0	1	01	01	H0712_025_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0712	029	0	1	01	01	H0712_029_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0724	801	0	1	01	01	H0724_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0738	001	0	1	01	01	H0738_001_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	4	6	1 every 5 years per member per year.	2					2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Prior authorization required. Pre and post-op radiographs required. Prior authorization required.	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. 1 per 24 mo. Per quadrant. Debridement once per year. Subject to the $3000 combined limit every year.	2	1				2	2	1	6	Periodicity varies by procedure, see full note below.	1		2	3000.00	3		2					2																		2		2																		1	2
H0755	030	0	1	02	01	H0755_030_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0755	031	0	1	02	01	H0755_031_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0755	032	0	1	02	01	H0755_032_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0755	033	0	1	02	01	H0755_033_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0755	037	0	1	02	01	H0755_037_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0755	038	0	1	02	01	H0755_038_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0755	044	0	1	02	01	H0755_044_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H0755	045	0	1	02	01	H0755_045_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H0755	810	0	1	01	01	H0755_810_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0755	811	0	1	01	01	H0755_811_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0755	812	0	1	01	01	H0755_812_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0755	813	0	1	01	01	H0755_813_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0755	814	0	1	01	01	H0755_814_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0755	815	0	1	01	01	H0755_815_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0764	001	0	1	04	01	H0764_001_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0783	002	0	1	01	01	H0783_002_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam/composite filling unlimited per year, bridge+crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefab. post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	14	6	Denture adj, rebase, reline, repair and tissue cond. 1/year, bridge-crown 2/5 years, bridge-pontic, complete+part denture 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year, implant 1/tooth/life	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0783	003	0	1	01	01	H0783_003_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	amalgam/composite filling unlimited per year, crown and other restorative services - core buildup and prefab post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0783	004	0	1	01	01	H0783_004_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H0809	001	0	1	20	08	H0809_001_0	1																																																																																																																																																							
H0809	002	0	1	20	08	H0809_002_0	1																																																																																																																																																							
H0819	001	0	1	20	08	H0819_001_0	1																																																																																																																																																							
H0819	002	0	1	20	08	H0819_002_0	1																																																																																																																																																							
H0838	024	0	1	01	01	H0838_024_0	8	1	1111	2	2	1	3		2	2	1	3		2	2	1	3		2	1				2					2				2		2												2		1	1111	2				0.00	17.00	0.00	0.00	13.00	13.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	2		2	1				2	1				2	2	4	3		2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	20.00	20.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	350.00	0.00	350.00	1	1
H0838	039	1	1	01	01	H0838_039_1	8	1	1111	2	2	1	4		2	2	2	3		2	1				2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	300.00	0.00	6.00	25.00	400.00	25.00	720.00	0.00	780.00	0.00	360.00	0.00	2160.00	1	1
H0838	039	2	1	01	01	H0838_039_2	8	1	1111	2	2	1	4		2	2	2	3		2	1				2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	300.00	0.00	6.00	25.00	400.00	25.00	720.00	0.00	780.00	0.00	360.00	0.00	2160.00	1	1
H0838	040	1	1	01	01	H0838_040_1	9	1	1111	2	2	1	3		2	2	1	3		2	2	1	3		2	1				2					2				2		2												2		1	1111	2				0.00	17.00	0.00	0.00	13.00	13.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	2		2	1				2	1				2	2	4	3		2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	20.00	20.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	350.00	0.00	350.00	1	1
H0838	040	2	1	01	01	H0838_040_2	10	1	1111	2	2	1	3		2	2	1	3		2	2	1	3		2	1				2					2				2		2												2		1	1111	2				0.00	17.00	0.00	0.00	13.00	13.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	2		2	1				2	1				2	2	4	3		2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	20.00	20.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	350.00	0.00	350.00	1	1
H0838	046	0	1	01	01	H0838_046_0	10	1	1111	2	2	1	4		2	2	2	3		2	1				2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	300.00	0.00	6.00	25.00	400.00	25.00	720.00	0.00	780.00	0.00	360.00	0.00	2160.00	1	1
H0838	047	0	1	01	01	H0838_047_0	10	1	1111	2	2	1	4		2	2	2	3		2	1				2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	300.00	0.00	6.00	25.00	400.00	25.00	720.00	0.00	780.00	0.00	360.00	0.00	2160.00	1	1
H0838	048	0	1	01	01	H0838_048_0	9	1	1111	2	2	1	4		2	2	2	3		2	1				2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	300.00	0.00	6.00	25.00	400.00	25.00	720.00	0.00	780.00	0.00	360.00	0.00	2160.00	1	1
H0838	049	0	1	01	01	H0838_049_0	9	1	1111	2	2	1	4		2	2	2	3		2	1				2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	300.00	0.00	6.00	25.00	400.00	25.00	720.00	0.00	780.00	0.00	360.00	0.00	2160.00	1	1
H0838	050	1	1	01	01	H0838_050_1	8	1	1111	2	2	1	4		2	2	2	3		2	1				2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	300.00	0.00	6.00	25.00	400.00	25.00	720.00	0.00	780.00	0.00	360.00	0.00	2160.00	1	1
H0838	050	2	1	01	01	H0838_050_2	8	1	1111	2	2	1	4		2	2	2	3		2	1				2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	300.00	0.00	6.00	25.00	400.00	25.00	720.00	0.00	780.00	0.00	360.00	0.00	2160.00	1	1
H0838	051	1	1	01	01	H0838_051_1	9	1	1111	2	2	1	4		2	2	2	3		2	1				2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	300.00	0.00	6.00	25.00	400.00	25.00	720.00	0.00	780.00	0.00	360.00	0.00	2160.00	1	1
H0838	051	2	1	01	01	H0838_051_2	8	1	1111	2	2	1	4		2	2	2	3		2	1				2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	300.00	0.00	6.00	25.00	400.00	25.00	720.00	0.00	780.00	0.00	360.00	0.00	2160.00	1	1
H0839	001	0	1	20	08	H0839_001_0	2																																																																																																																																																							
H0839	002	0	1	20	08	H0839_002_0	2																																																																																																																																																							
H0845	001	0	1	01	01	H0845_001_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0876	001	0	1	01	01	H0876_001_0	10	1	1111	2	2	2	3		2	2	4	6	Routine dental cleanings, is covered up to 2 times per plan year, and may be covered up to 4 per plan year with a documented history of chronic conditions.	2	2	2	3		2	2	1	6	An FMX  and Pano xray 1 every 3 plan years. Bitewings 1 per calendar year; Other xrays covered when required for medically necessary treatments and/or diagnosis	1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	Comprehensive exams covered one procedure every 3 plan years.	2	2	1	6	Fillings and recementing a fallen crown are unlimited per plan year. Crowns and fillings/pins when preparing a crown, as well as bridges: limited to 1 per tooth every 60 months.	2	2	1	6	Root canals are covered for 1 initial root canal procedure and 1 retreatment procedure per tooth per member lifetime.	2	2	1	6	Scaling and root planning 1 per quad every 24 months. Cleaning buildup 1 every 3 plan yrs. Gum disease med placement 1 per site during SRP. Perio maintenance cleanings:  up to 4 per plan yr.	2	2	1	6	Extractions are limited to 1 procedure per tooth per lifetime of the member.	2	2	1	6	Complete or partial dentures 1 every 60 months. Immediate complete /partial dentures once per lifetime. Adjustments 2 per plan yr. Repairs 1 of each type per denture per plan yr. 4 Implants per yr.	1		1				2					1	01000000	20	20															2		2																		1	2
H0885	001	0	1	04	01	H0885_001_0	7	1	1111	2	2	3	3		2	2	3	3		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	2	1	4		2	1									1	2	2	1000.00	3		2					1	01011111	20	20			50	50	50	50	50	50	50	50	50	50			2		2																		2	2
H0885	002	0	1	04	01	H0885_002_0	7	1	1111	2	2	3	3		2	2	3	3		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	2	1	4		2	1									1	2	2	1000.00	3		2					1	01011111	20	20			50	50	50	50	50	50	50	50	50	50			2		2																		2	2
H0885	003	0	1	04	01	H0885_003_0	7	1	1111	2	2	3	3		2	2	3	3		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	2	1	4		2	1									1	2	2	1000.00	3		2					1	01011111	20	20			50	50	50	50	50	50	50	50	50	50			2		2																		2	2
H0885	004	0	1	04	01	H0885_004_0	7	1	1111	2	2	3	3		2	2	3	3		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	2	1	4		2	1									1	2	2	1000.00	3		2					1	01011111	20	20			50	50	50	50	50	50	50	50	50	50			2		2																		2	2
H0885	005	0	1	04	01	H0885_005_0	7	1	1111	2	2	3	3		2	2	3	3		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	2	1	4		2	1									1	2	2	1000.00	3		2					1	01011111	20	20			50	50	50	50	50	50	50	50	50	50			2		2																		2	2
H0885	006	0	1	04	01	H0885_006_0	7	1	1111	2	2	3	3		2	2	3	3		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	2	1	4		2	1									1	2	2	1000.00	3		2					1	01011111	20	20			50	50	50	50	50	50	50	50	50	50			2		2																		2	2
H0885	801	0	1	04	01	H0885_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0885	802	0	1	04	01	H0885_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0885	805	0	1	04	01	H0885_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0885	806	0	1	04	01	H0885_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0885	807	0	1	04	01	H0885_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0885	808	0	1	04	01	H0885_808_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0885	809	0	1	04	01	H0885_809_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0885	810	0	1	04	01	H0885_810_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H0907	001	0	1	02	01	H0907_001_0	7	1	1111	2	1				2	1				2	1				2	1				1		6000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	1	6	Restorative: Fillings - 1 per tooth every 3 yearsRestorative Crowns - 1 per tooth every 5 years	2	1				2	2	1	6	Periodontal Root Planning and Scaling - 1 per quadrant every 2 years	2	1				2	2	1	6	Prosthodontics (Dentures) - 1 set every 5 years	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0907	002	0	1	02	01	H0907_002_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	2	1	6	Restorative: Fillings - 1 per tooth every 3 yearsRestorative Crowns - 1 per tooth every 5 years	2	1				2	2	1	6	Periodontal Root Planning and Scaling - 1 per quadrant every 2 years	2	1				2	2	1	6	Prosthodontics (Dentures) - 1 set every 5 years	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0908	001	0	1	01	01	H0908_001_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	5000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0908	003	0	1	01	01	H0908_003_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0908	004	0	1	01	01	H0908_004_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0908	005	0	1	01	01	H0908_005_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0110000	2	2	1	6	Every date of service to 24 months	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H0908	006	0	1	01	01	H0908_006_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0913	002	0	1	02	01	H0913_002_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	45.00	45.00	0.00	0.00	0.00	0.00											1	2
H0913	013	0	1	01	01	H0913_013_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H0913	015	0	1	01	01	H0913_015_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															1	2
H0913	017	0	1	01	01	H0913_017_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	35.00	35.00															1	2
H0913	020	0	1	01	01	H0913_020_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	40.00	40.00															1	2
H0913	021	0	1	01	01	H0913_021_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H0927	001	0	1	48	05	H0927_001_0	3	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				2		2												2		2		2												2	2	1	1011111						2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2						2					2																		2		2																		2	2
H0934	001	0	1	20	08	H0934_001_0	1																																																																																																																																																							
H0934	002	0	1	20	08	H0934_002_0	1																																																																																																																																																							
H0969	001	0	1	04	01	H0969_001_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1500.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	40.00	40.00															1	2
H0969	003	0	1	04	01	H0969_003_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H0969	005	0	1	04	01	H0969_005_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H0976	001	0	1	01	01	H0976_001_0	8	1	1111	2	1				2	2	2	3		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					1	01000000	20	20															2		1	10101111			0.00	125.00			0.00	350.00	0.00	395.00	0.00	250.00	0.00	350.00	0.00	350.00	1	2
H0976	002	0	1	01	01	H0976_002_0	10	1	1111	2	1				2	2	2	3		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					1	01000000	20	20															2		1	10101111			0.00	125.00			0.00	350.00	0.00	395.00	0.00	250.00	0.00	350.00	0.00	350.00	1	2
H0978	001	0	1	01	01	H0978_001_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H0978	002	0	1	01	01	H0978_002_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H0978	003	0	1	01	01	H0978_003_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H0978	004	0	1	01	01	H0978_004_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	5.00	5.00	0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H0978	005	0	1	01	01	H0978_005_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H0978	006	0	1	01	01	H0978_006_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H0978	007	0	1	01	01	H0978_007_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H0978	008	0	1	01	01	H0978_008_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	5.00	5.00	0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H0978	009	0	1	01	01	H0978_009_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	1
H0978	010	0	1	01	01	H0978_010_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010						2	2	2	3												2	1														2						2					1	01000000	20	20															2		2																		1	2
H0978	011	0	1	01	01	H0978_011_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H0978	802	0	1	01	01	H0978_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0978	803	0	1	01	01	H0978_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H0982	002	0	1	01	01	H0982_002_0	13	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	1	1	1011111						2	2	2	3		2	2	3	3		2	2	2	3		2	2	2	3		2	1				2	2	1	6	Dentures every 5 years	2						2					2																		2		2																		1	1
H0982	007	0	1	01	01	H0982_007_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	1	1	1011111						2	2	1	3		2	2	3	3		2	2	2	3		2	2	3	2		2	1				2	2	1	6	Dentures every 5 years	2						2					2																		2		2																		1	1
H0982	008	0	1	01	01	H0982_008_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	1	1	1011111						2	2	1	3		2	2	3	3		2	2	2	3		2	2	2	2		2	1				2	2	1	6	Dentures every 5 years	2						2					2																		2		2																		1	1
H0982	009	0	1	01	01	H0982_009_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	1	1	1011111						2	2	1	3		2	2	3	3		2	2	2	3		2	2	2	2		2	1				2	2	1	6	Dentures every 5 years	2						2					2																		2		2																		1	1
H0982	010	0	1	01	01	H0982_010_0	13	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	1	1	1011111						2	2	1	3		2	2	3	3		2	2	2	3		2	2	2	3		2	1				2	2	1	6	Dentures every 5 years	2						2					2																		2		2																		1	1
H0982	012	0	1	01	01	H0982_012_0	13	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	1	1	1011111						2	2	2	3		2	2	3	3		2	2	2	3		2	2	2	3		2	1				2	2	1	6	Dentures every 5 years	2						2					2																		2		2																		1	1
H0982	013	0	1	01	01	H0982_013_0	13	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	1	1	1011111						2	2	2	3		2	2	3	3		2	2	2	3		2	2	2	3		2	1				2	2	1	6	Dentures every 5 years	2						2					2																		2		2																		1	1
H0982	016	0	1	01	01	H0982_016_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	1	1	1011111						2	2	2	3		2	2	3	3		2	2	2	3		2	2	4	3		2	1				2	2	1	6	Dentures every 5 years	2						2					2																		2		2																		1	1
H0982	017	0	1	01	01	H0982_017_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	1	1	1011111						2	2	1	3		2	2	3	3		2	2	2	3		2	2	3	2		2	1				2	2	1	6	Dentures every 5 years	2						2					2																		2		2																		1	1
H0982	018	0	1	01	01	H0982_018_0	13	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	1	1	1011111						2	2	1	3		2	2	3	3		2	2	2	3		2	2	2	2		2	1				2	2	1	6	Dentures every 5 years	2						2					2																		2		2																		1	1
H0982	019	0	1	01	01	H0982_019_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	1	1	1011111						2	2	1	3		2	2	3	3		2	2	2	3		2	2	2	2		2	1				2	2	1	6	Dentures every 5 years	2						2					2																		2		2																		1	1
H0982	020	0	1	01	01	H0982_020_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	1	1	1011111						2	2	1	3		2	2	3	3		2	2	2	3		2	2	2	2		2	1				2	2	1	6	Dentures every 5 years	2						2					2																		2		2																		1	1
H0982	021	0	1	01	01	H0982_021_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	1	1	1011111						2	2	1	3		2	2	3	3		2	2	2	3		2	2	2	2		2	1				2	2	1	6	Dentures every 5 years	2						2					2																		2		2																		1	1
H0982	022	0	1	01	01	H0982_022_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	1	1	1011111						2	2	2	3		2	2	3	3		2	2	2	3		2	2	4	3		2	1				2	2	1	6	Dentures every 5 years	2						2					2																		2		2																		1	1
H1016	001	0	1	01	01	H1016_001_0	8	1	1110	2	1				2	2	2	3							2	2	1	2		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	2	4	3		2	2	3	3		2	1				2						2					2																		2		1	11111111	0.00	175.00	0.00	165.00	0.00	0.00	0.00	140.00	22.00	535.00	0.00	435.00	70.00	175.00	0.00	550.00	1	2
H1016	021	0	1	01	01	H1016_021_0	8	1	1110	2	1				2	2	2	3							2	2	1	2		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	2	4	3		2	2	3	3		2	1				2						2					2																		2		1	11111111	10.00	200.00	0.00	165.00	0.00	0.00	0.00	140.00	22.00	535.00	0.00	435.00	70.00	175.00	0.00	550.00	1	2
H1016	023	0	1	01	01	H1016_023_0	8	1	1110	2	1				2	2	2	3							2	2	1	2		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	2	3		2	2	1	3		2	2	1	3		2	2	3	3		2	2	1	6	For all listed dentures and partial dentures, Copayment includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement. The Enrollee must continue to be eligible, and the service must be provided at the Network Dentist's facility where the denture was originally delivered.Implant Services - 2 Implant covered at $0 copay	2						2					2																		2		1	11111111	0.00	100.00	0.00	0.00	0.00	147.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1016	024	0	1	01	01	H1016_024_0	8	1	1110	2	1				2	2	2	3							2	2	1	2		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	2	3		2	2	1	3		2	2	1	3		2	2	3	3		2	2	1	6	For all listed dentures and partial dentures, Copayment includes after delivery adjustments and tissue conditioning, if needed. Implant Services - 2 Implant covered at $0 copay	2						2					2																		2		1	11111111	0.00	100.00	0.00	0.00	0.00	147.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1016	025	0	1	02	01	H1016_025_0	9	1	1110	2	1				2	2	2	3							2	2	1	2		2					2				2		2												2		1	1110	2				0.00	25.00	0.00	0.00			0.00	35.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	2	4	3		2	2	3	3		2	1				2						2					2																		2		1	11111111	10.00	175.00	0.00	165.00	0.00	35.00	22.00	530.00	22.00	535.00	0.00	435.00	70.00	175.00	0.00	550.00	1	2
H1016	026	0	1	02	01	H1016_026_0	9	1	1110	2	1				2	2	2	3							2	2	1	2		2					2				2		2												2		1	1110	2				0.00	25.00	0.00	0.00			0.00	35.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	2	4	3		2	2	3	3		2	1				2						2					2																		2		1	11111111	10.00	175.00	0.00	165.00	0.00	35.00	22.00	530.00	22.00	535.00	0.00	435.00	70.00	175.00	0.00	550.00	1	2
H1016	029	0	1	01	01	H1016_029_0	8	1	1110	2	1				2	2	2	3							2	2	1	2		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	2	3		2	2	1	3		2	2	1	3		2	2	3	3		2	2	1	6	Oral, Maxillofacial Surgery, Prosthodontics	2						2					2																		2		1	11111111	20.00	175.00	0.00	165.00	0.00	0.00	0.00	140.00	22.00	535.00	0.00	435.00	70.00	175.00	0.00	550.00	1	2
H1016	030	0	1	01	01	H1016_030_0	7	1	1110	2	1				2	2	2	3							2	2	1	2		2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1011111						2	1				2	2	2	3		2	2	1	3		2	2	1	3		2	2	3	3		2	1				1		2	2500.00	3		2					1	10001111							20	50	20	20	20	20	20	20	20	50	2		1	01010000	20.00	50.00			0.00	0.00											1	2
H1016	031	0	1	01	01	H1016_031_0	8	1	1110	2	1				2	2	2	3							2	2	1	2		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	2	3		2	2	1	3		2	2	1	3		2	2	3	3		2	2	1	6	For all listed dentures and partial dentures, 2 Implant covered at $0 copay	2						2					2																		2		1	11111111	0.00	100.00	0.00	0.00	0.00	147.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1016	032	0	1	01	01	H1016_032_0	8	1	1110	2	1				2	2	2	3							2	2	1	2		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	2	3		2	2	1	3		2	2	1	3		2	2	3	3		2	2	1	6	For all listed dentures and partial dentures, Copayment includes after delivery adjustments and tissue conditioning, if needed.Implant Services - 2 Implant covered at $0 copay	2						2					2																		2		1	11111111	0.00	100.00	0.00	0.00	0.00	147.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1016	801	0	1	01	01	H1016_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1016	802	0	1	01	01	H1016_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1016	803	0	1	01	01	H1016_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1016	804	0	1	01	01	H1016_804_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1019	001	0	1	01	01	H1019_001_0	6	1	1111	2	2	4	3		2	2	6	3		2	2	2	3		2	2	3	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011111						2	2	1	1		2	2	5	3		2	2	1	3		2	2	1	3		2	2	3	3		2	2	4	6	Denture reline up to 1 per year, oral surgery up to 2 per year, partial or complete dentures up to 1 set(s) every 5 years.	2						2					2																		2		1	11011111	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	006	0	1	01	01	H1019_006_0	6	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	3	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011111						2	2	1	1		2	2	6	3		2	2	1	3		2	2	1	3		2	2	6	3		2	2	2	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include complete dentures or partial dentures up to 1 set(s) every 5 years and denture reline up to 1 per year.	2						2					2																		2		1	11011111	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	023	0	1	01	01	H1019_023_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	026	0	1	01	01	H1019_026_0	6	1	1111	2	1				2	1				2	1				2	1				1		6000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	043	0	1	01	01	H1019_043_0	6	1	1111	2	2	2	3		2	2	6	3		2	2	2	3		2	2	3	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011111						2	2	1	1		2	2	5	3		2	2	1	3		2	2	1	3		2	2	3	3		2	2	2	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include complete dentures up to 1 set(s) every 5 years and denture reline up to 1 per year.	2						2					2																		2		1	11011111	10.00	10.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	057	0	1	02	01	H1019_057_0	6	1	1111	2	2	4	3		2	2	6	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	1	3		2	2	3	6	Extractions include unlimited extractions which are covered only for the purpose of member receiving dentures, all other extractions are limited to 3 per year.	2	2	2	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include denture reline up to 1 per year, partial or complete dentures up to 1 set(s) every 5 years.	2						2					2																		2		1	11011111	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	065	0	1	01	01	H1019_065_0	6	1	1111	2	2	2	3		2	2	6	3		2	2	2	3		2	2	2	6	Dental X-Rays include bitewing x-rays up to 1 set(s) per year and panoramic film up to 1 every 3 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011001						2	2	1	1		2	2	2	3												2	2	2	3		2	2	1	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures or complete dentures up to 1 set(s) every 5 years.	2						2					2																		2		1	11011001	20.00	20.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	1
H1019	069	0	1	01	01	H1019_069_0	6	1	1111	2	2	2	3		2	2	6	3		2	2	2	3		2	2	2	6	Dental X-Rays include bitewing x-rays up to 1 set(s) per year and panoramic film up to 1 every 3 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011001						2	2	1	1		2	2	2	3												2	2	2	6	Extractions services include extractions for dentures up to unlimited per year, simple or surgical extraction up to 2 per year.	2	2	1	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures or complete dentures up to 1 set(s) every 5 years.	2						2					2																		2		1	11011001	30.00	30.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	1
H1019	073	0	1	01	01	H1019_073_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	076	0	1	01	01	H1019_076_0	6	1	1111	2	2	4	3		2	2	6	3		2	2	2	3		2	2	2	6	Dental X-Rays services include bitewing x-rays up to 1 set(s) per year, panoramic film up to 1 every 3 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0011011						2	2	1	1		2	2	4	3							2	2	1	3		2	2	4	3							2						2					2																		2		1	01011011	0.00	0.00			0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00			1	1
H1019	094	0	1	01	01	H1019_094_0	6	1	1111	2	2	4	3		2	2	6	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0011011						2	2	1	1		2	2	2	3							2	2	1	3		2	2	3	3							2						2					2																		2		1	01011011	30.00	30.00			0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00			1	1
H1019	098	0	1	01	01	H1019_098_0	6	1	1111	2	2	2	3		2	2	6	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011011						2	2	1	1		2	2	2	3							2	2	1	3		2	2	3	6	Extractions services include extractions for dentures up to unlimited per year, simple or surgical extraction up to 3 per year.	2	2	2	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures or complete dentures up to 1 set(s) every 5 years and denture reline up to 1 per year.	2						2					2																		2		1	11011011	10.00	10.00			0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	102	0	1	01	01	H1019_102_0	6	1	1111	2	2	4	3		2	2	6	3		2	2	2	3		2	2	3	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011111						2	2	1	1		2	2	5	3		2	2	1	3		2	2	1	3		2	2	3	3		2	2	2	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include complete dentures or partial dentures up to 1 set(s) every 5 years and denture reline up to 1 per year.	2						2					2																		2		1	11011111	5.00	5.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	103	1	1	01	01	H1019_103_1	5	1	1111	2	2	4	3		2	2	6	3		2	2	2	3		2	2	3	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011111						2	2	1	1		2	2	4	3		2	2	1	3		2	2	1	3		2	2	5	3		2	2	4	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include denture reline up to 1 per year, partial or complete dentures up to 1 set(s) every 5 years, oral surgery up to 2 per year.	2						2					2																		2		1	11011111	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	103	2	1	01	01	H1019_103_2	5	1	1111	2	2	2	3		2	2	6	3		2	2	2	3		2	2	2	6	Dental X-Rays include bitewing x-rays up to 1 set(s) per year and panoramic film up to 1 every 3 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011001						2	2	1	1		2	2	2	3												2	2	2	6	Extractions include unlimited extractions which are covered only for the purpose of member receiving dentures, all other extractions are limited to 2 per year.	2	2	1	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures or complete dentures up to 1 set(s) every 5 years.	2						2					2																		2		1	11011001	5.00	5.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	1
H1019	104	1	1	01	01	H1019_104_1	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include amalgam and/or composite filling up to unlimited per year, crown up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planning (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	10	6	Dent. Adj., rebase,reline,repair,and tissue conditioning 1/yr, comp/part. dent. 1 every 5 yrs., occlusal adjustment 1 every 3 yrs, oral surgery 2 per yrs.	1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	104	2	1	01	01	H1019_104_2	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include amalgam and/or composite filling up to unlimited per year, crown up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Dent. Adj., rebase,reline,repair,and tissue conditioning 1/yr, comp/part. dent. 1 every 5 yrs., occlusal adjustment 1 every 3 yrs, oral surgery 2 per yrs.	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	108	0	1	01	01	H1019_108_0	13	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include amalgam and/or composite filling up to unlimited per year, crown up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, and repair and tissue conditioning 1/yr. Complete/partial dentures 1/5 yrs. Occlusal adjustment 1/3 yrs. Oral surgery 2/yr.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	109	0	1	01	01	H1019_109_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include amalgam and/or composite filling up to unlimited per year, crown up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adj., denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete and partial dentures 1 every 5  years, occlusal adj. 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	110	0	1	02	01	H1019_110_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include amalgam and/or composite filling up to unlimited per year, crown up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adj., denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete and partial dentures 1 every 5  years, occlusal adj. 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	113	0	1	01	01	H1019_113_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include amalgam and/or composite filling up to unlimited per year, crown up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adj., denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete and partial dentures 1 every 5  years, occlusal adj. 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	117	0	1	01	01	H1019_117_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include amalgam and/or composite filling up to unlimited per year, crown up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adj., denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete and partial dentures 1 every 5  years, occlusal adj. 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	118	0	1	01	01	H1019_118_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include amalgam and/or composite filling up to unlimited per year, crown up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adj., denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete and partial dentures 1 every 5  years, occlusal adj. 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	119	0	1	01	01	H1019_119_0	4	1	1111	2	2	4	3		2	2	6	3		2	2	2	3		2	2	3	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011111						2	2	1	1		2	2	5	3		2	2	1	3		2	2	1	3		2	2	3	3		2	2	2	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include complete dentures or partial dentures up to 1 set(s) every 5 years and denture reline up to 1 per year.	2						2					2																		2		1	11011111	40.00	40.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	120	1	1	01	01	H1019_120_1	6	1	1111	2	2	2	3		2	2	6	3		2	2	2	3		2	2	2	6	Dental X-Rays include bitewing x-rays up to 1 set(s) per year and panoramic film up to 1 every 3 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011001						2	2	1	1		2	2	2	3												2	2	2	6	Extractions include unlimited extractions which are covered only for the purpose of member receiving dentures, all other extractions are limited to 2 per year.	2	2	1	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures or complete dentures up to 1 set(s) every 5 years.	2						2					2																		2		1	11011001	15.00	15.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	1
H1019	120	2	1	01	01	H1019_120_2	6	1	1111	2	2	2	3		2	2	6	3		2	2	2	3		2	2	2	6	Dental X-Rays include bitewing x-rays up to 1 set(s) per year and panoramic film up to 1 every 3 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011001						2	2	1	1		2	2	2	3												2	2	2	3		2	2	1	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures or complete dentures up to 1 set(s) every 5 years.	2						2					2																		2		1	11011001	25.00	25.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	1
H1019	121	0	1	01	01	H1019_121_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include amalgam and/or composite filling up to unlimited per year, bridge recementation and crown recementation up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	Denture adjustment, rebase, reline, repair, and tissue conditioning 1 per year, bridges, complete and partial 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	122	0	1	01	01	H1019_122_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include amalgam and/or composite filling up to unlimited per year, crown up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adj., denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete and partial dentures 1 every 5  years, occlusal adj. 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	123	0	1	01	01	H1019_123_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include amalgam and/or composite filling up to unlimited per year, bridge recementation and crown recementation up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	Denture adjustment, rebase, reline, repair, and tissue conditioning 1 per year, bridges, complete and partial 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	124	0	1	01	01	H1019_124_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include amalgam and/or composite filling up to unlimited per year, bridge recementation and crown recementation up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	Denture adj., rebase, reline, repair, and tissue conditioning up to 1/year, bridges, complete and partial dentures up to 1/5 years, occlusal adjustment up to 1/3 years, oral surgery up to 2/year	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	125	0	1	01	01	H1019_125_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include amalgam and/or composite filling up to unlimited per year, crown up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adj., denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete and partial dentures 1 every 5  years, occlusal adj. 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	130	0	1	01	01	H1019_130_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include amalgam and/or composite filling up to unlimited per year, bridge recementation and crown recementation up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	Denture adjustment, rebase, reline, repair, and tissue conditioning 1 per year, bridges, complete and partial 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	131	0	1	01	01	H1019_131_0	4	1	1111	2	2	2	3		2	2	6	3		2	2	2	3		2	2	3	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011111						2	2	1	1		2	2	5	3		2	2	1	3		2	2	1	3		2	2	6	6	Extractions services include extractions for dentures up to unlimited per year, simple or surgical extraction up to 6 per year.	2	2	3	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services services include denture reline and restoration implant up to 1 per year, partial or complete dentures up to 1 set(s) every 5 years.	2						2					2																		2		1	11011111	30.00	30.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	132	0	1	01	01	H1019_132_0	4	1	1111	2	2	4	3		2	2	6	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011011						2	2	1	1		2	2	2	3							2	2	1	3		2	2	3	6	Extractions include unlimited extractions which are covered only for the purpose of member receiving dentures, all other extractions are limited to 3 per year.	2	2	2	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include denture reline up to 1 per year, partial or complete dentures up to 1 set(s) every 5 years.	2						2					2																		2		1	11011011	30.00	30.00			0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	133	0	1	01	01	H1019_133_0	3	1	1111	2	2	4	3		2	2	6	3		2	2	2	3		2	2	3	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011011						2	2	1	1		2	2	6	3							2	2	1	3		2	2	6	3		2	2	2	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures or complete dentures up to 1 set(s) every 5 years and denture reline up to 1 per year.	2						2					2																		2		1	11011011	30.00	30.00			0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	134	0	1	01	01	H1019_134_0	5	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	2	6	Dental X-Rays include bitewing x-rays up to 1 set(s) per year and panoramic film up to 1 every 3 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011001						2	2	1	1		2	2	2	3												2	2	2	6	Extractions services include extractions for dentures up to unlimited per year, simple or surgical extraction up to 2 per year.	2	2	1	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include complete dentures, partial dentures up to 1 set(s) every 5 years.	2						2					2																		2		1	11011001	20.00	20.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	1
H1019	135	0	1	01	01	H1019_135_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include amalgam and/or composite filling up to unlimited per year, bridge recementation and crown recementation up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	Denture adjustment, rebase, reline, repair, and tissue conditioning 1 per year, bridges, complete and partial 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	136	0	1	01	01	H1019_136_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include amalgam and/or composite filling up to unlimited per year, crown up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adj., denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete and partial dentures 1 every 5  years, occlusal adj. 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	137	0	1	01	01	H1019_137_0	5	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	138	0	1	01	01	H1019_138_0	5	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	139	0	1	01	01	H1019_139_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include amalgam and/or composite filling up to unlimited per year, crown up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair and tissue conditioning up to 1/year, complete and partial dentures up to 1/5 years, occlusal adjustment up to 1/3 years, oral surgery up to 2/year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	140	0	1	01	01	H1019_140_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	141	0	1	02	01	H1019_141_0	11	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	2	6	Dental X-Rays include bitewing x-rays up to 1 set(s) per year and panoramic film up to 1 every 3 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011001						2	2	1	1		2	2	2	3												2	2	2	3		2	2	1	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures and complete dentures up to 1 set(s) every 5 years.	2						2					2																		2		1	11011001	5.00	5.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	1
H1019	142	0	1	02	01	H1019_142_0	5	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	2	6	Dental X-Rays include bitewing x-rays up to 1 set(s) per year and panoramic film up to 1 every 3 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011001						2	2	1	1		2	2	2	3												2	2	2	3		2	2	1	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures and complete dentures up to 1 set(s) every 5 years.	2						2					2																		2		1	11011001	5.00	5.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	1
H1019	143	0	1	02	01	H1019_143_0	3	1	1111	2	2	4	3		2	2	6	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	1	3		2	2	3	3		2	2	2	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include denture reline up to 1 per year, partial or complete dentures up to 1 set(s) every 5 years.	2						2					2																		2		1	11011111	40.00	40.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	144	0	1	01	01	H1019_144_0	5	1	1111	2	2	2	3		2	2	6	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1011011						2	2	1	1		2	2	2	3							2	2	1	3		2	2	3	3		2	2	2	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services services include denture reline up to 1 per year, partial or complete dentures up to 1 set(s) every 5 years.	2						2					2																		2		1	11011011	35.00	35.00			0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1019	145	0	1	01	01	H1019_145_0	5	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1019	146	0	1	01	01	H1019_146_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1032	124	0	1	01	01	H1032_124_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	170	0	1	01	01	H1032_170_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	175	0	1	01	01	H1032_175_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 months.Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	176	0	1	01	01	H1032_176_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 months.Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	189	0	1	01	01	H1032_189_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	30.00	30.00	0.00	0.00	0.00	0.00											1	2
H1032	190	0	1	01	01	H1032_190_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	16B Comprehensive Dental - OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1500.00	3		2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	191	0	1	01	01	H1032_191_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	25.00	25.00	0.00	0.00	0.00	0.00											1	2
H1032	192	0	1	01	01	H1032_192_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	193	0	1	01	01	H1032_193_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	10.00	10.00	0.00	0.00	0.00	0.00											1	2
H1032	194	0	1	01	01	H1032_194_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	195	0	1	01	01	H1032_195_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	0.00	0.00															1	2
H1032	196	0	1	01	01	H1032_196_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	198	0	1	01	01	H1032_198_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	15.00	15.00	0.00	0.00	0.00	0.00											1	2
H1032	199	0	1	01	01	H1032_199_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	200	0	1	01	01	H1032_200_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1500.00	3		2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	201	0	1	01	01	H1032_201_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	5000.00	3		2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	202	0	1	01	01	H1032_202_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	5000.00	3		2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	204	0	1	01	01	H1032_204_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	30.00	30.00	0.00	0.00	0.00	0.00											1	2
H1032	205	0	1	01	01	H1032_205_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	206	0	1	01	01	H1032_206_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	209	0	1	01	01	H1032_209_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	35.00	35.00	0.00	0.00	0.00	0.00											1	2
H1032	210	0	1	01	01	H1032_210_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	20.00	20.00	0.00	0.00	0.00	0.00											1	2
H1032	211	0	1	01	01	H1032_211_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	212	0	1	01	01	H1032_212_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	0.00	0.00	0.00	0.00	0.00	0.00											1	2
H1032	213	0	1	01	01	H1032_213_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	5000.00	3		2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	218	0	1	01	01	H1032_218_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1032	237	0	1	01	01	H1032_237_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	002	0	1	02	01	H1035_002_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, orFull mouth (Intraoral complete series) or Panoramic radiographic image X-rays: 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	20.00	20.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	006	0	1	01	01	H1035_006_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1000001																										2	2	2	3		2	2	2	3		2						2					2																		2		1	11000001	30.00	30.00											0.00	0.00	0.00	0.00	1	1
H1035	011	0	1	01	01	H1035_011_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing X-rays (1 series set) 1 a year, orFull mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1000001																										2	2	2	3		2	2	2	3		2						2					2																		2		1	11000001	20.00	20.00											0.00	0.00	0.00	0.00	1	2
H1035	014	0	1	01	01	H1035_014_0	7	2																																																															2																																											2					2																		2		1	01000000	50.00	50.00															1	1
H1035	016	0	1	01	01	H1035_016_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1000001																										2	2	2	3		2	2	2	3		2						2					2																		2		1	11000001	20.00	20.00											0.00	0.00	0.00	0.00	1	2
H1035	017	0	1	01	01	H1035_017_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	20.00	20.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	018	0	1	01	01	H1035_018_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1000001																										2	2	2	3		2	2	2	3		2						2					2																		2		1	11000001	5.00	5.00											0.00	0.00	0.00	0.00	1	2
H1035	019	0	1	01	01	H1035_019_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	40.00	40.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	020	0	1	01	01	H1035_020_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	35.00	35.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	021	0	1	01	01	H1035_021_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	40.00	40.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	022	0	1	01	01	H1035_022_0	9	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	5.00	5.00															1	2
H1035	023	0	1	01	01	H1035_023_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	6	3		2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	15.00	15.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	024	0	1	01	01	H1035_024_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	7	3		2	2	2	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	025	0	1	01	01	H1035_025_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	13	3		2	2	4	3		2	2	2	6	Scaling and root planning 1 per quadrant per 24 month periodFull mouth debridement 1 per 36 months	2	2	8	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	026	0	1	01	01	H1035_026_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	13	3		2	2	4	3		2	2	2	6	Scaling and root planning 1 per quadrant per 24 month periodFull mouth debridement 1 per 36 months	2	2	8	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	10.00	10.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	027	0	1	01	01	H1035_027_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	2	6	Scaling and root planning 1 per quadrant per 24 month periodFull mouth debridement 1 per 36 months	2	2	4	3		2	2	7	6	Denture - Complete/Partial: 1 set per 60 monthsDenture Adjustments: 2 per year Repairs, Replacements: 2 per year w/a max of 5 total within 5 calendar years Reline: 2 per year	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	028	0	1	01	01	H1035_028_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	2	6	Scaling and root planning 1 per quadrant per 24 month periodFull mouth debridement 1 per 36 months	2	2	4	3		2	2	7	6	Denture - Complete/Partial: 1 set per 60 monthsDenture Adjustments: 2 per year Repairs, Replacements: 2 per year w/a max of 5 total within 5 calendar years Reline: 2 per year	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	029	0	1	01	01	H1035_029_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	2	6	Scaling and root planning 1 per quadrant per 24 month periodFull mouth debridement 1 per 36 months	2	2	4	3		2	2	7	6	Denture - Complete/Partial: 1 set per 60 monthsDenture Adjustments: 2 per year Repairs, Replacements: 2 per year w/a max of 5 total within 5 calendar years Reline: 2 per year	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	030	0	1	01	01	H1035_030_0	12	1	1111	2	1				2	1				2	1				2	1				1		6000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	0.00															1	2
H1035	031	0	1	01	01	H1035_031_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	2	6	Scaling and root planning 1 per quadrant per 24 month periodFull mouth debridement 1 per 36 months	2	2	4	3		2	2	7	6	Denture - Complete/Partial: 1 set per 60 monthsDenture Adjustments: 2 per year Repairs, Replacements: 2 per year w/a max of 5 total within 5 calendar years Reline: 2 per year	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	032	0	1	01	01	H1035_032_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	2	6	Scaling and root planning 1 per quadrant per 24 month periodFull mouth debridement 1 per 36 months	2	2	4	3		2	2	7	6	Denture - Complete/Partial: 1 set per 60 monthsDenture Adjustments: 2 per year Repairs, Replacements: 2 per year w/a max of 5 total within 5 calendar years Reline: 2 per year	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	033	0	1	01	01	H1035_033_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	13	3		2	2	4	3		2	2	2	6	Scaling and root planning 1 per quadrant per 24 month periodFull mouth debridement 1 per 36 months	2	2	8	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	15.00	15.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	034	0	1	01	01	H1035_034_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	6	3		2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	10.00	10.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	040	0	1	01	01	H1035_040_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing X-rays (1 series set) 1 a year, orFull mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1000001																										2	2	2	3		2	2	2	3		2						2					2																		2		1	11000001	20.00	20.00											0.00	0.00	0.00	0.00	1	2
H1035	043	0	1	01	01	H1035_043_0	9	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H1035	045	0	1	01	01	H1035_045_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	6	3		2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	15.00	15.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	046	0	1	01	01	H1035_046_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	25.00	25.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	047	0	1	01	01	H1035_047_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	30.00	30.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	048	0	1	01	01	H1035_048_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	6	3		2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	10.00	10.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1035	050	0	1	01	01	H1035_050_0	12	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	0.00															1	2
H1035	052	0	1	01	01	H1035_052_0	9	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	5.00	5.00															1	2
H1035	801	0	1	01	01	H1035_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1035	802	0	1	01	01	H1035_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1036	025	0	1	01	01	H1036_025_0	5	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	044	0	1	01	01	H1036_044_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays - Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.						2	2	2	1		2	1				2	2	8	6	Services include partial denturescomplete dentures up to 1 5 years, denture adjustment enture reline denture repair denture rebase tissue conditioning up to 1 per year, occ adjustments up to 1 every 3	1		1				2					2																		2		1	11111011	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	054	0	1	01	01	H1036_054_0	6	1	1111	2	1				2	1				2	1				2	1				1		6000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	062	0	1	01	01	H1036_062_0	7	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	065	0	1	01	01	H1036_065_0	6	1	1111	2	1				2	1				2	1				2	1				1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	068	0	1	01	01	H1036_068_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.						2	2	2	1		2	1				2	2	8	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year.	1		1				2					2																		2		1	11111011	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	074	0	1	01	01	H1036_074_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	2	6	Fillings to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.						2	2	2	1		2	1				2	2	8	6	Denture adjustments, rebase, reline, repair, tissue conditioning up to 1 per year, complete dentures and partial dentures up to 1 every 5 years, occlusal adjustment up to 1 every 3 years.	1		1				2					2																		2		1	11111011	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	077	0	1	01	01	H1036_077_0	6	1	1111	2	1				2	1				2	1				2	1				1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	102	0	1	01	01	H1036_102_0	6	1	1111	2	1				2	1				2	1				2	1				1		6000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	119	0	1	01	01	H1036_119_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	4	6	Fillings to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.						2	2	2	1		2	1				2	2	8	6	Denture adjustments, rebase, reline, repair, tissue conditioning up to 1 per year, complete dentures and partial dentures up to 1 every 5 years, occlusal adjustment up to 1 every 3 years.	1		1				2					2																		2		1	11111011	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	121	0	1	01	01	H1036_121_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings $25 up to unlimited per year, recementation of crown $25 up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	9	6	Adjustments to dentures, denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete/partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	15.00	15.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1
H1036	137	0	1	02	01	H1036_137_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1500.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1036	143	0	1	01	01	H1036_143_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	2	6	Fillings to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.						2	2	2	1		2	1				2	2	8	6	Denture adjustments, rebase, reline, repair, tissue conditioning up to 1 per year, complete dentures and partial dentures up to 1 every 5 years, occlusal adjustment up to 1 every 3 years.	1		1				2					2																		2		1	11111011	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	146	0	1	01	01	H1036_146_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	2	6	Fillings to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.						2	2	2	1		2	1				2	2	8	6	Denture adjustments, rebase, reline, repair, tissue conditioning up to 1 per year, complete dentures and partial dentures up to 1 every 5 years, occlusal adjustment up to 1 every 3 years.	1		1				2					2																		2		1	11111011	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	151	0	1	01	01	H1036_151_0	6	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1036	153	0	1	01	01	H1036_153_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1036	157	0	1	01	01	H1036_157_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111011	2	2	2	3		2	2	1	1		2	2	5	6	Amalgam and/or Composite fillings 2 per year; Recementation of crown 1 every 5 years; Crown 1 per tooth per lifetime; Core buildup and prefabricated post and core 1 per tooth per lifetime						2	2	2	1		2	2	2	3		2	2	8	6	Adjustments to dentures, denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete/partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years.	1		1				2					1	10011000					0	0	50	50							50	50	2		1	01101011	25.00	25.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1
H1036	160	0	1	01	01	H1036_160_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010						2	2	1	1		2	1									2	2	2	1												1		1				2					2																		2		1	01011010	15.00	15.00			0.00	0.00	0.00	0.00			0.00	0.00					1	1
H1036	167	0	1	01	01	H1036_167_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays 1 set(s) per year, panoramic film or diagnostic x-rays 1 every 5 years	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1036	209	0	1	01	01	H1036_209_0	7	1	1111	2	1				2	1				2	1				2	1				1		6000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	210	0	1	01	01	H1036_210_0	7	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	213	0	1	01	01	H1036_213_0	7	1	1111	2	1				2	1				2	1				2	1				1		6000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	214	0	1	01	01	H1036_214_0	7	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	217	0	1	01	01	H1036_217_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	3	6	Fillings unlimited per year, crown recementation 1 every 5 years, crown 1 per tooth per lifetime, other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.						2	2	2	1		2	1				2	2	8	6	Partial dentures and complete dentures up to 1 every 5 years, denture adjustment and denture reline and denture repair and denture rebase and tissue conditioning up to 1 per year, occlusal adjustments	1		1				2					2																		2		1	11111011	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	219	0	1	01	01	H1036_219_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Amalgam and/or composite filling unlimited per yr, bridge/crown recementation 1 every 5 yrs, crown/other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1036	222	0	1	01	01	H1036_222_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1036	226	0	1	01	01	H1036_226_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	Adjustments to dentures, denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete/partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years.	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	229	0	1	01	01	H1036_229_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays up to 1 set(s) per year and panoramic film and/or diagnostic x-rays up to 2 every 3 years.	1		2000.00	3		2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	0011010						2	2	1	1		2	1									2	2	1	1												1		1				2					2																		2		1	01001000	15.00	15.00					0.00	0.00									1	1
H1036	230	0	1	01	01	H1036_230_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	2	6	Fillings to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.						2	2	2	1		2	1				2	2	8	6	Denture adjustments, rebase, reline, repair, tissue conditioning up to 1 per year, complete dentures and partial dentures up to 1 every 5 years, occlusal adjustment up to 1 every 3 years.	1		1				2					2																		2		1	11111011	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	233	0	1	02	01	H1036_233_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1036	234	0	1	01	01	H1036_234_0	7	1	1111	2	1				2	1				2	1				2	1				1		6000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1036	235	0	1	01	01	H1036_235_0	6	1	1111	2	1				2	1				2	1				2	1				1		6000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1036	236	0	1	01	01	H1036_236_0	7	1	1111	2	1				2	1				2	1				2	1				1		6000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1036	265	1	1	01	01	H1036_265_1	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	4	6	Fillings to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.						2	2	2	1		2	1				2	2	8	6	Denture adjustments, rebase, reline, repair, tissue conditioning up to 1 per year, complete dentures and partial dentures up to 1 every 5 years, occlusal adjustment up to 1 every 3 years.	1		1				2					2																		2		1	11111011	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	265	2	1	01	01	H1036_265_2	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime, core buildup and prefabricated post and core up to 1 per tooth per lifetime						2	2	2	1		2	1				2	2	8	6	Partial dentures and complete dentures up to 1 every 5 years, denture adjustment and denture reline and denture repair and denture rebase and tissue conditioning up to 1 per year, occlusal adjustments	1		1				2					2																		2		1	11111011	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	266	0	1	01	01	H1036_266_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	4	6	Fillings to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.						2	2	2	1		2	1				2	2	8	6	Denture adjustments, rebase, reline, repair, tissue conditioning up to 1 per year, complete dentures and partial dentures up to 1 every 5 years, occlusal adjustment up to 1 every 3 years.	1		1				2					2																		2		1	11111011	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	269	0	1	01	01	H1036_269_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime, core buildup and prefabricated post and core up to 1 per tooth per lifetime						2	2	2	1		2	1				2	2	8	6	Partial/complete Dentures up to 1 every 5 years, denture adjustment, denture reline, denture repair, denture rebase, tissue conditioning up to 1 per year, occlusal adjustments up to 1 every 3 years	1		1				2					2																		2		1	11111011	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	270	0	1	01	01	H1036_270_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.						2	2	2	1		2	1				2	2	8	6	includes partial dentures, complete dentures up to 1 per 5 years, denture adjustment, denture reline, denture repair, denture rebase and tissue conditioning up to 1 per year, occlusal up to 1 per 3 yr	1		1				2					2																		2		1	11111011	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	271	0	1	01	01	H1036_271_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	2	6	Fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime core buildup and prefabricated post and core up to 1 per tooth per lifetime.						2	2	2	1		2	1				2	2	8	6	Partial/complete dentures up to 1 every 5 years, denture adjustment, denture reline, denture repair, denture rebase, tissue conditioning up to 1 per year, occlusal adjustments up to 1 every 3 years.	1		1				2					2																		2		1	11111011	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	278	0	1	01	01	H1036_278_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010						2	2	1	1		2	1									2	2	2	1												1		1				2					2																		2		1	01011010	35.00	35.00			0.00	0.00	0.00	0.00			0.00	0.00					1	1
H1036	279	0	1	01	01	H1036_279_0	10	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	280	0	1	01	01	H1036_280_0	5	1	1111	2	1				2	1				2	1				2	1				1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	285	0	1	01	01	H1036_285_0	6	1	1111	2	1				2	1				2	1				2	1				1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	286	0	1	01	01	H1036_286_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	Adjustments to dentures, denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete/partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	290	0	1	01	01	H1036_290_0	3	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010						2	2	1	1		2	1									2	2	2	1												1		1				2					2																		2		1	01011010	25.00	25.00			0.00	0.00	0.00	0.00			0.00	0.00					1	1
H1036	291	0	1	02	01	H1036_291_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1036	292	0	1	01	01	H1036_292_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings $25 up to unlimited per year, recementation of crown $25 up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Adjustments to dentures, denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete/partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	20.00	20.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1
H1036	295	0	1	01	01	H1036_295_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Every 5 years	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	1	1111011	2	2	2	3		2	2	1	1		2	2	3	6	Fillings to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.						2	2	2	1		2	1				2	2	8	6	Denture adjustments, rebase, reline, repair, tissue conditioning up to 1 per year, complete dentures and partial dentures up to 1 every 5 years, occlusal adjustment up to 1 every 3 years.	1		1				2					2																		2		1	11111011	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	297	0	1	01	01	H1036_297_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings $25 up to unlimited per year, recementation of crown $25 up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	15.00	15.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1
H1036	298	0	1	01	01	H1036_298_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings $25 up to unlimited per year, recementation of crown $25 up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	Adjustments to dentures, denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete/partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years.	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	299	0	1	01	01	H1036_299_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111011	2	2	2	3		2	2	1	1		2	2	3	6	Fillings to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.						2	2	2	1		2	1				2	2	8	6	Denture adjustments, rebase, reline, repair, tissue conditioning up to 1 per year, complete dentures and partial dentures up to 1 every 5 years, occlusal adjustment up to 1 every 3 years.	1		1				2					2																		2		1	11111011	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	300	0	1	01	01	H1036_300_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.						2	2	2	1		2	1				2	2	8	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services, partial dentures complete dentures up to 1 every 5 years	1		1				2					2																		2		1	11111011	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	301	0	1	01	01	H1036_301_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010						2	2	1	1		2	1									2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.											1		1				2					2																		2		1	01011010	35.00	35.00			0.00	0.00	0.00	0.00			0.00	0.00					1	1
H1036	302	0	1	01	01	H1036_302_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.						2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	8	6	Adjustments to dentures, denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete/partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years.	1		1				2					2																		2		1	11111011	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	304	0	1	01	01	H1036_304_0	5	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	305	0	1	01	01	H1036_305_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings $25 up to unlimited per year, recementation of crown $25 up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services services include adjustments to dentures, denture rebase, denture reline, denture repair and tissue conditioning up to 1 per year, comp	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	20.00	20.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1
H1036	306	0	1	01	01	H1036_306_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1036	307	0	1	01	01	H1036_307_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1036	308	0	1	01	01	H1036_308_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	11	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1036	309	0	1	01	01	H1036_309_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Prosthodontics,  Oral/Maxillofacial Surgy, Othr Servcs up to 1 evry 5 yrs, oral surgy up to 2 per yr, denture adjustmnt, tissue conditioning up to 1 per yr, occlusal adjustmts up to 1 evry 3 yrs.	1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1036	310	0	1	01	01	H1036_310_0	4	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010						2	2	1	1		2	1									2	2	2	1												1		1				2					2																		2		1	01011010	15.00	15.00			0.00	0.00	0.00	0.00			0.00	0.00					1	1
H1036	311	0	1	01	01	H1036_311_0	4	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010						2	2	1	1		2	1									2	2	2	1												1		1				2					2																		2		1	01011010	15.00	15.00			0.00	0.00	0.00	0.00			0.00	0.00					1	1
H1036	312	0	1	01	01	H1036_312_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111011	2	2	2	3		2	2	1	1		2	2	3	6	Fillings to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.						2	2	2	1		2	1				2	2	8	6	Denture adjustments, rebase, reline, repair, tissue conditioning up to 1 per year, complete dentures and partial dentures up to 1 every 5 years, occlusal adjustment up to 1 every 3 years.	1		1				2					2																		2		1	11111011	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	313	0	1	01	01	H1036_313_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	2	6	Fillings to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.						2	2	2	1		2	1				2	2	8	6	Denture adjustments, rebase, reline, repair, tissue conditioning up to 1 per year, complete dentures and partial dentures up to 1 every 5 years, occlusal adjustment up to 1 every 3 years.	1		1				2					2																		2		1	11111011	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	314	0	1	01	01	H1036_314_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	315	0	1	01	01	H1036_315_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010						2	2	1	1		2	1									2	2	2	1												1		1				2					2																		2		1	01011010	35.00	35.00			0.00	0.00	0.00	0.00			0.00	0.00					1	1
H1036	316	0	1	01	01	H1036_316_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.						2	2	2	1		2	1				2	2	8	6	Adjustments to dentures, denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete/partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years.	1		1				2					2																		2		1	11111011	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1036	801	0	1	01	01	H1036_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	806	0	1	01	01	H1036_806_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	810	0	1	01	01	H1036_810_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	811	0	1	01	01	H1036_811_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	814	0	1	01	01	H1036_814_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	815	0	1	01	01	H1036_815_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	816	0	1	01	01	H1036_816_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	817	0	1	01	01	H1036_817_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	818	0	1	01	01	H1036_818_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	819	0	1	01	01	H1036_819_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	820	0	1	01	01	H1036_820_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	821	0	1	01	01	H1036_821_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	822	0	1	01	01	H1036_822_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	823	0	1	01	01	H1036_823_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	824	0	1	01	01	H1036_824_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	825	0	1	01	01	H1036_825_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	826	0	1	01	01	H1036_826_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	827	0	1	01	01	H1036_827_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	828	0	1	01	01	H1036_828_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	829	0	1	01	01	H1036_829_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	832	0	1	01	01	H1036_832_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1036	833	0	1	01	01	H1036_833_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1043	001	0	1	20	08	H1043_001_0	2																																																																																																																																																							
H1043	002	0	1	20	08	H1043_002_0	2																																																																																																																																																							
H1045	001	0	1	01	01	H1045_001_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1011001						2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.											2	2	1	3		2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2						2					2																		2		1	11011001	0.00	0.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	2
H1045	005	0	1	01	01	H1045_005_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1011001						2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.											2	2	1	3		2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2						2					2																		2		1	11011001	0.00	0.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	2
H1045	012	0	1	01	01	H1045_012_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1011001						2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.											2	2	1	3		2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2						2					2																		2		1	11011001	0.00	0.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	2
H1045	018	0	1	01	01	H1045_018_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1011001						2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.											2	2	1	3		2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2						2					2																		2		1	11011001	0.00	0.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	2
H1045	025	0	1	02	01	H1045_025_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	026	0	1	02	01	H1045_026_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	028	0	1	02	01	H1045_028_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	030	0	1	02	01	H1045_030_0	9	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	031	0	1	02	01	H1045_031_0	9	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	033	0	1	02	01	H1045_033_0	8	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	034	0	1	02	01	H1045_034_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	036	0	1	02	01	H1045_036_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	037	0	1	01	01	H1045_037_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1011001						2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.											2	2	1	3		2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2						2					2																		2		1	11011001	0.00	0.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	2
H1045	038	0	1	01	01	H1045_038_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1011001						2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.											2	2	1	3		2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2						2					2																		2		1	11011001	0.00	0.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	2
H1045	039	0	1	02	01	H1045_039_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1045	041	0	1	02	01	H1045_041_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	042	0	1	02	01	H1045_042_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	043	0	1	02	01	H1045_043_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	045	0	1	02	01	H1045_045_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	048	1	1	02	01	H1045_048_1	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	048	2	1	02	01	H1045_048_2	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	048	3	1	02	01	H1045_048_3	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	048	4	1	02	01	H1045_048_4	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	055	0	1	02	01	H1045_055_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	056	0	1	02	01	H1045_056_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1045	801	0	1	01	01	H1045_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1045	802	0	1	01	01	H1045_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1045	803	0	1	01	01	H1045_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1045	804	0	2	01	01	H1045_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1099	001	0	1	02	01	H1099_001_0	4	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H1099	006	0	1	01	01	H1099_006_0	4	1	1111	2	1				2	1				2	1				2	1				1		750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H1099	009	0	1	01	01	H1099_009_0	2	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Dental X-Rays are covered every 12 to 36 months, depending on the procedure.	1		1000.00	3		2				2		2												2		2		2												2	2	1	1001011											2	2	1	6	Fillings, whether amalgam or resin-based, are limited to coverage once every 36 months per surface per tooth.						2	2	1	6	Periodontics are covered every 12 to 36 months.	2	1				2	2	1	6	Prosthodontics are not covered. Oroantral fistula closure is covered once every 60 months. Other Services are covered every 0-12 months, depending on the procedure.	1		1				2					2																		2		1	01000000	0.00	0.00															1	2
H1099	014	0	1	01	01	H1099_014_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Dental X-Rays are covered every 12 to 36 months, depending on the procedure.	1		1250.00	3		2				2		2												2		2		2												2	2	1	1001011											2	2	1	6	Fillings, whether amalgam or resin-based, are limited to coverage once every 36 months per surface per tooth.						2	2	1	6	Periodontics are covered every 12 to 36 months.	2	1				2	2	1	6	Prosthodontics are not covered. Oroantral fistula closure is covered once every 60 months. Other Services are covered every 0-12 months, depending on the procedure.	1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H1099	016	0	1	01	01	H1099_016_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Dental X-Rays are covered every 12 to 36 months, depending on the procedure.	1		1000.00	3		2				2		2												2		2		2												2	2	1	1001011											2	2	1	6	Fillings, whether amalgam or resin-based, are limited to coverage once every 36 months per surface per tooth.						2	2	1	6	Periodontics are covered every 12 to 36 months.	2	1				2	2	1	6	Prosthodontics are not covered. Oroantral fistula closure is covered once every 60 months. Other Services are covered every 0-12 months, depending on the procedure.	1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H1109	005	0	1	01	01	H1109_005_0	6	1	1111	2	1				2	1				2	1				2	1				1		1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1109	801	0	1	01	01	H1109_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1109	802	0	1	01	01	H1109_802_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1112	006	0	1	01	01	H1112_006_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 months.Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1112	033	0	1	01	01	H1112_033_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 months.Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1112	034	0	1	02	01	H1112_034_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1112	038	0	1	01	01	H1112_038_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1112	039	0	1	01	01	H1112_039_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1112	042	0	1	01	01	H1112_042_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 60 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H1112	043	0	1	01	01	H1112_043_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1112	044	0	1	01	01	H1112_044_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	40.00	40.00															1	2
H1119	001	0	1	01	01	H1119_001_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1170	002	0	1	01	01	H1170_002_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1011011	3					4	1				4	1				3					4	1				4	1				4	1				2						2					1	10000000															75	75	2		1	11011011	15.00	15.00			0.00	0.00	28.00	580.00			0.00	400.00	22.00	22.00	0.00	480.00	1	1
H1170	008	0	1	01	01	H1170_008_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1011011	3					4	1				4	1				3					4	1				4	1				4	1				2						2					1	10000000															75	75	2		1	11011011	0.00	0.00			0.00	0.00	28.00	580.00			0.00	400.00	22.00	22.00	0.00	480.00	1	1
H1170	009	0	1	01	01	H1170_009_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1011011	3					4	1				4	1				3					4	1				4	1				4	1				2						2					1	10000000															75	75	2		1	11011011	25.00	25.00			0.00	0.00	28.00	580.00			0.00	400.00	22.00	22.00	0.00	480.00	1	1
H1170	010	0	1	01	01	H1170_010_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1011011	3					4	1				4	1				3					4	1				4	1				4	1				2						2					1	10000000															75	75	2		1	11011011	15.00	15.00			0.00	0.00	28.00	580.00			0.00	400.00	22.00	22.00	0.00	480.00	1	1
H1170	011	0	1	01	01	H1170_011_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1011011	3					4	1				4	1				3					4	1				4	1				4	1				2						2					1	10000000															75	75	2		1	11011011	0.00	0.00			0.00	0.00	28.00	580.00			0.00	400.00	22.00	22.00	0.00	480.00	1	1
H1170	012	0	1	01	01	H1170_012_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1011011	3					4	1				4	1				3					4	1				4	1				4	1				2						2					1	10000000															75	75	2		1	11011011	25.00	25.00			0.00	0.00	28.00	580.00			0.00	400.00	22.00	22.00	0.00	480.00	1	1
H1170	013	0	1	02	01	H1170_013_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1011011	3					4	1				4	1				3					4	1				4	1				4	1				2						2					1	10000000															75	75	2		1	11011011	35.00	35.00			0.00	0.00	28.00	580.00			0.00	400.00	22.00	22.00	0.00	480.00	1	1
H1170	014	0	1	01	01	H1170_014_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1011011	3					4	1				4	1				3					4	1				4	1				4	1				2						2					1	10000000															75	75	2		1	11011011	40.00	40.00			0.00	0.00	28.00	580.00			0.00	400.00	22.00	22.00	0.00	480.00	1	1
H1170	801	0	1	01	01	H1170_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1170	802	0	1	01	01	H1170_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1170	805	0	1	01	01	H1170_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1181	001	0		07	02	H1181_001_0	5																																																																																																																																																							
H1189	002	0	1	01	01	H1189_002_0	11	1	1111	2	2	1	3		2	2	1	4		2	2	1	4		2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H1189	003	0	1	01	01	H1189_003_0	10	1	1111	2	2	1	3		2	2	1	4		2	2	1	4		2	2	1	3		1		2500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H1189	004	0	1	01	01	H1189_004_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	3		1		5500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H1189	005	0	1	01	01	H1189_005_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		1		3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H1189	006	0	1	01	01	H1189_006_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		1		3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H1189	007	0	1	01	01	H1189_007_0	8	1	1111	2	2	1	3		2	2	1	4		2	2	1	4		2	2	1	3		1		2000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H1189	008	0	1	01	01	H1189_008_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	3		1		2500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H1189	009	0	1	01	01	H1189_009_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		1		4000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H1189	010	0	1	01	01	H1189_010_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		1		5000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H1206	001	0	1	02	01	H1206_001_0	5	1	1111	2	1				2	1				2	1				2	1				1		2300.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1206	002	0	1	02	01	H1206_002_0	5	1	1111	2	1				2	1				2	1				2	1				1		2300.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1206	801	0	1	01	01	H1206_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1206	802	0	1	01	01	H1206_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1215	001	0	1	01	01	H1215_001_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1500.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1215	002	0	1	01	01	H1215_002_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	2000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1215	003	0	1	01	01	H1215_003_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H1224	001	0	1	01	01	H1224_001_0	7	1	1111	2	1				2	2	3	3		2	1				2	1				2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	4		2	1				2	2	1	6	Covered endodontic services are limited to 1 per tooth per lifetime; Covered Endodontic Therapy, 1 per tooth per lifetime. No limit for all other covered services in this category.	2	1				2	1				2	2	2	6	Covered rebases, relines and tissue conditioning are limited to 2 per denture per calendar year. No limit for all other covered services in this category.	2						2					1	01000000	20	20															2		2																		1	1
H1225	001	0	1	01	01	H1225_001_0	10	1	1110	2	2	1	6	See notes for details.	2	2	1	3							2	2	1	6	See notes for details.	2					2				2		2												2		1	1110	2				20.00	20.00	20.00	20.00			20.00	20.00	2	2	2												3					3					3					3					3											2					1	01000000	20	20															2		2																		2	2
H1225	003	0	1	01	01	H1225_003_0	9	1	1110	2	2	1	6	See notes for details.	2	2	2	3							2	2	2	6	See notes for details	2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	See notes for details	2	2	1	6	Frequency of services: • Root canals and retreatment, apicoectomy, clinical crown lenghtening-once per tooth per lifetime	2	2	1	6	See notes for details	2	2	1	6	Frequency of services: • Extractions, coronectomy, surgical access of an unerupted tooth-once per tooth	2	2	1	6	See notes in details	1		2	2500.00	3		2					2																		2		2																		1	2
H1225	004	0	1	01	01	H1225_004_0	7	1	1111	2	2	2	6	Members must see a DentaQuest provider to utilize this benefit in-network. Exclusions may apply.	2	2	2	6	Prophylaxis Cleaning - 2 every year	2	2	2	6	Fluoride Treatment - 2 every year	2	2	2	6	Intraoral-complete series of radiographic images, one set of vertical bitewing-7 to 8 films, panoramic radiographic image- one every 36 monthsSee notes for additional detail	2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	See notes for additional details.	2	2	1	6	• Root canals and retreatment, apicoectomy, retrograde filling - once per tooth per lifetime	2	2	1	6	• Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 36 months	2	2	1	6	• Extractions, coronectomy - once per tooth	2	2	1	6	See notes for details.	1		2	2000.00	3		2					2																		2		2																		1	2
H1228	001	0	1	20	08	H1228_001_0	1																																																																																																																																																							
H1228	002	0	1	20	08	H1228_002_0	1																																																																																																																																																							
H1230	001	0	1	01	01	H1230_001_0	13	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	2					2				1	1000	2										0	30	2		1	0110	2				0.00	0.00	0.00	0.00					2	2	1	0100000	4	1				3					3					3					3					3					3					2						2					1	00100000			30	30													2		1	01000000	35.00	35.00															1	1
H1230	003	0	1	01	01	H1230_003_0	13	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	2					2				1	1000	2										0	30	2		1	0110	2				0.00	0.00	0.00	0.00					2	2	1	0100000	4	1				3					3					3					3					3					3					2						2					1	00100000			30	30													2		1	01000000	50.00	50.00															1	1
H1230	008	0	1	01	01	H1230_008_0	13	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	2					2				1	1000	2										0	30	2		1	0110	2				0.00	0.00	0.00	0.00					1	2	1	0100000	2	1																																		2						2					1	00100000			30	30													2		1	01000000	0.00	0.00															1	1
H1230	013	0	1	01	01	H1230_013_0	13	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	2					2				1	1000	2										0	30	2		1	0110	2				0.00	0.00	0.00	0.00					2	2	1	0100000	4	1				3					3					3					3					3					3					2						2					1	00100000			30	30													2		1	01000000	35.00	35.00															1	1
H1230	014	0	1	01	01	H1230_014_0	13	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	2					2				1	1000	2										0	30	2		1	0110	2				0.00	0.00	0.00	0.00					2	2	1	0100000	4	1				3					3					3					3					3					3					2						2					1	00100000			30	30													2		1	01000000	35.00	35.00															1	1
H1230	801	0	1	01	01	H1230_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1230	803	0	1	01	01	H1230_803_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1230	804	0	2	01	01	H1230_804_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1230	805	0	1	01	01	H1230_805_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1230	806	0	2	01	01	H1230_806_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1234	001	0	1	20	08	H1234_001_0	1																																																																																																																																																							
H1234	002	0	1	20	08	H1234_002_0	1																																																																																																																																																							
H1239	001	0	1	20	08	H1239_001_0	1																																																																																																																																																							
H1239	002	0	1	20	08	H1239_002_0	1																																																																																																																																																							
H1248	004	0	1	04	01	H1248_004_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H1248	007	0	1	04	01	H1248_007_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H1248	801	0	1	04	01	H1248_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1248	802	0	1	04	01	H1248_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1248	803	0	1	04	01	H1248_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1277	001	0	1	02	01	H1277_001_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		1				2					1	01000000	20	20															2		2																		1	2
H1277	002	0	1	02	01	H1277_002_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		1				2					1	01000000	20	20															2		2																		1	2
H1277	004	0	1	02	01	H1277_004_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	One bitewing radiograph is a covered benefit every year.One panoramic radiograph or One complete series is a covered benefit once every three years.Continued in notes.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		2	2000.00	3		2					1	01000000	20	20															2		2																		1	2
H1278	001	0	1	04	01	H1278_001_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	003	0	1	04	01	H1278_003_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	004	0	1	04	01	H1278_004_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	005	0	1	04	01	H1278_005_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	007	0	1	04	01	H1278_007_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H1278	009	0	1	04	01	H1278_009_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	010	0	1	04	01	H1278_010_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	013	0	1	04	01	H1278_013_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	014	0	1	04	01	H1278_014_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	015	0	1	04	01	H1278_015_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	016	0	1	04	01	H1278_016_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	018	0	1	04	01	H1278_018_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	019	0	1	04	01	H1278_019_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	020	0	1	04	01	H1278_020_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	021	0	1	04	01	H1278_021_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H1278	022	0	1	04	01	H1278_022_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H1278	023	0	1	04	01	H1278_023_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	024	0	1	04	01	H1278_024_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H1278	025	0	1	04	01	H1278_025_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	026	0	1	04	01	H1278_026_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	027	0	1	04	01	H1278_027_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	028	0	1	04	01	H1278_028_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	029	0	1	04	01	H1278_029_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	030	0	1	04	01	H1278_030_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	031	0	1	04	01	H1278_031_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1278	032	0	1	04	01	H1278_032_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1280	001	0	1	01	01	H1280_001_0	5	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															2	2
H1280	002	0	1	01	01	H1280_002_0	5	1	1111	2	1				2	1				2	1				2	1				1		4500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															2	2
H1290	001	0	1	01	01	H1290_001_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatements per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treament once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Other Oral/Maxillofacial Surgery, Other Services: Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3000.00	3		2					2																		2		2																		1	2
H1290	002	0	1	01	01	H1290_002_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatements per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treament once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Other Oral/Maxillofacial Surgery, Other Services: Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3000.00	3		2					2																		2		2																		1	2
H1290	003	0	1	01	01	H1290_003_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatements per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treament once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Other Oral/Maxillofacial Surgery, Other Services: Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3000.00	3		2					2																		2		2																		1	2
H1290	005	0	1	01	01	H1290_005_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3000.00	3		2					2																		2		1	01000000	5.00	5.00															1	2
H1290	013	0	1	01	01	H1290_013_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H1290	014	0	1	01	01	H1290_014_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H1290	015	0	1	01	01	H1290_015_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H1290	018	0	1	01	01	H1290_018_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H1290	019	0	1	01	01	H1290_019_0	13	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	2						2					2																		2		2																		1	2
H1290	020	0	1	01	01	H1290_020_0	13	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	2						2					2																		2		2																		1	2
H1290	021	0	1	01	01	H1290_021_0	13	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	2						2					2																		2		2																		1	2
H1290	022	0	1	01	01	H1290_022_0	13	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3000.00	3		2					2																		2		2																		1	2
H1290	023	0	1	01	01	H1290_023_0	13	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3000.00	3		2					2																		2		2																		1	2
H1290	024	0	1	01	01	H1290_024_0	13	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3000.00	3		2					2																		2		2																		1	2
H1290	025	0	1	01	01	H1290_025_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	2000.00	3		2					2																		2		1	01000000	10.00	10.00															1	2
H1290	027	0	1	01	01	H1290_027_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	2000.00	3		2					2																		2		1	01000000	5.00	5.00															1	2
H1290	029	0	1	01	01	H1290_029_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	2000.00	3		2					2																		2		1	01000000	10.00	10.00															1	2
H1290	031	0	1	01	01	H1290_031_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H1290	032	0	1	01	01	H1290_032_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Diagnostic Services: Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H1290	033	0	1	01	01	H1290_033_0	13	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3000.00	3		2					2																		2		2																		1	2
H1290	034	0	1	01	01	H1290_034_0	13	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3000.00	3		2					2																		2		2																		1	2
H1290	035	0	1	01	01	H1290_035_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H1290	036	1	1	01	01	H1290_036_1	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3000.00	3		2					2																		2		1	01000000	5.00	5.00															1	2
H1290	036	2	1	01	01	H1290_036_2	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3000.00	3		2					2																		2		1	01000000	10.00	10.00															1	2
H1290	037	1	1	01	01	H1290_037_1	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	2000.00	3		2					2																		2		2																		1	2
H1290	037	2	1	01	01	H1290_037_2	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	2000.00	3		2					2																		2		2																		1	2
H1290	037	3	1	01	01	H1290_037_3	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	2000.00	3		2					2																		2		2																		1	2
H1290	037	4	1	01	01	H1290_037_4	9	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	2000.00	3		2					2																		2		2																		1	2
H1290	037	5	1	01	01	H1290_037_5	9	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	2000.00	3		2					2																		2		2																		1	2
H1290	039	0	1	01	01	H1290_039_0	13	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3000.00	3		2					2																		2		2																		1	2
H1290	041	0	1	01	01	H1290_041_0	13	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3000.00	3		2					2																		2		2																		1	2
H1290	042	0	1	01	01	H1290_042_0	12	1	1111	2	2	2	6	Plan covers up to two oral exams per year. Coverage frequency for other exam services vary by covered procedure code.	2	2	2	6	Plan covers up to two basic cleanings per year. Coverage frequency for other cleanings vary by covered procedure code.	2	2	2	6	Plan covers up to two fluoride treatments per year. Coverage frequency for other fluoride treatments vary by covered procedure code.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year. Coverage frequency for other non-routine services vary by covered procedure code.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year. Coverage frequency for other diagnostic services vary by covered procedure code.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years. Coverage frequency for other restorative services vary by covered procedure code.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime. Coverage frequency for other endodontic services vary by covered procedure code.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years. Coverage frequency for other periodontal services vary by covered procedure code.	2	2	1	6	$4,000 plan max for comprehensive services with unlimited extractions.Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	4000.00	3		2					2																		2		2																		1	2
H1290	043	0	1	01	01	H1290_043_0	12	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	$3,000 plan max for comprehensive serviceswith unlimited extractions.Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3000.00	3		2					2																		2		2																		1	2
H1290	044	1	1	01	01	H1290_044_1	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	5000.00	3		2					2																		2		2																		1	2
H1290	044	2	1	01	01	H1290_044_2	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	5000.00	3		2					2																		2		2																		1	2
H1290	044	3	1	01	01	H1290_044_3	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	5000.00	3		2					2																		2		2																		1	2
H1290	045	0	1	01	01	H1290_045_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H1290	046	0	1	01	01	H1290_046_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	2500.00	3		2					2																		2		1	01000000	15.00	15.00															1	2
H1290	049	0	1	01	01	H1290_049_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H1290	050	0	1	01	01	H1290_050_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3000.00	3		2					2																		2		1	01000000	10.00	10.00															1	2
H1290	051	1	1	01	01	H1290_051_1	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H1290	051	2	1	01	01	H1290_051_2	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treament once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Other Oral/Maxillofacial Surgery, Other Services: Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	1500.00	3		2					2																		2		1	01000000	35.00	35.00															1	2
H1290	052	0	1	01	01	H1290_052_0	13	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	2						2					2																		2		2																		1	2
H1302	004	0	1	04	01	H1302_004_0	5	1	1111	2	2	3	6	Two oral exams per calendar yearOne emergency oral exam per calendar year	2	2	2	3		2	2	1	3		2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	1	2	500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1101111	2	1									2	2	1	6	Same tooth surface restoration is covered once in a two year period.	2	2	1	6	Root canals not to exceed one per tooth per lifetime.	2	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	2	1				2	2	1	6	Limited to one crown per year. Bridge, bridge repair, crowns, and implants not to exceed one per tooth every seven years. One set of dentures is covered every seven years.	1	2	2	1500.00	3		2					1	01000000	10	10															2		1	10101111			0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1302	802	0	1	04	01	H1302_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1302	803	0	1	04	01	H1302_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1302	804	0	1	04	01	H1302_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1304	001	0	1	04	01	H1304_001_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											2	2
H1304	004	0	1	04	01	H1304_004_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											2	2
H1304	011	1	1	04	01	H1304_011_1	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	50.00	50.00			0.00	0.00											2	2
H1304	011	2	1	04	01	H1304_011_2	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											2	2
H1304	012	1	1	04	01	H1304_012_1	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1	2	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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											2	2
H1304	012	2	1	04	01	H1304_012_2	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1	2	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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											2	2
H1304	803	0	1	04	01	H1304_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1304	804	0	1	04	01	H1304_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1304	805	0	1	04	01	H1304_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1304	806	0	1	04	01	H1304_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1310	001	0	1	20	08	H1310_001_0	1																																																																																																																																																							
H1310	003	0	1	20	08	H1310_003_0	1																																																																																																																																																							
H1312	001	0	1	20	08	H1312_001_0	1	2																																																																																																																																																						
H1312	002	0	1	20	08	H1312_002_0	1	2																																																																																																																																																						
H1339	001	0	1	01	01	H1339_001_0	8	1	1111	2	2	2	6	See notes for details.	2	2	2	3		2	2	2	3		2	2	2	6	See notes for details.	2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	See notes for additional details.	2	2	1	6	• Root canals and retreatment, apicoectomy, retrograde filling - once per tooth per lifetime	2	2	1	6	• Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 36 months	2	2	1	6	• Extractions, coronectomy - once per tooth	2	2	1	6	See notes for details.	1		2	2500.00	3		2					2																		2		2																		1	2
H1347	001	0	1	04	01	H1347_001_0	3	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															2	2
H1347	002	0	1	04	01	H1347_002_0	3	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															2	2
H1347	003	0	1	04	01	H1347_003_0	3	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															2	2
H1350	006	0	1	01	01	H1350_006_0	3	1	1111	2	2	3	6	Two oral exams per calendar yearOne emergency oral exam per calendar year	2	2	2	3		2	2	1	3		2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	1		500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1101111	2	1									2	2	1	6	Same tooth surface restoration is covered once in a two year period.	2	2	1	6	Root canals not to exceed one per tooth per lifetime.	2	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	2	1				2	2	1	6	Limited to one crown per year. Bridge, bridge repair, crowns, and implants not to exceed one per tooth every seven years. One set of dentures is covered every seven years.	1		2	1500.00	3		2					2																		2		1	11101111	25.00	25.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1350	023	1	1	01	01	H1350_023_1	5	1	1111	2	2	3	6	Two oral exams per calendar yearOne emergency oral exam per calendar year	2	2	2	3		2	2	1	3		2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	1		500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1101111	2	1									2	2	1	6	Same tooth surface restoration is covered once in a two year period.	2	2	1	6	Root canals not to exceed one per tooth per lifetime.	2	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	2	1				2	2	1	6	Limited to one crown per year. Bridge, bridge repair, crowns, and implants not to exceed one per tooth every seven years. One set of dentures is covered every seven years.	1		2	1650.00	3		2					2																		2		1	11101111	25.00	25.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1350	023	2	1	01	01	H1350_023_2	4	1	1111	2	2	3	6	Two oral exams per calendar yearOne emergency oral exam per calendar year	2	2	2	3		2	2	1	3		2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	1		500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1101111	2	1									2	2	1	6	Same tooth surface restoration is covered once in a two year period.	2	2	1	6	Root canals not to exceed one per tooth per lifetime.	2	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	2	1				2	2	1	6	Limited to one crown per year. Bridge, bridge repair, crowns, and implants not to exceed one per tooth every seven years. One set of dentures is covered every seven years.	1		2	1650.00	3		2					2																		2		1	11101111	25.00	25.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1350	024	1	1	01	01	H1350_024_1	5	1	1111	2	2	3	6	Two oral exams per calendar yearOne emergency oral exam per calendar year	2	2	2	3		2	2	1	3		2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	1		500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1101111	2	1									2	2	1	6	Same tooth surface restoration is covered once in a two year period.	2	2	1	6	Root canals not to exceed one per tooth per lifetime.	2	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	2	1				2	2	1	6	Limited to one crown per year. Bridge, bridge repair, crowns, and implants not to exceed one per tooth every seven years. One set of dentures is covered every seven years.	1		2	2250.00	3		2					2																		2		1	11101111	30.00	30.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1350	024	2	1	01	01	H1350_024_2	5	1	1111	2	2	3	6	Two oral exams per calendar yearOne emergency oral exam per calendar year	2	2	2	3		2	2	1	3		2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	1		500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1101111	2	1									2	2	1	6	Same tooth surface restoration is covered once in a two year period.	2	2	1	6	Root canals not to exceed one per tooth per lifetime.	2	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	2	1				2	2	1	6	Limited to one crown per year. Bridge, bridge repair, crowns, and implants not to exceed one per tooth every seven years. One set of dentures is covered every seven years.	1		2	2000.00	3		2					2																		2		1	11101111	40.00	40.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1350	024	3	1	01	01	H1350_024_3	5	1	1111	2	2	3	6	Two oral exams per calendar yearOne emergency oral exam per calendar year	2	2	2	3		2	2	1	3		2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	1		500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1101111	2	1									2	2	1	6	Same tooth surface restoration is covered once in a two year period.	2	2	1	6	Root canals not to exceed one per tooth per lifetime.	2	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	2	1				2	2	1	6	Limited to one crown per year. Bridge, bridge repair, crowns, and implants not to exceed one per tooth every seven years. One set of dentures is covered every seven years.	1		2	2000.00	3		2					2																		2		1	11101111	40.00	40.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1350	026	0	1	01	01	H1350_026_0	4	1	1111	2	2	3	6	Two oral exams per calendar yearOne emergency oral exam per calendar year	2	2	2	3		2	2	1	3		2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	1		500.00	3		2				2		2												2		1		1	1111	20.00	20.00									2	2	2		3										3					3					3					3					3											2					2																		2		1	01000000	50.00	50.00															2	2
H1350	028	0	1	01	01	H1350_028_0	4	2		3					3					3					3																																														2		3										3															3																2					2																		2		1	01000000	30.00	30.00															2	2
H1350	029	0	1	01	01	H1350_029_0	5	2		3					3					3					3																																														2		3										3															3																2					2																		2		1	01000000	30.00	30.00															2	2
H1350	030	0	1	01	01	H1350_030_0	4	1	1111	2	2	3	6	Two oral exams per calendar yearOne emergency oral exam per calendar year	2	2	2	3		2	2	1	3		2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	1		500.00	3		2				2		2												2		1		1	1111	20.00	20.00									2	2	2		3										3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															2	2
H1350	031	1	1	01	01	H1350_031_1	5	1	1111	2	2	3	6	Two oral exams per calendar yearOne emergency oral exam per calendar year	2	2	2	3		2	2	1	3		2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	1		500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1101111	2	1									2	2	1	6	Same tooth surface restoration is covered once in a two year period.	2	2	1	6	Root canals not to exceed one per tooth per lifetime.	2	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	2	1				2	2	1	6	Limited to one crown per year. Bridge, bridge repair, crowns, and implants not to exceed one per tooth every seven years. One set of dentures is covered every seven years.	1		2	2000.00	3		2					2																		2		1	11101111	25.00	25.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1350	031	2	1	01	01	H1350_031_2	4	1	1111	2	2	3	6	Two oral exams per calendar yearOne emergency oral exam per calendar year	2	2	2	3		2	2	1	3		2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	1		500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1101111	2	1									2	2	1	6	Same tooth surface restoration is covered once in a two year period.	2	2	1	6	Root canals not to exceed one per tooth per lifetime.	2	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	2	1				2	2	1	6	Limited to one crown per year. Bridge, bridge repair, crowns, and implants not to exceed one per tooth every seven years. One set of dentures is covered every seven years.	1		2	2000.00	3		2					2																		2		1	11101111	35.00	35.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1350	031	3	1	01	01	H1350_031_3	4	1	1111	2	2	3	6	Two oral exams per calendar yearOne emergency oral exam per calendar year	2	2	2	3		2	2	1	3		2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	1		500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1101111	2	1									2	2	1	6	Same tooth surface restoration is covered once in a two year period.	2	2	1	6	Root canals not to exceed one per tooth per lifetime.	2	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	2	1				2	2	1	6	Limited to one crown per year. Bridge, bridge repair, crowns, and implants not to exceed one per tooth every seven years. One set of dentures is covered every seven years.	1		2	2000.00	3		2					2																		2		1	11101111	35.00	35.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1350	803	0	1	01	01	H1350_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1350	804	0	1	01	01	H1350_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1350	805	0	1	01	01	H1350_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1350	806	0	1	02	01	H1350_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1350	807	0	1	02	01	H1350_807_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1352	004	0	1	01	01	H1352_004_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	0111111	2	1				2	1				2	1				2	1				2	1				2	1									1		1				2					1	00111111			50	50	50	50	50	50	50	50	50	50	50	50			2		1	01000000	30.00	30.00															1	2
H1352	801	0	1	01	01	H1352_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1352	803	0	1	01	01	H1352_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1352	804	0	1	01	01	H1352_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1352	805	0	1	02	01	H1352_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1353	002	0	1	01	01	H1353_002_0	20	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1353	004	0	1	01	01	H1353_004_0	20	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1353	005	0	1	01	01	H1353_005_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	2000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1353	006	0	1	01	01	H1353_006_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1353	007	0	1	01	01	H1353_007_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1357	001	0	1	20	08	H1357_001_0	1																																																																																																																																																							
H1357	002	0	1	20	08	H1357_002_0	1																																																																																																																																																							
H1360	001	0	1	02	01	H1360_001_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1365	001	0	1	04	01	H1365_001_0	6	2																																																															2																																											2					2																		2		1	01000000	40.00	40.00															1	1
H1365	004	2	1	04	01	H1365_004_2	6	1	1110	2	2	1	3		2	2	2	3							2	2	1	3		1	2	1000.00	3		2				2		2												2		1		1	1110	50.00	50.00									2	2	2																																											2					2																		2		1	01000000	40.00	40.00															1	1
H1365	004	3	1	04	01	H1365_004_3	6	1	1110	2	2	1	3		2	2	2	3							2	2	1	3		1	2	2000.00	3		2				2		2												2		1		1	1110	50.00	50.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	11111111	35.00	35.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	1	1
H1365	802	0	1	04	01	H1365_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1365	803	0	1	04	01	H1365_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1372	001	0	1	01	01	H1372_001_0	4	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Refer to the Notes for periodicity details.	1		700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Refer to the Notes for periodicity details.	2	1				2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	1		1				2					1	01000000	20	20															2		2																		1	2
H1372	002	0	1	01	01	H1372_002_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Refer to the Notes for periodicity details.	1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Refer to the Notes for periodicity details.	2	1				2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	1		1				2					1	01000000	20	20															2		2																		1	2
H1372	003	0	1	01	01	H1372_003_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Refer to the Notes for periodicity details.	1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Refer to the Notes for periodicity details.	2	1				2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	1		1				2					1	01000000	20	20															2		2																		1	2
H1395	001	0	1	04	01	H1395_001_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1	2	2	1000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1395	002	0	1	04	01	H1395_002_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1500.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1395	003	0	1	04	01	H1395_003_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth.	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	009	0	1	02	01	H1416_009_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	5000.00	3		2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	023	0	1	01	01	H1416_023_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					2																		2		1	11111111	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	026	0	1	02	01	H1416_026_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	033	0	1	02	01	H1416_033_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	034	0	1	01	01	H1416_034_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	035	0	1	01	01	H1416_035_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	5000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	036	0	1	01	01	H1416_036_0	20	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	041	0	1	01	01	H1416_041_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1500.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	042	0	1	01	01	H1416_042_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	043	0	1	02	01	H1416_043_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	044	0	1	01	01	H1416_044_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	055	0	1	01	01	H1416_055_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	056	0	1	01	01	H1416_056_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	45.00	45.00	0.00	0.00	0.00	0.00											1	2
H1416	057	0	1	01	01	H1416_057_0	22	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H1416	058	0	1	02	01	H1416_058_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	059	0	1	02	01	H1416_059_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	060	0	1	02	01	H1416_060_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	061	0	1	02	01	H1416_061_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth.	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	064	0	1	01	01	H1416_064_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H1416	065	0	1	01	01	H1416_065_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	45.00	45.00	0.00	0.00	0.00	0.00											1	2
H1416	068	0	1	01	01	H1416_068_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	070	0	1	01	01	H1416_070_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	071	0	1	01	01	H1416_071_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	072	0	1	01	01	H1416_072_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	077	0	1	02	01	H1416_077_0	20	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth.	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	079	0	1	01	01	H1416_079_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H1416	081	0	1	01	01	H1416_081_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1416	082	0	1	02	01	H1416_082_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1423	001	0	1	01	01	H1423_001_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1423	002	0	1	01	01	H1423_002_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1423	004	0	1	01	01	H1423_004_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1423	005	0	1	01	01	H1423_005_0	7	2		3					3					3					3																																														2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	40.00															1	2
H1423	007	0	1	01	01	H1423_007_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1423	008	0	1	01	01	H1423_008_0	6	1	1111	4	1				4	1				4	1				4	1				1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1423	009	0	1	01	01	H1423_009_0	7	1	1111	4	1				4	1				4	1				4	1				1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1426	001	0	1	01	01	H1426_001_0	11	1	1111	2	2	2	6	Periodic oral exams are payable twice per calendar year. Comprehensive oral exams are payable once per 3 year period.	2	2	2	3		2	2	2	3		2	2	1	6	X-rays are payable between once per calendar year to once per 3 year period depending on the service.	1		2000.00	3		2				2		2												2		2		2												2	2	1	1001011											2	2	1	6	Minor restorative services which include fillings covered. Composite resin (white) restorations are covered services on posterior teeth. No major services covered.						2	2	1	6	2 per calendar year. Perio non-surgical procedures are covered. Scaling and root planing: once per quadrant per 24 month period and full mouth debridement which is payable once per lifetime	2	2	1	6	Extractions (simple or surgical) are payable once per tooth per lifetime.	2	2	1	6	Full and partial dentures are limited to once in a five-year period.	1		1				2					1	11001001	20	20					50	50					50	50	0	50	2		2																		1	2
H1426	002	0	1	01	01	H1426_002_0	12	1	1111	2	2	2	6	Periodic oral exams are payable twice per calendar year. Comprehensive oral exams are payable once per 3 year period.	2	2	2	3		2	2	2	3		2	2	1	6	X-rays are payable between once per calendar year to once per 3 year period depending on the service.	1		2000.00	3		2				2		2												2		2		2												2	2	1	1001011											2	2	1	6	Minor restorative services which include fillings covered. Composite resin (white) restorations are covered services on posterior teeth.						2	2	1	6	2 per calendar year. Perio non-surgical procedures are covered. Scaling and root planing: once per quadrant per 24 month period and full mouth debridement which is payable once per lifetime	2	2	1	6	Extractions (simple or surgical) are payable once per tooth per lifetime.	2	2	1	6	Full and partial dentures are limited to once in a five-year period.	1		1				2					1	11001001	20	20					50	50					50	50	0	50	2		2																		1	2
H1463	003	0	1	01	01	H1463_003_0	5	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10101111			20	20			20	20	20	20	20	20	20	20	20	40	2		1	01000000	25.00	25.00															2	2
H1463	008	0	1	01	01	H1463_008_0	4	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10101111			20	20			20	20	20	20	20	20	20	20	20	50	2		1	01000000	25.00	25.00															2	2
H1463	015	0	1	02	01	H1463_015_0	5	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10101111			20	20			20	20	20	20	20	20	20	20	20	40	2		1	01000000	20.00	20.00															2	2
H1463	019	0	1	02	01	H1463_019_0	5	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10101111			20	20			20	20	20	20	20	20	20	20	20	40	2		1	01000000	20.00	20.00															2	2
H1463	041	0	1	01	01	H1463_041_0	5	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10101111			20	20			20	20	20	20	20	20	20	20	20	40	2		1	01000000	40.00	40.00															2	2
H1463	042	0	1	02	01	H1463_042_0	5	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	40	2		2																		2	2
H1463	044	0	1	02	01	H1463_044_0	5	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10101111			20	20			20	20	20	20	20	20	20	20	20	40	2		1	01000000	40.00	40.00															2	2
H1463	801	0	1	01	01	H1463_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1463	802	0	1	01	01	H1463_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1463	810	0	1	01	01	H1463_810_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1463	811	0	1	02	01	H1463_811_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1463	812	0	1	02	01	H1463_812_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1463	813	0	1	02	01	H1463_813_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1463	814	0	1	02	01	H1463_814_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1468	007	0	1	01	01	H1468_007_0	4	1	1111	2	2	3	3		2	2	2	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime	2	2	2	1		2	1				2	2	10	6	dentures, denture rebase, reline, repair and tissue conditioning up to 1 per yr, complete and partial dentures up to 1 every 5 yrs, occlusal adj up to 1 every 3 yrs, oral surgery up to 2 per yr.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1468	013	0	1	01	01	H1468_013_0	5	1	1111	2	2	2	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Complete and partial dentures 1 every 5 years, oral surgery 2 per year, denture adjustment, reline, repair, rebase, and tissue conditioning 1 per year, occlusal adjustments 1 every 3 years	1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1468	014	0	1	01	01	H1468_014_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	1
H1468	017	0	1	01	01	H1468_017_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	include partial dentures, complete dentures up to 1 every 5 yrs, oral surgery up to 2 per yr, denture adj, reline, repair, rebase, tissue conditioning up to 1 per yr, occlusal adj up to 1 every 3 yrs.	1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1468	018	0	1	01	01	H1468_018_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	oComplete and partial dentures 1 every 5 years, oral surgery 2 per year, denture adjustment, reline, repair, rebase, and tissue conditioning 1 per year, occlusal adjustments 1 every 3 years	1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H1468	802	0	1	01	01	H1468_802_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1468	803	0	1	01	01	H1468_803_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1468	805	0	1	01	01	H1468_805_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1468	806	0	1	01	01	H1468_806_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1500	001	0	1	20	08	H1500_001_0	1																																																																																																																																																							
H1500	002	0	1	20	08	H1500_002_0	1																																																																																																																																																							
H1518	001	0	1	20	08	H1518_001_0	1																																																																																																																																																							
H1518	002	0	1	20	08	H1518_002_0	1																																																																																																																																																							
H1526	001	0	1	02	01	H1526_001_0	12	1	1111	2	1				2	1				2	1				2	1				1		625.00	5		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H1526	002	0	1	02	01	H1526_002_0	10	1	1111	2	1				2	1				2	1				2	1				1		875.00	5		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H1526	003	0	1	02	01	H1526_003_0	11	1	1111	2	1				2	1				2	1				2	1				1		625.00	5		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H1526	004	0	1	02	01	H1526_004_0	10	1	1111	2	1				2	1				2	1				2	1				1		875.00	5		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H1526	005	0	1	02	01	H1526_005_0	13	1	1111	2	1				2	1				2	1				2	1				1		325.00	5		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H1526	006	0	1	02	01	H1526_006_0	11	1	1111	2	1				2	1				2	1				2	1				1		625.00	5		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H1533	001	0	1	20	08	H1533_001_0	1																																																																																																																																																							
H1533	002	0	1	20	08	H1533_002_0	1																																																																																																																																																							
H1537	801	0	1	04	01	H1537_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	802	0	1	04	01	H1537_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	803	0	1	04	01	H1537_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	804	0	2	04	01	H1537_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	805	0	2	04	01	H1537_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	806	0	2	04	01	H1537_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	807	0	1	04	01	H1537_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	808	0	1	04	01	H1537_808_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	809	0	1	04	01	H1537_809_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	816	0	1	04	01	H1537_816_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	817	0	1	04	01	H1537_817_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	823	0	1	04	01	H1537_823_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	824	0	1	04	01	H1537_824_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	825	0	1	04	01	H1537_825_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	826	0	1	04	01	H1537_826_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	827	0	2	04	01	H1537_827_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	828	0	2	04	01	H1537_828_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	829	0	2	04	01	H1537_829_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	830	0	1	04	01	H1537_830_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	831	0	1	04	01	H1537_831_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	832	0	1	04	01	H1537_832_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	833	0	1	04	01	H1537_833_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	834	0	1	04	01	H1537_834_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	835	0	2	04	01	H1537_835_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	836	0	1	04	01	H1537_836_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	837	0	1	04	01	H1537_837_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	838	0	1	04	01	H1537_838_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	839	0	1	04	01	H1537_839_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	840	0	1	04	01	H1537_840_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	841	0	1	04	01	H1537_841_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	842	0	1	04	01	H1537_842_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1537	843	0	1	04	01	H1537_843_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1544	001	0	1	20	08	H1544_001_0	1																																																																																																																																																							
H1544	002	0	1	20	08	H1544_002_0	1																																																																																																																																																							
H1587	001	0	1	02	01	H1587_001_0	9	1	1111	2	1				2	1				2	1				2	1				1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	11111111	20	20	20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		2																		2	2
H1587	003	0	1	02	01	H1587_003_0	11	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1607	012	0	1	04	01	H1607_012_0	9	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H1607	015	0	1	04	01	H1607_015_0	13	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1607	809	0	1	04	01	H1607_809_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1607	811	0	1	04	01	H1607_811_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1607	812	0	1	04	01	H1607_812_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1607	813	0	1	04	01	H1607_813_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1607	815	0	1	04	01	H1607_815_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1607	816	0	1	04	01	H1607_816_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1607	817	0	2	04	01	H1607_817_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1607	819	0	2	04	01	H1607_819_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1607	820	0	2	04	01	H1607_820_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1607	821	0	1	04	01	H1607_821_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1607	822	0	1	04	01	H1607_822_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1607	823	0	2	04	01	H1607_823_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1607	824	0	2	04	01	H1607_824_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1608	001	0	1	04	01	H1608_001_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	012	0	1	04	01	H1608_012_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	1150.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	013	0	1	04	01	H1608_013_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	016	0	1	04	01	H1608_016_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	017	0	1	04	01	H1608_017_0	7	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	See Notes	2	2	2	6	Plan will cover 1 root canal and the retreatment of 1 root canal per tooth per lifetime.	2	2	4	6	See Notes	2	2	1	6	See notes	2	2	6	6	Plan will cover complete or partial dentures once per arch every five years, fixed prosthodontics once per tooth every 5 years, and denture/prosthodontic repairs as needed.	1	2	2	4000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											1	2
H1608	018	0	1	04	01	H1608_018_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	021	0	1	04	01	H1608_021_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	024	0	1	04	01	H1608_024_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	026	0	1	04	01	H1608_026_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	027	0	1	04	01	H1608_027_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	028	0	1	04	01	H1608_028_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	1100.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	029	0	1	04	01	H1608_029_0	7	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	0.00	0.00			0.00	0.00											1	2
H1608	031	0	1	04	01	H1608_031_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	037	0	1	04	01	H1608_037_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1150.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	038	0	1	04	01	H1608_038_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	040	0	1	04	01	H1608_040_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	041	0	1	04	01	H1608_041_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	1125.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	043	0	1	04	01	H1608_043_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	048	0	1	04	01	H1608_048_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1150.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	050	0	1	04	01	H1608_050_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	051	0	1	04	01	H1608_051_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	052	0	1	04	01	H1608_052_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	054	0	1	04	01	H1608_054_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	2150.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	061	0	1	04	01	H1608_061_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	062	0	1	04	01	H1608_062_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	064	0	1	04	01	H1608_064_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	065	0	1	04	01	H1608_065_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	067	0	1	04	01	H1608_067_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	068	0	1	04	01	H1608_068_0	9	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	070	0	1	04	01	H1608_070_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	071	0	1	04	01	H1608_071_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	072	0	1	04	01	H1608_072_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	073	0	1	04	01	H1608_073_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	074	0	1	04	01	H1608_074_0	3	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	075	0	1	04	01	H1608_075_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	076	0	1	04	01	H1608_076_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	077	0	1	04	01	H1608_077_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	078	0	1	04	01	H1608_078_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	079	0	1	04	01	H1608_079_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1608	801	0	1	04	01	H1608_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1608	802	0	1	04	01	H1608_802_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1609	001	0	1	02	01	H1609_001_0	6	1	1111	2	1				2	1				2	1				2	1				1		1650.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	016	0	1	01	01	H1609_016_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	8	3		2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	017	0	1	01	01	H1609_017_0	7	1	1111	2	2	1	6	Plan will only cover 1 periodic oral evaluation or comprehensive oral exam every six months.  Age restrictions may apply to certain services when appropriate.	2	2	1	4		2	2	1	4		2	2	1	6	Plan will cover 1 bitewing x-ray per year and 1 intraoral or 1 panoramic x-ray every three years.Age restrictions may apply to certain services when appropriate.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary.  Plan will cover 1 occlusal guard per arch every 5 years.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See notes	2	2	1	6	Plan will cover 4 fillings per year and 3 crowns per year (1 per tooth every 5 years) as well as recement as needed.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	Plan will cover 2 root canals as well as retreatment of root canals per year (one per tooth per lifetime).  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See note	2	2	8	3		2	2	1	6	See note	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	018	0	1	01	01	H1609_018_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	8	3		2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	019	0	1	01	01	H1609_019_0	7	1	1111	2	2	1	6	Plan will only cover 1 periodic oral evaluation or comprehensive oral exam every six months.  Age restrictions may apply to certain services when appropriate.	2	2	1	4		2	2	1	4		2	2	1	6	Plan will cover 1 bitewing x-ray per year and 1 intraoral or 1 panoramic x-ray every three years.Age restrictions may apply to certain services when appropriate.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary.  Plan will cover 1 occlusal guard per arch every 5 years.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See notes	2	2	1	6	Plan will cover 4 fillings per year and 3 crowns per year (1 per tooth every 5 years) as well as recement as needed.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	Plan will cover 2 root canals as well as retreatment of root canals per year (one per tooth per lifetime).  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See note	2	2	8	3		2	2	1	6	See note	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	020	0	1	01	01	H1609_020_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	8	3		2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	021	0	1	01	01	H1609_021_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	8	3		2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	022	0	1	01	01	H1609_022_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	8	3		2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111111	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	025	0	1	01	01	H1609_025_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	8	3		2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	026	0	1	01	01	H1609_026_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111011	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.						2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see below.	2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111011	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	027	0	1	01	01	H1609_027_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	8	3		2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	028	0	1	02	01	H1609_028_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111011	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.						2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see below.	2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111011	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	034	0	1	01	01	H1609_034_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	8	3		2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	035	0	1	01	01	H1609_035_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111011	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.						2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see below.	2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111011	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	038	0	1	01	01	H1609_038_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111011	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.						2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see below.	2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111011	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	041	0	1	01	01	H1609_041_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111011	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.						2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see below.	2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111011	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	042	0	1	01	01	H1609_042_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	8	3		2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	043	0	1	01	01	H1609_043_0	7	1	1111	2	2	1	6	Plan will only cover 1 periodic oral evaluation or comprehensive oral exam every six months.  Age restrictions may apply to certain services when appropriate.	2	2	1	4		2	2	1	4		2	2	1	6	Plan will cover 1 bitewing x-ray per year and 1 intraoral or 1 panoramic x-ray every three years.Age restrictions may apply to certain services when appropriate.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary.  Plan will cover 1 occlusal guard per arch every 5 years.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See notes	2	2	1	6	Plan will cover 4 fillings per year and 3 crowns per year (1 per tooth every 5 years) as well as recement as needed.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	Plan will cover 2 root canals as well as retreatment of root canals per year (one per tooth per lifetime).  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See note	2	2	8	3		2	2	1	6	See note	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	044	0	1	01	01	H1609_044_0	7	1	1111	2	2	1	6	Plan will only cover 1 periodic oral evaluation or comprehensive oral exam every six months.  Age restrictions may apply to certain services when appropriate.	2	2	1	4		2	2	1	4		2	2	1	6	Plan will cover 1 bitewing x-ray per year and 1 intraoral or 1 panoramic x-ray every three years.Age restrictions may apply to certain services when appropriate.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary.  Plan will cover 1 occlusal guard per arch every 5 years.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See notes	2	2	1	6	Plan will cover 4 fillings per year and 3 crowns per year (1 per tooth every 5 years) as well as recement as needed.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	Plan will cover 2 root canals as well as retreatment of root canals per year (one per tooth per lifetime).  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See note	2	2	8	3		2	2	1	6	See note	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	045	0	1	01	01	H1609_045_0	7	1	1111	2	2	1	6	Plan will only cover 1 periodic oral evaluation or comprehensive oral exam every six months.  Age restrictions may apply to certain services when appropriate.	2	2	1	4		2	2	1	4		2	2	1	6	Plan will cover 1 bitewing x-ray per year and 1 intraoral or 1 panoramic x-ray every three years.Age restrictions may apply to certain services when appropriate.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary.  Plan will cover 1 occlusal guard per arch every 5 years.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See notes	2	2	1	6	Plan will cover 4 fillings per year and 3 crowns per year (1 per tooth every 5 years) as well as recement as needed.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	Plan will cover 2 root canals as well as retreatment of root canals per year (one per tooth per lifetime).  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See note	2	2	8	3		2	2	1	6	See note	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	046	0	1	01	01	H1609_046_0	7	1	1111	2	2	1	6	Plan will only cover 1 periodic oral evaluation or comprehensive oral exam every six months.  Age restrictions may apply to certain services when appropriate.	2	2	1	4		2	2	1	4		2	2	1	6	Plan will cover 1 bitewing x-ray per year and 1 intraoral or 1 panoramic x-ray every three years.Age restrictions may apply to certain services when appropriate.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary.  Plan will cover 1 occlusal guard per arch every 5 years.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See notes	2	2	1	6	Plan will cover 4 fillings per year and 3 crowns per year (1 per tooth every 5 years) as well as recement as needed.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	Plan will cover 2 root canals as well as retreatment of root canals per year (one per tooth per lifetime).  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See note	2	2	8	3		2	2	1	6	See note	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	047	0	1	01	01	H1609_047_0	7	1	1111	2	2	1	6	Plan will only cover 1 periodic oral evaluation or comprehensive oral exam every six months.  Age restrictions may apply to certain services when appropriate.	2	2	1	4		2	2	1	4		2	2	1	6	Plan will cover 1 bitewing x-ray per year and 1 intraoral or 1 panoramic x-ray every three years.Age restrictions may apply to certain services when appropriate.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary.  Plan will cover 1 occlusal guard per arch every 5 years.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See notes	2	2	1	6	Plan will cover 4 fillings per year and 3 crowns per year (1 per tooth every 5 years) as well as recement as needed.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	Plan will cover 2 root canals as well as retreatment of root canals per year (one per tooth per lifetime).  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See note	2	2	8	3		2	2	1	6	See note	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	048	0	1	01	01	H1609_048_0	7	1	1111	2	2	1	6	Plan will only cover 1 periodic oral evaluation or comprehensive oral exam every six months.  Age restrictions may apply to certain services when appropriate.	2	2	1	4		2	2	1	4		2	2	1	6	Plan will cover 1 bitewing x-ray per year and 1 intraoral or 1 panoramic x-ray every three years.Age restrictions may apply to certain services when appropriate.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary.  Plan will cover 1 occlusal guard per arch every 5 years.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See notes	2	2	1	6	Plan will cover 4 fillings per year and 3 crowns per year (1 per tooth every 5 years) as well as recement as needed.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	Plan will cover 2 root canals as well as retreatment of root canals per year (one per tooth per lifetime).  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See note	2	2	8	3		2	2	1	6	See note	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	049	0	1	01	01	H1609_049_0	7	1	1111	2	2	1	6	Plan will only cover 1 periodic oral evaluation or comprehensive oral exam every six months.  Age restrictions may apply to certain services when appropriate.	2	2	1	4		2	2	1	4		2	2	1	6	Plan will cover 1 bitewing x-ray per year and 1 intraoral or 1 panoramic x-ray every three years.Age restrictions may apply to certain services when appropriate.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary.  Plan will cover 1 occlusal guard per arch every 5 years.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See notes	2	2	1	6	Plan will cover 4 fillings per year and 3 crowns per year (1 per tooth every 5 years) as well as recement as needed.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	Plan will cover 2 root canals as well as retreatment of root canals per year (one per tooth per lifetime).  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See note	2	2	8	3		2	2	1	6	See note	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	052	0	1	01	01	H1609_052_0	3	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111011	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.						2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see below.	2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111011	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	053	0	1	01	01	H1609_053_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111011	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.						2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see below.	2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111011	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	055	0	1	01	01	H1609_055_0	7	1	1111	2	2	1	6	Plan will only cover 1 periodic oral evaluation or comprehensive oral exam every six months.  Age restrictions may apply to certain services when appropriate.	2	2	1	4		2	2	1	4		2	2	1	6	Plan will cover 1 bitewing x-ray per year and 1 intraoral or 1 panoramic x-ray every three years.Age restrictions may apply to certain services when appropriate.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary.  Plan will cover 1 occlusal guard per arch every 5 years.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See notes	2	2	1	6	Plan will cover 4 fillings per year and 3 crowns per year (1 per tooth every 5 years) as well as recement as needed.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	Plan will cover 2 root canals as well as retreatment of root canals per year (one per tooth per lifetime).  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See note	2	2	8	3		2	2	1	6	See note	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	056	0	1	01	01	H1609_056_0	7	1	1111	2	2	1	6	Plan will only cover 1 periodic oral evaluation or comprehensive oral exam every six months.  Age restrictions may apply to certain services when appropriate.	2	2	1	4		2	2	1	4		2	2	1	6	Plan will cover 1 bitewing x-ray per year and 1 intraoral or 1 panoramic x-ray every three years.Age restrictions may apply to certain services when appropriate.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary.  Plan will cover 1 occlusal guard per arch every 5 years.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See notes	2	2	1	6	Plan will cover 4 fillings per year and 3 crowns per year (1 per tooth every 5 years) as well as recement as needed.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	Plan will cover 2 root canals as well as retreatment of root canals per year (one per tooth per lifetime).  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See note	2	2	8	3		2	2	1	6	See note	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	058	0	1	02	01	H1609_058_0	3	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	059	0	1	01	01	H1609_059_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	8	3		2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	060	0	1	01	01	H1609_060_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111011	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.						2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see below.	2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111011	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	061	0	1	01	01	H1609_061_0	6	1	1111	2	2	1	6	Plan will only cover 1 periodic oral evaluation or comprehensive oral exam every six months.  Age restrictions may apply to certain services when appropriate.	2	2	1	4		2	2	1	4		2	2	1	6	Plan will cover 1 bitewing x-ray per year and 1 intraoral or 1 panoramic x-ray every three years.Age restrictions may apply to certain services when appropriate.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary.  Plan will cover 1 occlusal guard per arch every 5 years.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See notes	2	2	1	6	Plan will cover 4 fillings per year and 3 crowns per year (1 per tooth every 5 years) as well as recement as needed.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	Plan will cover 2 root canals as well as retreatment of root canals per year (one per tooth per lifetime).  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See note	2	2	8	3		2	2	1	6	See note	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	062	0	1	01	01	H1609_062_0	8	1	1111	2	2	1	6	Plan will only cover 1 periodic oral evaluation or comprehensive oral exam every six months.  Age restrictions may apply to certain services when appropriate.	2	2	1	4		2	2	1	4		2	2	1	6	Plan will cover 1 bitewing x-ray per year and 1 intraoral or 1 panoramic x-ray every three years.Age restrictions may apply to certain services when appropriate.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary.  Plan will cover 1 occlusal guard per arch every 5 years.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See notes	2	2	1	6	Plan will cover 4 fillings per year and 3 crowns per year (1 per tooth every 5 years) as well as recement as needed.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	Plan will cover 2 root canals as well as retreatment of root canals per year (one per tooth per lifetime).  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See note	2	2	8	3		2	2	1	6	See note	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	063	0	1	01	01	H1609_063_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	8	3		2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	064	0	1	01	01	H1609_064_0	7	1	1111	2	2	1	6	Plan will only cover 1 periodic oral evaluation or comprehensive oral exam every six months.  Age restrictions may apply to certain services when appropriate.	2	2	1	4		2	2	1	4		2	2	1	6	Plan will cover 1 bitewing x-ray per year and 1 intraoral or 1 panoramic x-ray every three years.Age restrictions may apply to certain services when appropriate.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary.  Plan will cover 1 occlusal guard per arch every 5 years.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See notes	2	2	1	6	Plan will cover 4 fillings per year and 3 crowns per year (1 per tooth every 5 years) as well as recement as needed.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	Plan will cover 2 root canals as well as retreatment of root canals per year (one per tooth per lifetime).  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See note	2	2	8	3		2	2	1	6	See note	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	065	0	1	01	01	H1609_065_0	7	1	1111	2	2	1	6	Plan will only cover 1 periodic oral evaluation or comprehensive oral exam every six months.  Age restrictions may apply to certain services when appropriate.	2	2	1	4		2	2	1	4		2	2	1	6	Plan will cover 1 bitewing x-ray per year and 1 intraoral or 1 panoramic x-ray every three years.Age restrictions may apply to certain services when appropriate.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary.  Plan will cover 1 occlusal guard per arch every 5 years.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See notes	2	2	1	6	Plan will cover 4 fillings per year and 3 crowns per year (1 per tooth every 5 years) as well as recement as needed.  Age restrictions may apply to certain services when appropriate.	2	2	1	6	Plan will cover 2 root canals as well as retreatment of root canals per year (one per tooth per lifetime).  Age restrictions may apply to certain services when appropriate.	2	2	1	6	See note	2	2	8	3		2	2	1	6	See note	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	066	0	1	01	01	H1609_066_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	8	3		2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	067	0	1	01	01	H1609_067_0	6	1	1110	2	2	1	6	Varies by procedure, see notes.	2	2	2	3							2	2	1	6	Varies by procedure, see notes.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	1	6	Varies by procedure, see notes.	2	2	8	3		2	2	1	6	Varies by procedure, see notes.	2						2					2																		2		1	11111111	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	068	0	1	02	01	H1609_068_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	069	0	1	02	01	H1609_069_0	6	1	1111	2	1				2	1				2	1				2	1				1		1850.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1609	801	0	1	01	01	H1609_801_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1609	807	0	1	01	01	H1609_807_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1610	001	0	1	01	01	H1610_001_0	7	2																																																															1	1111110	2	1				2	2	1	6	1 every 3 years	2	2	1	6	1 per tooth every 5 years	2	1				2	1									2	1				1		2	3000.00	3		2					1	01000000	20	20															2		1	10111110			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	1	2
H1610	002	0	1	01	01	H1610_002_0	7	2																																																															1	1111110	2	1				2	2	1	6	1 every 3 years	2	2	1	6	1 per tooth every 5 years	2	1				2	1									2	1				1		2	3000.00	3		2					1	01000000	20	20															2		1	10111110			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	1	2
H1610	003	0	1	01	01	H1610_003_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1619	001	0	1	04	01	H1619_001_0	10	1	1110	2	2	3	3		2	2	3	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	1000.00	3		2					2																		2		1	01000000	35.00	35.00															1	2
H1619	002	0	1	04	01	H1619_002_0	11	1	1110	2	2	3	3		2	2	3	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	2000.00	3		2					2																		2		1	01000000	20.00	20.00															1	2
H1622	001	0	1	20	08	H1622_001_0	1																																																																																																																																																							
H1622	003	0	1	20	08	H1622_003_0	1																																																																																																																																																							
H1644	001	0	1	01	01	H1644_001_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1651	001	0	1	18	06	H1651_001_0	3	2																																																															2																																											2					2																		2		2																		2	2
H1651	002	0	1	18	06	H1651_002_0	3	2																																																															2																																											2					2																		2		2																		2	2
H1651	003	0	1	18	06	H1651_003_0	3	2																																																															2																																											2					2																		2		2																		2	2
H1651	004	0	1	18	06	H1651_004_0	3	2																																																															2																																											2					2																		2		2																		2	2
H1651	005	0	1	18	06	H1651_005_0	3	2																																																															2																																											2					2																		2		2																		2	2
H1651	008	0	1	18	06	H1651_008_0	3	2																																																															2																																											2					2																		2		2																		2	2
H1651	009	0	1	18	06	H1651_009_0	3	2																																																															2																																											2					2																		2		2																		2	2
H1651	011	0	1	18	06	H1651_011_0	3	2																																																															2																																											2					2																		2		2																		2	2
H1651	013	0	1	18	06	H1651_013_0	3	2																																																															2																																											2					2																		2		2																		2	2
H1651	015	0	1	18	06	H1651_015_0	3	2																																																															2																																											2					2																		2		2																		2	2
H1651	016	0	1	18	06	H1651_016_0	3	2																																																															2																																											2					2																		2		2																		2	2
H1651	017	0	1	18	06	H1651_017_0	3	2																																																															2																																											2					2																		2		2																		2	2
H1651	025	0	1	18	06	H1651_025_0	3	2																																																															2																																											2					2																		2		2																		2	2
H1659	002	0	1	04	01	H1659_002_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1659	003	0	1	04	01	H1659_003_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1664	001	0	1	01	01	H1664_001_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1664	004	0	1	01	01	H1664_004_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1664	005	0	1	01	01	H1664_005_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	5000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1664	006	0	1	01	01	H1664_006_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	40.00	40.00															1	2
H1664	007	0	1	01	01	H1664_007_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1666	003	0	1	04	01	H1666_003_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1	2	2	1000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	45.00	45.00															2	2
H1666	006	0	1	04	01	H1666_006_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	50.00	50.00															2	2
H1666	008	0	1	04	01	H1666_008_0	7	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1	2	2	1000.00	3		2					1	10001111							0	0	20	20	20	20	20	20	20	20	2		1	01100000	50.00	50.00	0.00	0.00													2	2
H1666	012	0	1	04	01	H1666_012_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	2000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	40.00	40.00															2	2
H1666	013	0	1	04	01	H1666_013_0	5	2		3					3										3																																														2		3										3					3					3					3					3											2					1	01000000	0	0															2		2																		2	2
H1666	014	0	1	04	01	H1666_014_0	5	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1	2	2	1000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H1666	015	0	1	04	01	H1666_015_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H1666	016	0	1	04	01	H1666_016_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1	2	2	5000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H1666	018	0	1	04	01	H1666_018_0	5	2		3					3										3																																														2		3										3					3					3					3					3											2					1	01000000	0	0															2		2																		2	2
H1666	801	0	1	04	01	H1666_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1666	803	0	1	04	01	H1666_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1666	805	0	1	04	01	H1666_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1666	807	0	1	04	01	H1666_807_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1666	808	0	1	04	01	H1666_808_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1692	002	0	1	02	01	H1692_002_0	7	1	1111	2	1				2	1				2	1				2	1				1		2800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1692	003	0	1	02	01	H1692_003_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1692	005	0	1	01	01	H1692_005_0	6	1	1111	2	1				2	1				2	1				2	1				1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1692	006	0	1	02	01	H1692_006_0	3	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1692	007	0	1	02	01	H1692_007_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1692	801	0	1	01	01	H1692_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1692	802	0	1	01	01	H1692_802_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1693	002	0	1	20	08	H1693_002_0	1																																																																																																																																																							
H1693	003	0	1	20	08	H1693_003_0	1																																																																																																																																																							
H1714	001	0	1	20	08	H1714_001_0	2																																																																																																																																																							
H1714	002	0	1	20	08	H1714_002_0	2																																																																																																																																																							
H1722	002	0	1	01	01	H1722_002_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Dental X-rays: 1 set per year	1		2500.00	3		2				2		2												2		2		2												1	2	1	1111111	2	2	1	6	Limits vary by procedure.	2	2	1	6	Limits vary by procedure.	2	2	1	6	Restorative Services: Limits vary by procedure, ranging from once every 24 months to once every 60 months per tooth.	2	2	1	6	Endodontics are limited to one surgery per tooth per lifetime.	2	2	1	6	Limits vary by procedure. Periodontic scaling and root planing is covered once every 24 months, per area.	2	2	1	6	Extractions are limited to one surgery per tooth per lifetime.	2	2	1	6	Prosthodontic limits vary by procedure. Dentures are limited to one set every 5 years. Crowns are limited to once every 5 years for each tooth.	1		1				2					2																		2		2																		1	2
H1723	001	0	1	48	05	H1723_001_0	13	2																																																															2																																											2					2																		2		2																		2	2
H1732	001	0	1	01	01	H1732_001_0	6	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1732	003	0	1	01	01	H1732_003_0	6	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1737	001	0	1	01	01	H1737_001_0	5	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10101111			20	20			20	20	20	20	20	20	20	20	20	40	2		1	01000000	35.00	35.00															2	2
H1737	801	0	1	01	01	H1737_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1737	802	0	1	01	01	H1737_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1737	803	0	1	01	01	H1737_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1742	001	0	1	20	08	H1742_001_0	1																																																																																																																																																							
H1742	002	0	1	20	08	H1742_002_0	1																																																																																																																																																							
H1748	001	0	1	01	01	H1748_001_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	2		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H1748	003	0	1	01	01	H1748_003_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	2		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H1748	004	0	1	01	01	H1748_004_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	2		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H1748	005	0	1	01	01	H1748_005_0	12	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	2		1		5000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H1748	010	0	1	01	01	H1748_010_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	2		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	01000000	40.00	40.00															2	2
H1774	001	0	1	04	01	H1774_001_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months pre tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	35.00	35.00															1	2
H1787	001	0	1	01	01	H1787_001_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	X-rays limit to once every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every two years.	1		2	2000.00	3		2					1	01000000	20	20															2		2																		2	2
H1787	002	0	1	01	01	H1787_002_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Limit of once every 5 years	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every two years.	1		2	2000.00	3		2					1	01000000	20	20															2		2																		2	2
H1799	001	0	1	01	01	H1799_001_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1050.00	3		2					1	01000000	20	20															2		2																		2	2
H1799	002	0	1	01	01	H1799_002_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1050.00	3		2					2																		2		2																		2	2
H1822	001	0	1	01	01	H1822_001_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H1822	002	0	1	01	01	H1822_002_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H1822	003	0	1	01	01	H1822_003_0	10	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H1822	004	0	1	01	01	H1822_004_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H1822	005	0	1	02	01	H1822_005_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H1822	006	0	1	01	01	H1822_006_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010						2	2	2	3												2	1														2						2					1	01000000	20	20															2		2																		1	2
H1822	801	0	1	01	01	H1822_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1822	802	0	1	01	01	H1822_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1846	004	0	1	04	01	H1846_004_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Benefit is either two series of bitewing per year, or one full mouth every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	45.00	45.00			0.00	0.00											2	2
H1846	005	0	1	04	01	H1846_005_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Benefit is either two series of bitewing per year, or one full mouth every 36 consecutive months. Benefit is combined in and out-of-network for all covered services (includes all preventive services).	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	40.00	40.00			0.00	0.00											2	2
H1846	006	0	1	04	01	H1846_006_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Benefit is either two series of bitewing per year, or one full mouth every 36 consecutive months. Benefit is combined in and out-of-network for all covered services (includes all preventive services).	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	35.00	35.00			0.00	0.00											2	2
H1846	007	0	1	04	01	H1846_007_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Benefit is either two series of bitewing per year, or one full mouth every 36 consecutive months. Benefit is combined in and out-of-network for all covered services (includes all preventive services).	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	35.00	35.00			0.00	0.00											2	2
H1846	801	0	1	04	01	H1846_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1846	803	0	1	04	01	H1846_803_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1846	804	0	1	04	01	H1846_804_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1846	805	0	1	04	01	H1846_805_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1848	001	0	1	04	01	H1848_001_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	45.00	45.00	0.00	0.00	0.00	0.00											1	2
H1848	002	0	1	04	01	H1848_002_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1848	003	0	1	04	01	H1848_003_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	5000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1862	001	0	1	01	01	H1862_001_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1889	002	1	1	04	01	H1889_002_1	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1889	002	2	1	04	01	H1889_002_2	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1889	005	0	1	04	01	H1889_005_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1889	006	0	1	04	01	H1889_006_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1889	007	0	1	04	01	H1889_007_0	13	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1889	008	0	1	04	01	H1889_008_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1889	009	0	1	04	01	H1889_009_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1889	010	0	1	04	01	H1889_010_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1889	011	0	1	04	01	H1889_011_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1889	012	0	1	04	01	H1889_012_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1889	013	0	1	04	01	H1889_013_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1889	014	0	1	04	01	H1889_014_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1889	015	0	1	04	01	H1889_015_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1889	016	0	1	04	01	H1889_016_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1889	017	0	1	04	01	H1889_017_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1889	018	0	1	04	01	H1889_018_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1889	019	0	1	04	01	H1889_019_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1889	020	0	1	04	01	H1889_020_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1889	021	0	1	04	01	H1889_021_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H1889	022	0	1	04	01	H1889_022_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1889	023	0	1	04	01	H1889_023_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1894	002	0	1	01	01	H1894_002_0	6	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	1	6	Restorative: Fillings - 1 per tooth every 3 yearsRestorative Crowns - 1 per tooth every 5 years	2	1				2	2	1	6	Periodontal Root Planning and Scaling - 1 per quadrant every 2 years	2	2	1	6	Extractions: 1 per tooth per lifetime	2	2	1	6	Prosthodontics (Dentures) - 1 set every 5 years	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1894	008	0	1	01	01	H1894_008_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	2	1	6	Restorative: Fillings - 1 per tooth every 3 yearsRestorative Crowns - 1 per tooth every 5 years	4	1				4	2	1	6	Periodontal Root Planning and Scaling - 1 per quadrant every 2 years	4	1				4	2	1	6	Prosthodontics (Dentures) - 1 set every 5 years	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1904	001	0	1	20	08	H1904_001_0	1																																																																																																																																																							
H1904	002	0	1	20	08	H1904_002_0	1																																																																																																																																																							
H1914	001	0	1	04	01	H1914_001_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1	2	2	1000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	45.00	45.00															1	2
H1914	002	0	1	04	01	H1914_002_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	45.00	45.00	0.00	0.00	0.00	0.00											1	2
H1914	006	0	1	04	01	H1914_006_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1	2	2	1000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1917	001	0	1	20	08	H1917_001_0	1	2																																																																																																																																																						
H1917	002	0	1	20	08	H1917_002_0	1	2																																																																																																																																																						
H1944	001	0	1	02	01	H1944_001_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1944	004	0	1	02	01	H1944_004_0	8	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H1944	005	0	1	02	01	H1944_005_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1944	006	0	1	02	01	H1944_006_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H1944	009	0	1	02	01	H1944_009_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1944	010	0	1	02	01	H1944_010_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1944	011	0	1	02	01	H1944_011_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1944	014	0	1	02	01	H1944_014_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1944	015	0	1	02	01	H1944_015_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1944	016	0	1	02	01	H1944_016_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1944	017	0	1	02	01	H1944_017_0	6	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H1944	018	0	1	02	01	H1944_018_0	7	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H1944	024	0	1	02	01	H1944_024_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1944	030	0	1	02	01	H1944_030_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1944	031	0	1	02	01	H1944_031_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1944	032	0	1	02	01	H1944_032_0	7	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H1944	033	0	1	02	01	H1944_033_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1944	034	0	1	02	01	H1944_034_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1944	035	0	1	02	01	H1944_035_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1944	805	0	1	01	01	H1944_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1944	806	0	1	01	01	H1944_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1944	807	0	1	01	01	H1944_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1947	001	0	1	01	01	H1947_001_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1947	003	0	1	01	01	H1947_003_0	6	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	013	0	1	01	01	H1951_013_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	024	0	1	01	01	H1951_024_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	028	0	1	01	01	H1951_028_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	032	0	1	01	01	H1951_032_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling up to unlimited per year, bridge and crown recementation up to 1 every 5 years, core buildup and prefabricated post and core up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	038	0	1	01	01	H1951_038_0	7	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	039	0	1	01	01	H1951_039_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					1	00010000					0	0											2		1	01001010	30.00	30.00					25.00	25.00			25.00	25.00					1	2
H1951	041	0	1	01	01	H1951_041_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	044	0	1	01	01	H1951_044_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	047	1	1	01	01	H1951_047_1	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	047	2	1	01	01	H1951_047_2	7	1	1111	2	1				2	1				2	1				2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	048	1	1	01	01	H1951_048_1	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	048	2	1	01	01	H1951_048_2	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	049	1	1	01	01	H1951_049_1	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	049	2	1	01	01	H1951_049_2	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	049	3	1	01	01	H1951_049_3	5	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	051	0	1	01	01	H1951_051_0	5	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	052	0	1	01	01	H1951_052_0	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	053	0	1	01	01	H1951_053_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	054	0	1	01	01	H1951_054_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	30.00	30.00			0.00	0.00	25.00	25.00			25.00	25.00					1	2
H1951	055	0	1	01	01	H1951_055_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	056	0	1	01	01	H1951_056_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include dentures up to 1 per 5 years, oral surgery up to 2 per year, denture adjustment, denture repair,	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	057	0	1	01	01	H1951_057_0	6	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1951	801	0	1	01	01	H1951_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1951	804	0	1	01	01	H1951_804_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1951	807	0	1	01	01	H1951_807_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1951	808	0	1	01	01	H1951_808_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H1961	003	0	1	02	01	H1961_003_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1961	014	1	1	02	01	H1961_014_1	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1961	014	2	1	02	01	H1961_014_2	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1961	014	3	1	02	01	H1961_014_3	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1961	014	4	1	02	01	H1961_014_4	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1961	017	0	1	02	01	H1961_017_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1961	019	0	1	02	01	H1961_019_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H1961	020	0	1	02	01	H1961_020_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H1961	801	0	1	02	01	H1961_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1961	802	0	1	02	01	H1961_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1961	803	0	1	01	01	H1961_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1961	804	0	1	01	01	H1961_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H1969	002	0	1	01	01	H1969_002_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	20.00	20.00			0.00	0.00											2	2
H1969	006	0	1	01	01	H1969_006_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	25.00	25.00			0.00	0.00											2	2
H1969	007	3	1	01	01	H1969_007_3	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	25.00	25.00			0.00	0.00											2	2
H1969	007	4	1	01	01	H1969_007_4	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	25.00	25.00			0.00	0.00											2	2
H1977	001	0	1	48	05	H1977_001_0	4	1	1111	2	2	1	4		2	2	1	4		2	2	6	6	Per lifetime.	2	2	1	6	Every 12months: Bitewing Radiographs Every 3yrs per arch (under age 21): Occlusal Radiograph Every 5yrs (over age 5): Panoramic Radiograph, Full mouth/Complete series everyday, with medical necessity.	2					2				2		2												2		2		2												2	2	1	1011011						2	1				2	1									2	2	1	6	Prosthododontics(removable)-Once per 5yrs per arch when prognosis of complete/partial denture is at least 5yrs: Complete/partial dentures. Every day per medical need: Other Oral/Maxillofacial Surgery.	2	2	999	6	Everyday, based on medical necessity	2	2	1	6	Prosthodontics(removable)-Once per 5yrs per arch when prognosis of complete/partial denture is at least 5yrs: Complete/partial dentures. Every day per medical need: Other Oral/Maxillofacial Surgery.	2						2					2																		2		2																		2	2
H1980	001	0	1	20	08	H1980_001_0	1																																																																																																																																																							
H1980	002	0	1	20	08	H1980_002_0	1																																																																																																																																																							
H1993	001	0	1	01	01	H1993_001_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		250.00	5		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	1
H1993	007	0	1	01	01	H1993_007_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		15000.00	3		2				2		2												2		1	0010	2						0.00	95.00					2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10001111							25.00	400.00	25.00	720.00	40.00	780.00	40.00	380.00	0.00	600.00	1	1
H1993	008	0	1	01	01	H1993_008_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		500.00	5		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	1
H1993	010	0	1	01	01	H1993_010_0	13	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		4100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	1
H1994	001	0	1	01	01	H1994_001_0	11	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H1994	002	0	1	01	01	H1994_002_0	13	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H1994	003	0	1	01	01	H1994_003_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					1	10001000							20	20							20	20	2		1	01000000	20.00	20.00															1	2
H1994	004	0	1	01	01	H1994_004_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					1	10001000							20	20							20	20	2		1	01000000	20.00	20.00															1	2
H1994	007	0	1	01	01	H1994_007_0	12	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H1994	008	0	1	01	01	H1994_008_0	10	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1500.00	3		2					1	10001000							20	20							20	20	2		1	01000000	10.00	10.00															1	2
H1994	012	0	1	01	01	H1994_012_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	2500.00	3		2					2																		2		2																		1	2
H1994	013	0	1	01	01	H1994_013_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					1	10001000							20	20							20	20	2		1	01000000	50.00	50.00															1	2
H1994	014	0	1	01	01	H1994_014_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					1	10001000							20	20							20	20	2		1	01000000	50.00	50.00															1	2
H1994	015	0	1	01	01	H1994_015_0	9	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	30	30															2		2																		1	2
H1994	016	0	1	01	01	H1994_016_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H1994	017	0	1	01	01	H1994_017_0	8	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H1994	021	0	1	01	01	H1994_021_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H1994	022	0	1	01	01	H1994_022_0	8	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H1994	023	0	1	01	01	H1994_023_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					1	10001000							20	20							20	20	2		1	01000000	20.00	20.00															1	2
H1994	024	0	1	01	01	H1994_024_0	7	1	1110	2	1				2	1									2	1				2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	01000000	20.00	20.00															1	2
H1994	025	0	1	01	01	H1994_025_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					1	10001000							20	20							20	20	2		1	01000000	30.00	30.00															1	2
H1994	027	0	1	01	01	H1994_027_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H1994	028	0	1	01	01	H1994_028_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	30	30															2		2																		1	2
H1994	029	0	1	01	01	H1994_029_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H1994	030	0	1	01	01	H1994_030_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H1994	031	0	1	01	01	H1994_031_0	8	1	1111	2	1				2	1				2	1				2	1				2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	01000000	25.00	25.00															1	2
H1994	801	0	1	01	01	H1994_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1994	802	0	1	01	01	H1994_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1994	803	0	1	01	01	H1994_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H1997	002	0	1	01	01	H1997_002_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											2	2
H1997	008	0	1	01	01	H1997_008_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											2	2
H1997	012	1	1	01	01	H1997_012_1	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	25.00	25.00			0.00	0.00											2	2
H1997	012	2	1	01	01	H1997_012_2	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											2	2
H2001	001	0	1	04	01	H2001_001_0	6	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2001	010	0	1	04	01	H2001_010_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2001	017	0	1	04	01	H2001_017_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2001	018	0	1	04	01	H2001_018_0	7	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2001	019	0	1	04	01	H2001_019_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2001	021	0	1	04	01	H2001_021_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2001	023	0	1	04	01	H2001_023_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2001	816	0	1	04	01	H2001_816_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	817	0	1	04	01	H2001_817_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	818	0	1	04	01	H2001_818_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	819	0	2	04	01	H2001_819_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	820	0	2	04	01	H2001_820_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	821	0	2	04	01	H2001_821_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	822	0	1	04	01	H2001_822_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	823	0	1	04	01	H2001_823_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	824	0	1	04	01	H2001_824_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	825	0	1	04	01	H2001_825_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	826	0	1	04	01	H2001_826_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	827	0	1	04	01	H2001_827_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	828	0	1	04	01	H2001_828_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	829	0	1	04	01	H2001_829_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	830	0	1	04	01	H2001_830_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	831	0	1	04	01	H2001_831_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	832	0	2	04	01	H2001_832_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	833	0	2	04	01	H2001_833_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	834	0	2	04	01	H2001_834_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	835	0	1	04	01	H2001_835_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	836	0	1	04	01	H2001_836_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	837	0	1	04	01	H2001_837_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	838	0	1	04	01	H2001_838_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	839	0	2	04	01	H2001_839_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	840	0	1	04	01	H2001_840_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	841	0	1	04	01	H2001_841_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	842	0	1	04	01	H2001_842_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	843	0	1	04	01	H2001_843_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	844	0	1	04	01	H2001_844_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	845	0	1	04	01	H2001_845_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	846	0	1	04	01	H2001_846_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	847	0	1	04	01	H2001_847_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	848	0	1	04	01	H2001_848_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	849	0	1	04	01	H2001_849_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	850	0	1	04	01	H2001_850_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	851	0	1	04	01	H2001_851_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	852	0	1	04	01	H2001_852_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	853	0	1	04	01	H2001_853_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	854	0	1	04	01	H2001_854_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	855	0	1	04	01	H2001_855_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	856	0	1	04	01	H2001_856_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	857	0	1	04	01	H2001_857_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	858	0	1	04	01	H2001_858_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	859	0	1	04	01	H2001_859_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	860	0	1	04	01	H2001_860_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	861	0	1	04	01	H2001_861_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	862	0	1	04	01	H2001_862_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	863	0	1	04	01	H2001_863_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	864	0	1	04	01	H2001_864_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	865	0	1	04	01	H2001_865_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	866	0	1	04	01	H2001_866_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	867	0	1	04	01	H2001_867_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	868	0	1	04	01	H2001_868_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	869	0	1	04	01	H2001_869_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	870	0	1	04	01	H2001_870_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	871	0	1	04	01	H2001_871_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	872	0	1	04	01	H2001_872_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	873	0	1	04	01	H2001_873_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	874	0	1	04	01	H2001_874_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	875	0	1	04	01	H2001_875_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	876	0	1	04	01	H2001_876_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	877	0	1	04	01	H2001_877_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	878	0	1	04	01	H2001_878_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	879	0	1	04	01	H2001_879_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	880	0	1	04	01	H2001_880_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	881	0	1	04	01	H2001_881_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	882	0	1	04	01	H2001_882_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	883	0	1	04	01	H2001_883_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2001	884	0	1	04	01	H2001_884_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2029	001	0	1	04	01	H2029_001_0	12	1	1110	2	2	2	3		2	2	2	3							2	2	8	6	Dental X-Rays include bitewing x-rays up to 1 set(s) every 2 years, intraoral x-rays up to 6 per year, panoramic film up to 1 every 3 years.	2					2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	1011111						2	2	1	1		2	2	2	6	Restorative services include fillings 0% up to 1 per tooth every 3 years, crown 0% up to 1 per tooth every 5 years, $1500 maximum benefit per year that only applies to crowns.	2	1				2	2	1	3		2	1				2	2	5	6	Denture adjustments unlimited/year, implant services 1 per tooth/lifetime, implant supported prosthetics 1 per tooth/5 years, complete and partial dentures 1/5 years, bridges 1/5 years	1	2	2	1500.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	8.00	8.00															1	2
H2029	801	0	1	04	01	H2029_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2029	802	0	1	04	01	H2029_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2029	805	0	2	04	01	H2029_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2029	806	0	2	04	01	H2029_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2029	809	0	1	04	01	H2029_809_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2029	810	0	1	04	01	H2029_810_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2029	811	0	1	04	01	H2029_811_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2029	812	0	1	04	01	H2029_812_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2029	815	0	1	04	01	H2029_815_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2029	816	0	1	04	01	H2029_816_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2029	821	0	1	04	01	H2029_821_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2029	822	0	1	04	01	H2029_822_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2032	001	0	1	04	01	H2032_001_0	16	1	1110	2	2	1	4		2	2	3	3							2	2	1	6	Full mouth x-rays 1x every 60 months.  Bite-wing x-rays 1x every 12 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	4		2	2	1	6	Up to 8 periapical x-rays per visit.	2	2	1	6	Dentures 1x/5 years at 0% coinsurance.  Fillings 1x/24 months at 0% coinsurance.Crown/inlays/onlays/bridges/implants (one per tooth position) 1x/10 years at 50% coinsurance.	2	2	1	6	Root canal one per tooth per lifetime.	2	2	1	6	Periodontal surgery 1x every 36 months.  Periodontal maintenance up to 4x every calendar year.  Scaling and root planing 1x every 24 months.	2	1				2	2	1	6	Dentures through Prosthodontist 1x every 5 calendar years at 0% coinsurance.Bridges covered through Prosthodontist 1x every 10 calendar years at 50% coinsurance.	1	2	2	3500.00	3		2					1	10101110			0	50			0	50	50	50	50	50			0	50	2		2																		2	2
H2032	002	0	1	04	01	H2032_002_0	16	1	1110	2	2	1	4		2	2	3	3							2	2	1	6	Full mouth x-rays 1x every 60 months.  Bite-wing x-rays 1x every 12 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	4		2	2	1	6	Up to 8 periapical x-rays per visit.	2	2	1	6	Dentures 1x/5 years at 0% coinsurance.  Fillings 1x/24 months 0% coinsurance.Crown/inlays/onlays/bridges/implants (one per tooth position) 1x/10 years at 50% coinsurance.	2	2	1	6	Root canal one per tooth per lifetime.	2	2	1	6	Periodontal surgery 1x every 36 months.  Periodontal maintenance up to 4x every calendar year.  Scaling and root planing 1x every 24 months.	2	1				2	2	1	6	Dentures through Prosthodontist 1x every 5 calendar years at 0% coinsurance.Bridges covered through Prosthodontist 1x every 10 calendar years at 50% coinsurance.	1	2	2	3500.00	3		2					1	10101110			0	50			0	50	50	50	50	50			0	50	2		2																		2	2
H2032	003	0	1	04	01	H2032_003_0	17	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Full mouth x-rays 1x every 60 months.  Bite-wing x-rays 1x every 12 months.	1	2	3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	3		2	2	1	6	Up to 8 periapical x-rays per visit.	2	2	1	6	Dentures 1x/5 years at 0% coinsurance.  Fillings 1x/24 months at 0% coinsurance.Crown/inlays/onlays/bridges/implants (one per tooth position) 1x/10 years at 50%.	2	2	1	6	Root canal one per tooth per lifetime.	2	2	1	6	Periodontal surgery 1x every 36 months.  Periodontal maintenance up to 4x every calendar year.  Scaling and root planing 1x every 24 months.	2	1				2	2	1	6	Dentures through Prosthodontist 1x every 5 calendar years at 0% coinsurance.Bridges covered through Prosthodontist 1x every 10 calendar years at 50% coinsurance.	1		1				2					1	10101110			0	50			0	50	50	50	50	50			0	50	2		2																		2	2
H2032	801	0	1	04	01	H2032_801_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2032	802	0	1	04	01	H2032_802_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2032	803	0	1	04	01	H2032_803_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2032	804	0	1	04	01	H2032_804_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2034	001	0	1	01	01	H2034_001_0	5	1	1111	2	1				2	1				2	1				2	1				2					2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		2																		1	2
H2056	001	0	1	02	01	H2056_001_0	7	1	1111	2	1				2	1				2	1				2	1				1		2100.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2056	002	0	1	02	01	H2056_002_0	7	1	1111	2	1				2	1				2	1				2	1				1		1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2056	003	0	1	02	01	H2056_003_0	7	1	1111	2	1				2	1				2	1				2	1				1		2100.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2056	004	0	1	02	01	H2056_004_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2056	005	0	1	02	01	H2056_005_0	7	1	1111	2	1				2	1				2	1				2	1				1		2100.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2056	010	0	1	02	01	H2056_010_0	7	1	1111	2	1				2	1				2	1				2	1				1		1800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2056	011	0	1	02	01	H2056_011_0	8	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2056	012	0	1	02	01	H2056_012_0	7	1	1111	2	1				2	1				2	1				2	1				1		1800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2056	013	0	1	02	01	H2056_013_0	7	1	1111	2	1				2	1				2	1				2	1				1		1800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2056	801	0	1	01	01	H2056_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2056	802	0	1	01	01	H2056_802_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2064	001	0	1	20	08	H2064_001_0	1																																																																																																																																																							
H2064	002	0	1	20	08	H2064_002_0	1																																																																																																																																																							
H2085	001	0	1	20	08	H2085_001_0	1																																																																																																																																																							
H2085	002	0	1	20	08	H2085_002_0	1																																																																																																																																																							
H2108	022	0	1	01	01	H2108_022_0	9	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		5000.00	3		2				2		2												2		2		2												2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	55.00	55.00															1	2
H2108	029	0	1	01	01	H2108_029_0	7	1	1111	2	1				2	1				2	1				2	1				1		1100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H2108	030	0	1	01	01	H2108_030_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		5000.00	3		2				2		2												2		2		2												2	2	2																																											2					2																		2		1	01000000	45.00	45.00															1	2
H2108	036	0	1	01	01	H2108_036_0	9	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		5000.00	3		2				2		2												2		2		2												2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	55.00	55.00															1	2
H2108	039	0	1	01	01	H2108_039_0	8	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H2108	040	0	1	01	01	H2108_040_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	40.00	40.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H2108	041	0	1	01	01	H2108_041_0	8	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H2108	042	1	1	01	01	H2108_042_1	7	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H2108	042	2	1	01	01	H2108_042_2	8	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		5000.00	3		2				2		2												2		2		2												2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															1	2
H2108	043	1	1	01	01	H2108_043_1	8	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H2108	043	2	1	01	01	H2108_043_2	8	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H2108	801	0	1	01	01	H2108_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2109	001	0	1	20	08	H2109_001_0	1																																																																																																																																																							
H2109	002	0	1	20	08	H2109_002_0	1																																																																																																																																																							
H2117	001	0	1	04	01	H2117_001_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1	2	2	2000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2117	002	0	1	04	01	H2117_002_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2117	003	0	1	04	01	H2117_003_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2128	002	0	1	04	01	H2128_002_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2128	004	0	1	04	01	H2128_004_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	45.00	45.00	0.00	0.00	0.00	0.00											1	2
H2128	005	0	1	04	01	H2128_005_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	5000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2134	001	0	1	01	01	H2134_001_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months	2	2	1	3		2	2	1	6	every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2134	003	0	1	01	01	H2134_003_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months	2	2	1	3		2	2	1	6	every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2134	005	0	1	01	01	H2134_005_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	2000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	30.00	30.00															1	2
H2162	001	0	1	01	01	H2162_001_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2168	001	0	1	01	01	H2168_001_0	11	1	1111	2	1				2	1				2	1				2	1				2					2				2		2												2		2		2												1	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary. Plan will cover 1 occlusal guard per arch every 24 months. Limited to codes covered by the plan for comprehensive dental.	2	2	1	3		2	2	1	6	Plan will cover 1 filling per surface per tooth every 36 months, and 1 crown per tooth every 60 months as well as recement as needed.	2	2	1	6	Plan will cover root canals as well as retreatment of root canals (one per tooth per lifetime).	2	2	1	6	Covers gingivectomy, osseous surgery, periodontal scaling, full mouth debridement to enable comprehensive evaluation and diagnosis, periodontal maintenance, and gingival irrigation. Limits apply.	2	1				2	2	1	6	Oral Surgery - extraction, removal of impacted tooth or removal of residual roots.  Prosthodontics, Other oral/maxillofacial surgery, other services. Limits apply.	1		2	1000.00	4		2					1	01000000	20	20															2		2																		1	2
H2168	002	0	1	01	01	H2168_002_0	10	2																																																															1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary. Plan will cover 1 occlusal guard per arch every 24 months.	2	2	1	3		2	2	1	6	Plan will cover 1 filling per surface per tooth every 36 months, and 1 crown per tooth every 60 months as well as recement as needed.	2	2	1	6	Plan will cover root canals as well as retreatment of root canals (one per tooth per lifetime).	2	2	1	6	Covers gingivectomy, osseous surgery, periodontal scaling, full mouth debridement to enable comprehensive evaluation and diagnosis, periodontal maintenance, and gingival irrigation. Limits apply.	2	1				2	2	1	6	Covers Retainer Crown and Pontic, and Extractions. Limits apply.	1		2	1000.00	4		2					1	01000000	20	20															2		2																		1	2
H2168	003	0	1	01	01	H2168_003_0	11	1	1111	2	1				2	1				2	1				2	1				2					2				2		2												2		2		2												1	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary. Plan will cover 1 occlusal guard per arch every 24 months.	2	2	1	3		2	2	1	6	Plan will cover 1 filling per surface per tooth every 36 months, and 1 crown per tooth every 60 months as well as recement as needed.	2	2	1	6	Plan will cover root canals as well as retreatment of root canals (one per tooth per lifetime).	2	2	1	6	Covers gingivectomy, osseous surgery, periodontal scaling, full mouth debridement to enable comprehensive evaluation and diagnosis, periodontal maintenance, and gingival irrigation.  Limits apply.	2	1				2	2	1	6	Oral Surgery - extraction, removal of impacted tooth or removal of residual roots Prosthodontics, Other oral/maxillofacial surgery, other services. Limits apply.	1		2	500.00	3		2					1	01000000	20	20															2		2																		1	2
H2168	004	0	1	01	01	H2168_004_0	9	1	1111	2	1				2	1				2	1				2	1				2					2				2		2												2		2		2												1	2	1	1111111	2	2	1	6	Anesthesia/sedation is covered as medically necessary. Plan will cover 1 occlusal guard per arch every 24 months.	2	2	1	3		2	2	1	6	Plan will cover 1 filling per surface per tooth every 36 months, and 1 crown per tooth every 60 months as well as recement as needed.	2	2	1	6	Plan will cover root canals as well as retreatment of root canals (one per tooth per lifetime).	2	2	1	6	Covers gingivectomy, osseous surgery, periodontal scaling, full mouth debridement to enable comprehensive evaluation and diagnosis, periodontal maintenance, and gingival irrigation.  Limits apply.	2	1				2	2	1	6	Oral Surgery - extraction, removal of impacted tooth or removal of residual roots Prosthodontics, Other oral/maxillofacial surgery, other services. Limits apply.	1		2	500.00	3		2					1	01000000	20	20															2		2																		1	2
H2171	001	0	1	01	01	H2171_001_0	11	1	1111	2	2	2	6	See notes for detail.	2	2	2	6	See notes for detail	2	2	2	6	Topical application of fluoride varnish, topical fluoride-2 every 12 months.	2	2	1	6	See notes for detail.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Service dependent. See notes for detail.	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail.	1		1				2					2																		2		2																		1	2
H2171	003	0	1	01	01	H2171_003_0	11	1	1111	2	2	2	6	See Notes	2	2	2	6	See Notes	2	2	2	6	Topical application of fluoride varnish, topical fluoride-2 every 12 months.	2	2	1	6	See Notes	1		3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Service dependent. See notes for detail.	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail.	1		1				2					2																		2		2																		1	2
H2171	801	0	1	01	01	H2171_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2171	802	0	1	01	01	H2171_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2171	803	0	1	01	01	H2171_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2171	804	0	1	01	01	H2171_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2172	001	0	1	02	01	H2172_001_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2					2				2		2												2		1		1	1111	0.00	30.00									2	2	1	1111111	4	1				2	1				4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	4	2	1	6	Extractions are limited to one per tooth.	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	500.00	3		2					1	10111111			50	50	0	0	50	50	50	50	50	50	50	50	50	50	2		1	01000001	30.00	30.00											30.00	30.00			1	1
H2172	002	0	1	02	01	H2172_002_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2					2				2		2												2		1		1	1111	0.00	35.00									2	2	1	1111111	4	1				2	1				4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	4	2	1	6	Extractions are limited to one per tooth.	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	500.00	3		2					1	10111111			50	50	0	0	50	50	50	50	50	50	50	50	50	50	2		1	01000001	35.00	35.00											35.00	35.00			1	1
H2172	003	0	1	02	01	H2172_003_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2					2				2		2												2		1		1	1111	0.00	40.00									2	2	1	1111111	4	1				2	1				4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	4	2	1	6	Extractions are limited to one per tooth.	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3		2					1	10111111			50	50	0	0	50	50	50	50	50	50	50	50	50	50	2		1	01000001	40.00	40.00											40.00	40.00			1	1
H2172	004	0	1	02	01	H2172_004_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2					2				2		2												2		1		1	1111	0.00	35.00									2	2	1	1111111	4	1				2	1				4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	4	2	1	6	Extractions are limited to one per tooth.	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3		2					1	10111111			50	50	0	0	50	50	50	50	50	50	50	50	50	50	2		1	01000001	35.00	35.00											35.00	35.00			1	1
H2172	005	0	1	01	01	H2172_005_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2					2				2		2												2		1		1	1111	0.00	40.00									2	2	1	1111111	4	1				2	1				4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	4	2	1	6	Extractions are limited to one per tooth.	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	500.00	3		2					1	10111111			50	50	0	0	50	50	50	50	50	50	50	50	50	50	2		1	01000001	40.00	40.00											40.00	40.00			1	1
H2172	006	0	1	01	01	H2172_006_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2					2				2		2												2		1		1	1111	0.00	40.00									2	2	1	1111111	4	1				2	1				4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	4	2	1	6	Extractions are limited to one per tooth.	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3		2					1	10111111			50	50	0	0	50	50	50	50	50	50	50	50	50	50	2		1	01000001	40.00	40.00											40.00	40.00			1	1
H2172	008	0	1	02	01	H2172_008_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2					2				2		2												2		1		1	1111	0.00	35.00									2	2	1	1111111	4	1				2	1				4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	4	2	1	6	Extractions are limited to one per tooth.	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	500.00	3		2					1	10111111			50	50	0	0	50	50	50	50	50	50	50	50	50	50	2		1	01000001	35.00	35.00											35.00	35.00			1	1
H2172	009	0	1	02	01	H2172_009_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2					2				2		2												2		1		1	1111	0.00	35.00									2	2	1	1111111	4	1				2	1				4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	4	2	1	6	Extractions are limited to one per tooth.	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3		2					1	10111111			50	50	0	0	50	50	50	50	50	50	50	50	50	50	2		1	01000001	35.00	35.00											35.00	35.00			1	1
H2172	010	0	1	02	01	H2172_010_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2					2				2		2												2		1		1	1111	0.00	40.00									2	2	1	1111111	4	1				2	1				4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	4	2	1	6	Extractions are limited to one per tooth.	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3		2					1	10111111			50	50	0	0	50	50	50	50	50	50	50	50	50	50	2		1	01000001	40.00	40.00											40.00	40.00			1	1
H2172	011	0	1	01	01	H2172_011_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2					2				2		2												2		1		1	1111	0.00	40.00									2	2	1	1111111	4	1				2	1				4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	4	2	1	6	Extractions are limited to one per tooth.	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3		2					1	10111111			50	50	0	0	50	50	50	50	50	50	50	50	50	50	2		1	01000001	40.00	40.00											40.00	40.00			1	1
H2172	012	0	1	02	01	H2172_012_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2					2				2		2												2		1		1	1111	0.00	40.00									2	2	1	1111111	4	1				2	1				4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	4	2	1	6	Extractions are limited to one per tooth.	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3		2					1	10111111			50	50	0	0	50	50	50	50	50	50	50	50	50	50	2		1	01000001	40.00	40.00											40.00	40.00			1	1
H2172	013	0	1	02	01	H2172_013_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2					2				2		2												2		1		1	1111	0.00	40.00									2	2	1	1111111	4	1				2	1				4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years.	4	2	1	6	Extractions are limited to one per tooth.	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year & pontics and retainer crowns to one per tooth per five years.	1		2	1000.00	3		2					1	10111111			50	50	0	0	50	50	50	50	50	50	50	50	50	50	2		1	01000001	40.00	40.00											40.00	40.00			1	1
H2172	801	0	1	01	01	H2172_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2172	803	0	1	01	01	H2172_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2172	804	0	2	01	01	H2172_804_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2172	805	0	1	01	01	H2172_805_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2174	001	0	1	01	01	H2174_001_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	5000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2185	001	0	1	01	01	H2185_001_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	1		2400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		1				2					1	01000000	20	20															2		2																		1	2
H2185	003	0	1	02	01	H2185_003_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	1		400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		1				2					1	01000000	20	20															2		2																		1	2
H2218	001	0	1	20	08	H2218_001_0	1																																																																																																																																																							
H2218	002	0	1	20	08	H2218_002_0	1																																																																																																																																																							
H2219	001	0	1	20	08	H2219_001_0	1																																																																																																																																																							
H2219	002	0	1	20	08	H2219_002_0	1																																																																																																																																																							
H2220	001	0	1	20	08	H2220_001_0	1																																																																																																																																																							
H2220	002	0	1	20	08	H2220_002_0	1																																																																																																																																																							
H2221	001	0	1	20	08	H2221_001_0	1																																																																																																																																																							
H2221	002	0	1	20	08	H2221_002_0	1																																																																																																																																																							
H2222	002	0	1	20	08	H2222_002_0	2																																																																																																																																																							
H2222	003	0	1	20	08	H2222_003_0	2																																																																																																																																																							
H2223	001	0	1	20	08	H2223_001_0	1																																																																																																																																																							
H2223	002	0	1	20	08	H2223_002_0	1																																																																																																																																																							
H2224	001	0	1	01	01	H2224_001_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2224	003	0	1	01	01	H2224_003_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2225	001	0	1	01	01	H2225_001_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2226	001	0	1	01	01	H2226_001_0	3	2																																																															2																																											2					2																		2		1	01000000	0.00	0.00															1	2
H2226	003	0	1	01	01	H2226_003_0	3	2																																																															2																																											2					2																		2		1	01000000	0.00	0.00															1	2
H2230	002	0	1	04	01	H2230_002_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	2																																											2					2																		2		1	01000000	35.00	35.00															2	2
H2230	017	0	1	04	01	H2230_017_0	7	1	1110	2	2	3	3		2	2	3	3							2	2	3	6	Full mouth X-rays, 7 or more films, or panoramic X-ray with bitewing X-rays once every 60 months. Bitewing X-rays once every 6 months. Single-tooth X-rays as needed.	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	6	Silver and white fillings: once per tooth in 12 months. Inlays: once per tooth in 60 months.	2	2	1	6	Root canals and retreatment of prior root canal on permanent teeth: once per tooth.	2	2	1	6	Periodontal scaling and root planning: once per quadrant per 24 months. Periodontal Surgery: once per quadrant per 36 months. Maintenance following active periodontal therapy: once within three months	2	1				2	2	1	6	See Notes Section for 16b7 for comprehensive list	1		1				2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	45.00	45.00															2	2
H2230	018	1	1	04	01	H2230_018_1	6	1	1110	2	2	3	3		2	2	3	3							2	2	3	6	Full mouth X-rays, 7 or more films, or panoramic X-ray with bitewing X-rays once every 60 months. Bitewing X-rays once every 6 months. Single-tooth X-rays as needed.	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	6	Silver and white fillings: once per tooth in 12 months. Inlays: once per tooth in 60 months.	2	2	1	6	Root canals and retreatment of prior root canal on permanent teeth: once per tooth.	2	2	1	6	Periodontal scaling and root planning: once per quadrant per 24 months. Periodontal Surgery: once per quadrant per 36 months. Maintenance following active periodontal therapy: once within three months	2	1				2	2	1	6	See Notes for 16b7 for comprehensive list.	1		1				2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	40.00	40.00															2	2
H2230	018	2	1	04	01	H2230_018_2	6	1	1110	2	2	3	3		2	2	3	3							2	2	3	6	Full mouth X-rays, 7 or more films, or panoramic X-ray with bitewing X-rays once every 60 months. Bitewing X-rays once every 6 months. Single-tooth X-rays as needed.	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	6	Silver and white fillings: once per tooth in 12 months. Inlays: once per tooth in 60 months.	2	2	1	6	Root canals and retreatment of prior root canal on permanent teeth: once per tooth.	2	2	1	6	Periodontal scaling and root planning: once per quadrant per 24 months. Periodontal Surgery: once per quadrant per 36 months. Maintenance following active periodontal therapy: once within three months	2	1				2	2	1	6	See Notes for 16b7 for comprehensive list.	1		1				2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	40.00	40.00															2	2
H2230	801	0	1	04	01	H2230_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2230	809	0	1	04	01	H2230_809_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2230	813	0	1	04	01	H2230_813_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2235	001	0	1	01	01	H2235_001_0	15	1	1111	2	2	1	6	See note below.	2	2	2	3		2	2	2	3		2	2	1	6	See note below.	2					2				2		2												2		2		2												2	2	1	1001111											4	2	1	6	See note below.	4	2	2	3		4	2	1	6	See note below.	4	2	2	3		4	2	1	6	See note below.	1		2	2000.00	3		2					2																		2		1	01000000	15.00	15.00															1	1
H2235	002	0	1	01	01	H2235_002_0	15	1	1111	2	2	1	6	See note below.	2	2	2	3		2	2	2	3		2	2	1	6	See note below.	2					2				2		2												2		2		2												2	2	1	1001111											4	2	1	6	See note below.	4	2	2	3		4	2	1	6	See note below.	4	2	2	3		4	2	1	6	See note below.	1		2	2000.00	3		2					2																		2		1	01000000	40.00	40.00															1	1
H2235	003	0	1	01	01	H2235_003_0	15	1	1111	2	2	1	6	See note below.	2	2	2	3		2	2	2	3		2	2	1	6	See note below.	2					2				2		2												2		2		2												2	2	1	1001111											4	2	1	6	See note below.	4	2	2	3		4	2	1	6	See note below.	4	2	2	3		4	2	1	6	See note below.	1		2	2000.00	3		2					2																		2		1	01000000	15.00	15.00															1	1
H2235	005	0	1	01	01	H2235_005_0	15	1	1111	2	2	1	6	See note below.	2	2	2	3		2	2	2	3		2	2	1	6	See note below.	2					2				2		2												2		2		2												2	2	1	1001111											4	2	1	6	See note below.	4	2	2	3		4	2	1	6	See note below.	4	2	2	3		4	2	1	6	See note below.	1		2	2000.00	3		2					2																		2		1	01000000	40.00	40.00															1	1
H2235	006	0	1	02	01	H2235_006_0	15	1	1111	2	2	1	6	See note below.	2	2	2	3		2	2	2	3		2	2	1	6	See note below.	2					2				2		2												2		2		2												2	2	1	1001111											4	2	1	6	See note below.	4	2	2	3		4	2	1	6	See note below.	4	2	2	3		4	2	1	6	See note below.	1		2	2000.00	3		2					2																		2		1	01000000	35.00	35.00															1	1
H2237	001	0	1	01	01	H2237_001_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	See notes	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include amalgam and/or composite filling up to unlimited per year, bridge recementation and crown recementation up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	services include adj to dentures, denture rebase, reline, repair and tissue conditioning 1/yr , bridges, complete and partial dentures 1 every 5 yrs occlusal adj1 every 3 yrs oral surgery 2/yr	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H2237	007	0	1	01	01	H2237_007_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include amalgam and/or composite filling up to unlimited per year, bridge recementation and crown recementation up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	Services include adj to dentures, rebase, reline, repair and tissue conditioning up to 1 per yr, bridges, complete and partial dentures 1 every 5 yrs, occlusal adj 1 every 3 yrs, oral surgery 2 per yr	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H2246	018	0	1	04	01	H2246_018_0	11	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H2246	019	0	1	04	01	H2246_019_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	2500.00	3		2					2																		2		1	01000000	35.00	35.00															1	2
H2246	020	0	1	04	01	H2246_020_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H2246	026	0	1	04	01	H2246_026_0	9	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	1000.00	3		2					1	10001000							20	20							20	20	2		1	01000000	30.00	30.00															1	2
H2246	032	0	1	04	01	H2246_032_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		1	2	1500.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H2247	001	0	1	02	01	H2247_001_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2247	003	0	1	02	01	H2247_003_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2256	001	1	1	01	01	H2256_001_1	7	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	15.00	15.00															2	2
H2256	001	2	1	01	01	H2256_001_2	7	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	15.00	15.00															2	2
H2256	001	6	1	01	01	H2256_001_6	7	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	15.00	15.00															2	2
H2256	015	1	1	01	01	H2256_015_1	7	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	15.00	15.00															2	2
H2256	015	2	1	01	01	H2256_015_2	7	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	15.00	15.00															2	2
H2256	015	6	1	01	01	H2256_015_6	7	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	15.00	15.00															2	2
H2256	016	1	1	01	01	H2256_016_1	5	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	15.00	15.00															2	2
H2256	016	2	1	01	01	H2256_016_2	5	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	15.00	15.00															2	2
H2256	018	1	1	01	01	H2256_018_1	7	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111011	4	2	1	3		4	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	4	2	1	2		3					4	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	4	2	1	6	Simple extraction covered once per tooth.	4	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	1		1				2					1	10111011			50	50	50	50	50	50			50	50	50	50	50	50	2		1	01000000	25.00	25.00															2	2
H2256	018	7	1	01	01	H2256_018_7	7	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111011	4	2	1	3		4	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	4	2	1	2		3					4	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	4	2	1	6	Simple extraction covered once per tooth.	4	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	1		1				2					1	10111011			50	50	50	50	50	50			50	50	50	50	50	50	2		1	01000000	25.00	25.00															2	2
H2256	018	8	1	01	01	H2256_018_8	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111011	4	2	1	3		4	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	4	2	1	2		3					4	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	4	2	1	6	Simple extraction covered once per tooth.	4	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	1		1				2					1	10111011			50	50	50	50	50	50			50	50	50	50	50	50	2		1	01000000	25.00	25.00															2	2
H2256	019	1	1	01	01	H2256_019_1	5	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111011	4	2	1	3		4	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	4	2	1	2		3					4	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	4	2	1	6	Simple extraction covered once per tooth.	4	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	1		1				2					1	10111011			50	50	50	50	50	50			50	50	50	50	50	50	2		1	01000000	25.00	25.00															2	2
H2256	019	7	1	01	01	H2256_019_7	5	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111011	4	2	1	3		4	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	4	2	1	2		3					4	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	4	2	1	6	Simple extraction covered once per tooth.	4	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	1		1				2					1	10111011			50	50	50	50	50	50			50	50	50	50	50	50	2		1	01000000	25.00	25.00															2	2
H2256	026	1	1	01	01	H2256_026_1	7	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111011	4	2	1	3		4	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	4	2	1	2		3					4	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	4	2	1	6	Simple extraction covered once per tooth.	4	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	1		1				2					1	10111011			50	50	50	50	50	50			50	50	50	50	50	50	2		1	01000000	40.00	40.00															2	2
H2256	026	2	1	01	01	H2256_026_2	7	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111011	4	2	1	3		4	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	4	2	1	2		3					4	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	4	2	1	6	Simple extraction covered once per tooth.	4	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	1		1				2					1	10111011			50	50	50	50	50	50			50	50	50	50	50	50	2		1	01000000	40.00	40.00															2	2
H2256	026	3	1	01	01	H2256_026_3	7	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111011	4	2	1	3		4	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	4	2	1	2		3					4	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	4	2	1	6	Simple extraction covered once per tooth.	4	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	1		1				2					1	10111011			50	50	50	50	50	50			50	50	50	50	50	50	2		1	01000000	40.00	40.00															2	2
H2256	028	0	1	01	01	H2256_028_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111011	4	2	1	3		4	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	4	2	1	2		3					4	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	4	2	1	6	Simple extraction covered once per tooth.	4	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	1		1				2					1	10111011			50	50	50	50	50	50			50	50	50	50	50	50	2		1	01000000	45.00	45.00															2	2
H2256	033	0	1	01	01	H2256_033_0	7	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	15.00	15.00															2	2
H2256	034	0	1	01	01	H2256_034_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111011	4	2	1	3		4	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	4	2	1	2		3					4	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	4	2	1	6	Simple extraction covered once per tooth.	4	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	1		1				2					1	10111011			50	50	50	50	50	50			50	50	50	50	50	50	2		1	01000000	25.00	25.00															2	2
H2256	036	0	1	01	01	H2256_036_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111011	4	2	1	3		4	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	4	2	1	2		3					4	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	4	2	1	6	Simple extraction covered once per tooth.	4	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	1		1				2					1	10111011			50	50	50	50	50	50			50	50	50	50	50	50	2		1	01000000	40.00	40.00															2	2
H2256	039	0	1	01	01	H2256_039_0	5	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	15.00	15.00															2	2
H2256	040	0	1	01	01	H2256_040_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111011	4	2	1	3		4	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	4	2	1	2		3					4	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	4	2	1	6	Simple extraction covered once per tooth.	4	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	1		1				2					1	10111011			50	50	50	50	50	50			50	50	50	50	50	50	2		1	01000000	25.00	25.00															2	2
H2256	041	0	1	01	01	H2256_041_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111011	4	2	1	3		4	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	4	2	1	2		3					4	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	4	2	1	6	Simple extraction covered once per tooth.	4	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	1		1				2					1	10111011			50	50	50	50	50	50			50	50	50	50	50	50	2		1	01000000	40.00	40.00															2	2
H2256	042	0	1	01	01	H2256_042_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111011	4	2	1	3		4	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	4	2	1	2		3					4	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	4	2	1	6	Simple extraction covered once per tooth.	4	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	1		1				2					1	10111011			50	50	50	50	50	50			50	50	50	50	50	50	2		1	01000000	40.00	40.00															2	2
H2256	046	0	1	01	01	H2256_046_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	3		2	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	2	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	2	2	1	6	Root canals are covered once per tooth per lifetime.	2	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	2	2	1	6	Simple extraction covered once per tooth.	2	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months.	1		1				2					1	10111111			20	20	20	20	20	50	50	50	50	50	50	50	50	50	2		1	01000000	45.00	45.00															2	2
H2256	801	0	1	01	01	H2256_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2256	802	0	1	01	01	H2256_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2256	803	0	1	01	01	H2256_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2256	808	0	1	01	01	H2256_808_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2261	005	0	1	01	01	H2261_005_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	2																																											2					2																		2		1	01000000	30.00	30.00															2	2
H2261	022	1	1	01	01	H2261_022_1	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	2																																											2					2																		2		1	01000000	40.00	40.00															2	2
H2261	022	2	1	01	01	H2261_022_2	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	2																																											2					2																		2		1	01000000	40.00	40.00															2	2
H2261	023	1	1	02	01	H2261_023_1	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	2																																											2					2																		2		1	01000000	35.00	35.00															2	2
H2261	023	2	1	02	01	H2261_023_2	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	2																																											2					2																		2		1	01000000	35.00	35.00															2	2
H2261	024	0	1	01	01	H2261_024_0	6	1	1110	2	2	3	3		2	2	3	3							2	2	3	6	Full mouth X-rays, 7 or more films, or panoramic X-ray with bitewing X-rays once every 60 months. Bitewing X-rays once every 6 months. Single-tooth X-rays as needed.	1		600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	6	Silver and white fillings: once per tooth in 12 months. Inlays: once per tooth in 60 months.	2	2	1	6	Root canals and retreatment of prior root canal on permanent teeth: once per tooth.	2	2	1	6	Periodontal scaling and root planning: once per quadrant per 24 months. Periodontal Surgery: once per quadrant per 36 months. Maintenance following active periodontal therapy: once within three months	2	1				2	2	1	6	See Notes for 16b7 for comprehensive list.	1		1				2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	45.00	45.00															2	2
H2261	801	0	1	01	01	H2261_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2261	809	0	1	01	01	H2261_809_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2272	001	0	1	02	01	H2272_001_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2292	001	0	1	04	01	H2292_001_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2292	002	0	1	04	01	H2292_002_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2292	003	0	1	04	01	H2292_003_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2293	001	0	1	04	01	H2293_001_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2293	002	0	1	04	01	H2293_002_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2293	003	0	1	04	01	H2293_003_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2293	004	0	1	04	01	H2293_004_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2293	005	0	1	04	01	H2293_005_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2293	006	0	1	04	01	H2293_006_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2293	007	0	1	04	01	H2293_007_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2293	008	0	1	04	01	H2293_008_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2293	009	0	1	04	01	H2293_009_0	2	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2293	010	0	1	04	01	H2293_010_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2293	011	0	1	04	01	H2293_011_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2293	013	0	1	04	01	H2293_013_0	8	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											1	2
H2293	014	0	1	04	01	H2293_014_0	8	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											1	2
H2293	015	0	1	04	01	H2293_015_0	4	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	3000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											1	2
H2293	016	0	1	04	01	H2293_016_0	8	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											1	2
H2293	017	0	1	04	01	H2293_017_0	8	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	25.00	25.00			0.00	0.00											1	2
H2293	018	0	1	04	01	H2293_018_0	8	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											1	2
H2293	019	0	1	04	01	H2293_019_0	8	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											1	2
H2293	021	0	1	04	01	H2293_021_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2293	022	0	1	04	01	H2293_022_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2293	023	0	1	04	01	H2293_023_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2318	001	0	1	20	08	H2318_001_0	1																																																																																																																																																							
H2318	002	0	1	20	08	H2318_002_0	1																																																																																																																																																							
H2320	022	1	1	02	01	H2320_022_1	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1001011											4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	3					2	2	2	3		4	2	1	6	Coverage for simple extractions once per tooth per lifetime.	4	2	1	6	Brush biopsy once a year and unlimited coverage for anesthesia in conjunction with qualifying dental services only.	1		2	2500.00	3		2					2																		2		1	01000000	0.00	290.00															1	2
H2320	022	2	1	02	01	H2320_022_2	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1001011											4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	3					2	2	2	3		4	2	1	6	Coverage for simple extractions once per tooth per lifetime.	4	2	1	6	Brush biopsy once a year and unlimited coverage for anesthesia in conjunction with qualifying dental services only.	1		2	2500.00	3		2					2																		2		1	01000000	0.00	290.00															1	2
H2320	022	3	1	02	01	H2320_022_3	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1001011											4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	3					2	2	2	3		4	2	1	6	Coverage for simple extractions once per tooth per lifetime.	4	2	1	6	Brush biopsy once a year and unlimited coverage for anesthesia in conjunction with qualifying dental services only.	1		2	2500.00	3		2					2																		2		1	01000000	10.00	290.00															1	2
H2320	022	4	1	02	01	H2320_022_4	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1001011											4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	3					2	2	2	3		4	2	1	6	Coverage for simple extractions once per tooth per lifetime.	4	2	1	6	Brush biopsy once a year and unlimited coverage for anesthesia in conjunction with qualifying dental services only.	1		2	2500.00	3		2					2																		2		1	01000000	10.00	290.00															1	2
H2320	022	5	1	02	01	H2320_022_5	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1001011											4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	3					2	2	2	3		4	2	1	6	Coverage for simple extractions once per tooth per lifetime.	4	2	1	6	Brush biopsy once a year and unlimited coverage for anesthesia in conjunction with qualifying dental services only.	1		2	2500.00	3		2					2																		2		1	01000000	0.00	290.00															1	2
H2320	028	1	1	02	01	H2320_028_1	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	10.00	175.00															1	2
H2320	028	2	1	02	01	H2320_028_2	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	10.00	175.00															1	2
H2320	028	3	1	02	01	H2320_028_3	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	10.00	175.00															1	2
H2320	028	4	1	02	01	H2320_028_4	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	10.00	175.00															1	2
H2320	028	5	1	02	01	H2320_028_5	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	10.00	175.00															1	2
H2320	029	1	1	02	01	H2320_029_1	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	5.00	225.00															1	2
H2320	029	2	1	02	01	H2320_029_2	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	5.00	225.00															1	2
H2320	029	3	1	02	01	H2320_029_3	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	5.00	225.00															1	2
H2320	029	4	1	02	01	H2320_029_4	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	5.00	225.00															1	2
H2320	029	5	1	02	01	H2320_029_5	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	5.00	225.00															1	2
H2320	030	1	1	02	01	H2320_030_1	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	0.00	285.00															1	2
H2320	030	2	1	02	01	H2320_030_2	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	0.00	285.00															1	2
H2320	802	0	1	02	01	H2320_802_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2320	803	0	1	02	01	H2320_803_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2320	804	0	1	01	01	H2320_804_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2320	805	0	1	01	01	H2320_805_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2320	810	0	1	01	01	H2320_810_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2320	811	0	1	01	01	H2320_811_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2320	812	0	1	02	01	H2320_812_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2320	813	0	1	02	01	H2320_813_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2320	814	0	1	01	01	H2320_814_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2322	008	0	1	04	01	H2322_008_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				4	1				4	1				4	2	2	3		2	1				4	1				1		1				2					1	10001101							50	50	50	50			50	50	0	50	2		1	01000000	0.00	25.00															2	2
H2322	011	0	1	04	01	H2322_011_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				4	1				4	1				4	2	2	3		2	1				4	1				1		1				2					1	10001101							50	50	50	50			50	50	0	50	2		1	01000000	0.00	45.00															2	2
H2322	801	0	1	04	01	H2322_801_0	10	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2322	803	0	1	04	01	H2322_803_0	10	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2334	005	0	1	04	01	H2334_005_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	2000.00	3		2					2																		2		1	01000000	50.00	50.00															2	2
H2354	015	0	1	01	01	H2354_015_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				4	1				4	1				4	2	2	3		2	1				4	1				1		1				2					1	10001101							50	50	50	50			50	50	0	50	2		1	01000000	0.00	45.00															2	2
H2354	018	0	1	01	01	H2354_018_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				4	1				4	1				4	2	2	3		2	1				4	1				1		1				2					1	10001101							50	50	50	50			50	50	0	50	2		1	01000000	0.00	50.00															2	2
H2354	019	0	1	01	01	H2354_019_0	15	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				4	1				4	1				4	2	2	3		2	1				4	1				1		1				2					1	10001101							50	50	50	50			50	50	0	50	2		1	01000000	0.00	35.00															2	2
H2354	021	0	1	02	01	H2354_021_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				4	1				4	1				4	2	2	3		2	1				4	1				1		1				2					1	10001101							50	50	50	50			50	50	0	50	2		1	01000000	15.00	40.00															2	2
H2354	025	0	1	01	01	H2354_025_0	17	1	1111	2	1				2	1				2	1				2	1				1		1300.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H2354	028	0	1	01	01	H2354_028_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				4	1				4	1				4	2	2	3		2	1				4	1				1		1				2					1	10001101							50	50	50	50			50	50	0	50	2		1	01000000	0.00	35.00															2	2
H2354	801	0	1	01	01	H2354_801_0	12	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2354	802	0	1	02	01	H2354_802_0	12	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2368	001	0	1	20	08	H2368_001_0	1																																																																																																																																																							
H2368	002	0	1	20	08	H2368_002_0	1																																																																																																																																																							
H2384	001	0	1	20	08	H2384_001_0	1																																																																																																																																																							
H2384	002	0	1	20	08	H2384_002_0	1																																																																																																																																																							
H2386	001	0	1	20	08	H2386_001_0	2																																																																																																																																																							
H2386	002	0	1	20	08	H2386_002_0	2																																																																																																																																																							
H2392	001	0	1	01	01	H2392_001_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2392	003	0	1	01	01	H2392_003_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2400	001	0	1	01	01	H2400_001_0	3	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					1	11001111	20	20					20	20	20	20	20	20	20	20	20	20	2		2																		2	2
H2400	002	0	1	01	01	H2400_002_0	3	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					1	11001111	20	20					20	20	20	20	20	20	20	20	20	20	2		2																		2	2
H2406	008	0	1	04	01	H2406_008_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	009	0	1	04	01	H2406_009_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	010	0	1	04	01	H2406_010_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	011	0	1	04	01	H2406_011_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	012	0	1	04	01	H2406_012_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	013	0	1	04	01	H2406_013_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	014	0	1	04	01	H2406_014_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	015	0	1	04	01	H2406_015_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	016	0	1	04	01	H2406_016_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	017	0	1	04	01	H2406_017_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	018	0	1	04	01	H2406_018_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	019	0	1	04	01	H2406_019_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	031	0	1	04	01	H2406_031_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2406	032	0	1	04	01	H2406_032_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2406	033	0	1	04	01	H2406_033_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2406	034	0	1	04	01	H2406_034_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	035	0	1	04	01	H2406_035_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	036	0	1	04	01	H2406_036_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	037	0	1	04	01	H2406_037_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	038	0	1	04	01	H2406_038_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	039	0	1	04	01	H2406_039_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	040	0	1	04	01	H2406_040_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	041	0	1	04	01	H2406_041_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	042	0	1	04	01	H2406_042_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	043	0	1	04	01	H2406_043_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	044	0	1	04	01	H2406_044_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	045	0	1	04	01	H2406_045_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	046	0	1	04	01	H2406_046_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	047	0	1	04	01	H2406_047_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	048	0	1	04	01	H2406_048_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	049	0	1	04	01	H2406_049_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2406	050	0	1	04	01	H2406_050_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2406	051	0	1	04	01	H2406_051_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2406	052	0	1	04	01	H2406_052_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2406	053	0	1	04	01	H2406_053_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	054	0	1	04	01	H2406_054_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	055	0	1	04	01	H2406_055_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	056	0	1	04	01	H2406_056_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	057	0	1	04	01	H2406_057_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	058	0	1	04	01	H2406_058_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	059	0	1	04	01	H2406_059_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	060	0	1	04	01	H2406_060_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	061	0	1	04	01	H2406_061_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	062	0	1	04	01	H2406_062_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	063	0	1	04	01	H2406_063_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	064	0	1	04	01	H2406_064_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	065	0	1	04	01	H2406_065_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	066	0	1	04	01	H2406_066_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	067	0	1	04	01	H2406_067_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	068	0	1	04	01	H2406_068_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	069	0	1	04	01	H2406_069_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	070	0	1	04	01	H2406_070_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	071	0	1	04	01	H2406_071_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	072	0	1	04	01	H2406_072_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	073	0	1	04	01	H2406_073_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	074	0	1	04	01	H2406_074_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	075	0	1	04	01	H2406_075_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	076	0	1	04	01	H2406_076_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	077	0	1	04	01	H2406_077_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	078	0	1	04	01	H2406_078_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	079	0	1	04	01	H2406_079_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	080	0	1	04	01	H2406_080_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	081	0	1	04	01	H2406_081_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	082	0	1	04	01	H2406_082_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	083	0	1	04	01	H2406_083_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2406	084	0	1	04	01	H2406_084_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	085	0	1	04	01	H2406_085_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	086	0	1	04	01	H2406_086_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	087	0	1	04	01	H2406_087_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	088	0	1	04	01	H2406_088_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	089	0	1	04	01	H2406_089_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	090	0	1	04	01	H2406_090_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	091	0	1	04	01	H2406_091_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	092	0	1	04	01	H2406_092_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	093	0	1	04	01	H2406_093_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	094	0	1	04	01	H2406_094_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	095	0	1	04	01	H2406_095_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	096	0	1	04	01	H2406_096_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2406	097	0	1	04	01	H2406_097_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2406	098	0	1	04	01	H2406_098_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	099	0	1	04	01	H2406_099_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2406	100	0	1	04	01	H2406_100_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	101	0	1	04	01	H2406_101_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	102	0	1	04	01	H2406_102_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	103	0	1	04	01	H2406_103_0	5	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2406	104	0	1	04	01	H2406_104_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2406	105	0	1	04	01	H2406_105_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	106	0	1	04	01	H2406_106_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	107	0	1	04	01	H2406_107_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	108	0	1	04	01	H2406_108_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	110	0	1	04	01	H2406_110_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	111	0	1	04	01	H2406_111_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	112	0	1	04	01	H2406_112_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	113	0	1	04	01	H2406_113_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	114	0	1	04	01	H2406_114_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	115	0	1	04	01	H2406_115_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	117	0	1	04	01	H2406_117_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	119	0	1	04	01	H2406_119_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	121	0	1	04	01	H2406_121_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	122	0	1	04	01	H2406_122_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	123	0	1	04	01	H2406_123_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	124	0	1	04	01	H2406_124_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	125	0	1	04	01	H2406_125_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	126	0	1	04	01	H2406_126_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2406	805	0	1	04	01	H2406_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	806	0	1	04	01	H2406_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	807	0	1	04	01	H2406_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	808	0	2	04	01	H2406_808_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	809	0	2	04	01	H2406_809_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	810	0	2	04	01	H2406_810_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	811	0	1	04	01	H2406_811_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	812	0	1	04	01	H2406_812_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	813	0	1	04	01	H2406_813_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	814	0	1	04	01	H2406_814_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	815	0	1	04	01	H2406_815_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	816	0	1	04	01	H2406_816_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	817	0	2	04	01	H2406_817_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	818	0	2	04	01	H2406_818_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	819	0	1	04	01	H2406_819_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	820	0	1	04	01	H2406_820_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	821	0	1	04	01	H2406_821_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	822	0	1	04	01	H2406_822_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	823	0	1	04	01	H2406_823_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	824	0	1	04	01	H2406_824_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	825	0	1	04	01	H2406_825_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	826	0	1	04	01	H2406_826_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	827	0	1	04	01	H2406_827_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	828	0	2	04	01	H2406_828_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	829	0	1	04	01	H2406_829_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	830	0	1	04	01	H2406_830_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	831	0	1	04	01	H2406_831_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	832	0	1	04	01	H2406_832_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	833	0	1	04	01	H2406_833_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	834	0	1	04	01	H2406_834_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2406	835	0	1	04	01	H2406_835_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2416	001	0	1	01	01	H2416_001_0	14	2																																																															1	1001100											2	2	1	3		2	2	2	3												2	2	1	6	Additional one replacement dentures per six years	2						2					2																		2		2																		1	2
H2417	001	0	1	01	01	H2417_001_0	11	2																																																															1	0100000	2	1																																		2						2					2																		2		2																		1	2
H2419	001	0	1	01	01	H2419_001_0	9	2																																																															1	1000000																															2	1				2						2					1	01000000	20	20															2		2																		1	2
H2422	002	0	1	01	01	H2422_002_0	7	1	0101	2	2	1	3							2	1									2					2				2		2												2		2		2												2	2	1	0001100											2	1				2	1																			1		2	2500.00	3		2					1	01000000	20	20															2		2																		2	2
H2425	001	0	1	01	01	H2425_001_0	8	1	0100	2	2	1	3																	2					2				2		2												2		2		2												2	2	1	0011000						2	2	1	3		2	2	4	6	Dental crown (Any tooth, No PA) 2/year (anytooth)Root canal--molar (No PA) 1/tooth/lifetimeOnce per tooth per lifetimeRoot canal retreat (No PA) 1/year One re-treatper lifetime per tooth																					2						2					1	01000000	20	20															2		2																		1	2
H2450	001	0	1	18	06	H2450_001_0	6	1	1111	2	1				2	1				2	1				2	1				1		300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	15.00															2	2
H2450	002	0	1	18	06	H2450_002_0	5	1	1111	2	1				2	1				2	1				2	1				1		400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	10.00															2	2
H2450	007	0	1	18	06	H2450_007_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2450	016	0	1	18	06	H2450_016_0	6	1	1111	2	1				2	1				2	1				2	1				1		300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	15.00															2	2
H2450	030	0	1	18	06	H2450_030_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2450	032	0	1	18	06	H2450_032_0	5	1	1111	2	1				2	1				2	1				2	1				1		300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	15.00															2	2
H2450	033	0	1	18	06	H2450_033_0	4	1	1111	2	1				2	1				2	1				2	1				1		400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	10.00															2	2
H2450	034	0	1	18	06	H2450_034_0	4	1	1111	2	1				2	1				2	1				2	1				1		300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	15.00															2	2
H2450	035	0	1	18	06	H2450_035_0	5	1	1111	2	1				2	1				2	1				2	1				1		300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	15.00															2	2
H2450	036	0	1	18	06	H2450_036_0	4	1	1111	2	1				2	1				2	1				2	1				1		400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H2450	037	0	1	18	06	H2450_037_0	5	1	1111	2	1				2	1				2	1				2	1				1		400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H2450	038	0	1	18	06	H2450_038_0	4	1	1111	2	1				2	1				2	1				2	1				1		300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	15.00															2	2
H2450	039	0	1	18	06	H2450_039_0	5	1	1111	2	1				2	1				2	1				2	1				1		300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	15.00															2	2
H2450	040	0	1	18	06	H2450_040_0	5	1	1111	2	1				2	1				2	1				2	1				1		400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	10.00															2	2
H2450	041	0	1	18	06	H2450_041_0	6	1	1111	2	1				2	1				2	1				2	1				1		400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	10.00															2	2
H2450	042	0	1	18	06	H2450_042_0	4	1	1111	2	1				2	1				2	1				2	1				1		400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H2450	043	0	1	18	06	H2450_043_0	4	1	1111	2	1				2	1				2	1				2	1				1		400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H2450	044	0	1	18	06	H2450_044_0	4	1	1111	2	1				2	1				2	1				2	1				1		400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	50.00															2	2
H2450	045	0	1	18	06	H2450_045_0	4	1	1111	2	1				2	1				2	1				2	1				1		300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	15.00															2	2
H2450	046	0	1	18	06	H2450_046_0	4	1	1111	2	1				2	1				2	1				2	1				1		300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	15.00															2	2
H2450	047	0	1	18	06	H2450_047_0	4	1	1111	2	1				2	1				2	1				2	1				1		300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	15.00															2	2
H2450	048	0	1	18	06	H2450_048_0	4	1	1111	2	1				2	1				2	1				2	1				1		400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H2450	049	0	1	18	06	H2450_049_0	5	1	1111	2	1				2	1				2	1				2	1				1		400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	50.00															2	2
H2450	050	0	1	18	06	H2450_050_0	4	1	1111	2	1				2	1				2	1				2	1				1		400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	50.00															2	2
H2450	801	0	1	18	06	H2450_801_0	4																																																																																																																																																							
H2456	002	0	1	01	01	H2456_002_0	8	1	1101	2	2	1	3							2	2	1	6	Plan covers one additional fluoride varnish per year for patients at high risk of cavities.	2	2	1	6	Plan provides panoramic xray once each year. Plan covers full mouth series x-ray per year	2					2				2		2												2		2		2												2	2	1	0001110											2	2	3	6	Restorative service is two crowns and one crown repair procedure per year.	2	2	1	6	Endontic service is one root canal and one root canal re-treatment per tooth per lifetime.	2	2	1	3												2						2					1	01000000	20	20															2		2																		2	2
H2458	002	0	1	01	01	H2458_002_0	6	1	1100	2	2	1	3												2	2	1	6	The plan covers one full mouth x-ray once per five years	2					2				2		2												2		2		2												2	2	1	0001100											2	2	1	3		2	2	1	6	Plan covers endodontic services of: molar root canal one per tooth per lifetime, root canal retreatment 1 per tooth per lifetime only covered if billed 24 months after original root canal.																2						2					1	01000000	20	20															2		2																		2	2
H2459	001	0	1	02	01	H2459_001_0	10	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			30	60	30	30	60	60	30	30	0	30	30	30	30	60	1	75.00	2																		2	2
H2459	021	1	1	02	01	H2459_021_1	8	1	1111	2	2	2	3		2	2	3	3		2	1				2	2	1	6	X-rays: one set of bitewing, and four periapical (Pas) once per calendar year. Full mouth X-rays every five years.	1		2500.00	3		2				2		2												2		2		2												2	2	1	0000010	3					3					3					3					4	2	3	3		3					3					1		1				2					2																		2		2																		2	2
H2459	021	2	1	02	01	H2459_021_2	8	1	1111	2	2	2	3		2	2	3	3		2	1				2	2	1	6	X-rays: one set of bitewing, and four periapical (Pas) once per calendar year. Full mouth X-rays every five years.	1		2500.00	3		2				2		2												2		2		2												2	2	1	0000010	3					3					3					3					4	2	3	3		3					3					1		1				2					2																		2		2																		2	2
H2459	021	3	1	02	01	H2459_021_3	8	1	1111	2	2	2	3		2	2	3	3		2	1				2	2	1	6	X-rays: one set of bitewing, and four periapical (Pas) once per calendar year. Full mouth X-rays every five years.	1		2500.00	3		2				2		2												2		2		2												2	2	1	0000010	3					3					3					3					4	2	3	3		3					3					1		1				2					2																		2		2																		2	2
H2459	023	1	1	02	01	H2459_023_1	8	1	1111	4	2	1	3		4	2	1	3		2	1				4	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	0000010	3					3					3					3					4	2	1	3		3					3					1		1				2					2																		2		2																		2	2
H2459	023	2	1	02	01	H2459_023_2	8	1	1111	4	2	1	3		4	2	1	3		2	1				4	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	0000010	3					3					3					3					4	2	1	3		3					3					1		1				2					2																		2		2																		2	2
H2459	024	0	1	02	01	H2459_024_0	8	1	1111	4	2	1	3		4	2	1	3		2	1				4	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	0000010	3					3					3					3					4	2	1	3		3					3					1		1				2					2																		2		2																		2	2
H2459	026	1	1	02	01	H2459_026_1	7	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			50	70	50	50	70	70	50	50	0	50	50	50	50	70	1	100.00	2																		2	2
H2459	026	3	1	02	01	H2459_026_3	7	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			50	70	50	50	70	70	50	50	0	50	50	50	50	70	1	100.00	2																		2	2
H2459	026	4	1	02	01	H2459_026_4	7	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			50	70	50	50	70	70	50	50	0	50	50	50	50	70	1	100.00	2																		2	2
H2459	029	0	1	02	01	H2459_029_0	7	1	1111	2	1				2	1				2	1				2	1				1		600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H2459	030	0	1	02	01	H2459_030_0	10	1	1111	4	2	1	3		4	2	1	3		2	1				4	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	0000010	3					3					3					3					4	2	1	3		3					3					1		1				2					2																		2		2																		2	2
H2459	031	0	1	01	01	H2459_031_0	7	1	1111	2	1				2	1				2	1				2	1				1		600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H2459	032	0	1	01	01	H2459_032_0	9	1	1111	2	1				2	1				2	1				2	1				1		700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H2459	801	0	1	02	01	H2459_801_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2461	005	0	1	18	06	H2461_005_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2461	006	0	1	18	06	H2461_006_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		2000.00	3		2				2		2												2		2		2												1	2	1	0000010																					2	2	2	3												1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H2461	007	0	1	18	06	H2461_007_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		2000.00	3		2				2		2												2		2		2												1	2	1	0000010																					2	2	2	3												1		1				2					2																		2		2																		1	2
H2461	008	0	1	18	06	H2461_008_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2461	009	0	1	18	06	H2461_009_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		2000.00	3		2				2		2												2		2		2												1	2	1	0000010																					2	2	2	3												1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H2461	010	0	1	18	06	H2461_010_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		2000.00	3		2				2		2												2		2		2												1	2	1	0000010																					2	2	2	3												1		1				2					2																		2		2																		1	2
H2462	022	0	1	18	06	H2462_022_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2462	023	0	1	18	06	H2462_023_0	5	2																																																															2																																											2					2																		2		2																		2	2
H2462	024	0	1	18	06	H2462_024_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		750.00	3		2				2		2												2		2		2												2	2	1	0111111	2	1				2	1				2	1				2	1				2	2	2	3		2	1									1		1				2					2																		2		2																		2	2
H2462	025	0	1	18	06	H2462_025_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	2	2	3		2	1				2	1				1		1				2					1	10101111			0	20			20	20	20	20	0	50	20	50	50	50	2		2																		2	2
H2462	026	0	1	18	06	H2462_026_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2462	027	0	1	18	06	H2462_027_0	4	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					2																		2		2																		2	2
H2462	028	0	1	18	06	H2462_028_0	5	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					2																		2		2																		2	2
H2462	029	0	1	18	06	H2462_029_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	2	2	3		2	1				2	1				1		1				2					1	10101111			0	20			20	20	20	20	0	50	20	50	50	50	2		2																		2	2
H2462	801	0	1	18	06	H2462_801_0	1																																																																																																																																																							
H2462	802	0	1	18	06	H2462_802_0	1																																																																																																																																																							
H2463	001	0	1	01	01	H2463_001_0	8	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	35.00	35.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
H2478	001	0	1	01	01	H2478_001_0	5	1	1111	2	1				2	1				2	1				2	1				1		2400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H2478	002	0	1	01	01	H2478_002_0	7	1	1111	2	1				2	1				2	1				2	1				1		1150.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															2	2
H2486	003	0	1	01	01	H2486_003_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2486	005	0	1	01	01	H2486_005_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2486	006	0	1	01	01	H2486_006_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H2486	007	0	1	01	01	H2486_007_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H2486	009	0	1	01	01	H2486_009_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	40.00	40.00			0.00	0.00	25.00	25.00									1	2
H2486	010	0	1	01	01	H2486_010_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					1		2	2000.00	3		2					2																		2		1	01010000	55.00	55.00			0.00	0.00											1	2
H2486	801	0	1	01	01	H2486_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2486	802	0	1	01	01	H2486_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2486	805	0	1	01	01	H2486_805_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2486	806	0	1	01	01	H2486_806_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2491	004	0	1	01	01	H2491_004_0	18	2																																																															1	1111111	2	2	1	6	Every day to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months.	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2491	009	0	1	01	01	H2491_009_0	20	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	40.00	55.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2491	010	0	1	01	01	H2491_010_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2491	011	0	1	01	01	H2491_011_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2491	012	0	1	01	01	H2491_012_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2491	015	0	1	01	01	H2491_015_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	40.00	40.00															1	2
H2491	016	0	1	01	01	H2491_016_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2491	017	0	1	01	01	H2491_017_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	NON-ROUTINE SERVICES every date of service to 24 months.	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES every 12 to 84 months per tooth.	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	30.00	30.00															1	2
H2491	021	0	1	01	01	H2491_021_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	NON-ROUTINE SERVICES every date of service to 24 months.	2	2	1	3		2	2	1	6	every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	40.00	40.00															1	2
H2491	022	0	1	01	01	H2491_022_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	NON-ROUTINE SERVICES every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth.	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2491	025	0	1	01	01	H2491_025_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2491	026	0	1	01	01	H2491_026_0	17	2																																																															1	1111111	2	2	1	6	Every day to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months.	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2491	027	1	1	01	01	H2491_027_1	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2491	027	2	1	01	01	H2491_027_2	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2491	027	3	1	01	01	H2491_027_3	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2506	001	0	1	48	05	H2506_001_0	3	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	2	999	3		2	2	999	6	As medically necessary	2	2	999	6	As medically necessary	2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	1		2	800.00	3		2					2																		2		2																		1	2
H2509	001	0	1	02	01	H2509_001_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2509	002	0	1	02	01	H2509_002_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2526	001	0	1	04	01	H2526_001_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	5000.00	3		2					2																		2		1	01000000	30.00	30.00															1	2
H2531	001	0	1	48	05	H2531_001_0	2	1	1111	2	2	1	6	Annually for individuals 21 and over and twice annually for those 20 and under.	2	2	1	3		2	2	1	4		2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		2																		1	2
H2533	001	0	1	48	05	H2533_001_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H2537	001	0	1	20	08	H2537_001_0	1																																																																																																																																																							
H2537	002	0	1	20	08	H2537_002_0	1																																																																																																																																																							
H2541	001	0	1	20	08	H2541_001_0	1																																																																																																																																																							
H2541	002	0	1	20	08	H2541_002_0	1																																																																																																																																																							
H2563	004	0	1	01	01	H2563_004_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	4000.00	3		2					1	01000000	20	20															2		1	10011111					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2563	005	1	1	01	01	H2563_005_1	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	3500.00	3		2					2																		2		1	11011111	0.00	0.00			75.00	75.00	75.00	75.00	75.00	75.00	75.00	75.00	75.00	75.00	75.00	75.00	1	2
H2563	005	2	1	01	01	H2563_005_2	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	3500.00	3		2					2																		2		1	11011111	0.00	0.00			75.00	75.00	75.00	75.00	75.00	75.00	75.00	75.00	75.00	75.00	75.00	75.00	1	2
H2563	008	0	1	01	01	H2563_008_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	2500.00	3		2					2																		2		1	11011111	0.00	0.00			25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	1	2
H2563	009	0	1	01	01	H2563_009_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	2500.00	3		2					2																		2		1	11011111	0.00	0.00			25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	1	2
H2563	014	0	1	01	01	H2563_014_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					2																		2		1	11011111	0.00	0.00			50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	1	2
H2563	015	0	1	01	01	H2563_015_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	2500.00	3		2					2																		2		1	11011111	0.00	0.00			25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	1	2
H2563	016	0	1	01	01	H2563_016_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	2500.00	3		2					2																		2		1	11011111	0.00	0.00			25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	1	2
H2563	017	1	1	01	01	H2563_017_1	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	3000.00	3		2					2																		2		1	10011111					25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	1	2
H2563	017	2	1	01	01	H2563_017_2	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	3000.00	3		2					2																		2		1	10011111					25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	1	2
H2563	018	0	1	01	01	H2563_018_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	3000.00	3		2					2																		2		1	11011111	0.00	0.00			25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	25.00	1	2
H2563	019	0	1	01	01	H2563_019_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	30.00	30.00									2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					2																		2		1	11011111	0.00	0.00			30.00	30.00	30.00	30.00	30.00	30.00	30.00	30.00	30.00	30.00	30.00	30.00	1	2
H2563	020	0	1	01	01	H2563_020_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	4000.00	3		2					1	01000000	20	20															2		1	10011111					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2563	801	0	1	01	01	H2563_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2563	802	0	1	01	01	H2563_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2563	803	0	1	01	01	H2563_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2563	804	0	1	01	01	H2563_804_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2577	001	1	1	04	01	H2577_001_1	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2577	001	2	1	04	01	H2577_001_2	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2577	002	0	1	04	01	H2577_002_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2577	003	1	1	04	01	H2577_003_1	5	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2577	003	2	1	04	01	H2577_003_2	5	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2577	004	0	1	04	01	H2577_004_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2577	005	0	1	04	01	H2577_005_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2577	006	0	1	04	01	H2577_006_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2577	007	0	1	04	01	H2577_007_0	4	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2577	008	0	1	04	01	H2577_008_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2577	009	0	1	04	01	H2577_009_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2577	011	0	1	04	01	H2577_011_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2577	013	0	1	04	01	H2577_013_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2577	014	0	1	04	01	H2577_014_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2577	015	0	1	04	01	H2577_015_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2577	016	0	1	04	01	H2577_016_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2577	017	0	1	04	01	H2577_017_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2577	018	0	1	04	01	H2577_018_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2577	019	0	1	04	01	H2577_019_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2577	020	0	1	04	01	H2577_020_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2577	021	0	1	04	01	H2577_021_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2577	022	0	1	04	01	H2577_022_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2577	023	0	1	04	01	H2577_023_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2577	026	0	1	04	01	H2577_026_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2577	027	0	1	04	01	H2577_027_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2577	028	0	1	04	01	H2577_028_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2577	030	0	1	04	01	H2577_030_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2577	031	0	1	04	01	H2577_031_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2582	002	0	1	02	01	H2582_002_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2582	004	0	1	02	01	H2582_004_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2582	005	0	1	02	01	H2582_005_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2591	801	0	1	04	01	H2591_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2591	802	0	1	04	01	H2591_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2591	803	0	1	04	01	H2591_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2593	001	0	1	01	01	H2593_001_0	7	1	1111	4	1				4	1				4	1				4	1				1		200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	003	0	1	01	01	H2593_003_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	005	0	1	01	01	H2593_005_0	8	1	1111	4	1				4	1				4	1				4	1				1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	006	0	1	01	01	H2593_006_0	8	1	1111	4	1				4	1				4	1				4	1				1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	029	0	1	01	01	H2593_029_0	7	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	30.00	30.00															1	2
H2593	031	0	1	02	01	H2593_031_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	032	0	1	01	01	H2593_032_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	040	0	1	01	01	H2593_040_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	043	0	1	01	01	H2593_043_0	6	1	1111	4	1				4	1				4	1				4	1				1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	044	0	1	01	01	H2593_044_0	6	1	1111	2	1				2	1				2	1				2	1				1		5500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	045	0	1	01	01	H2593_045_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	046	0	1	01	01	H2593_046_0	6	1	1111	2	1				2	1				2	1				2	1				1		5500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	047	0	1	01	01	H2593_047_0	5	1	1111	2	1				2	1				2	1				2	1				1		5500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	048	0	1	01	01	H2593_048_0	6	1	1111	2	1				2	1				2	1				2	1				1		5500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	049	0	1	01	01	H2593_049_0	6	1	1111	2	1				2	1				2	1				2	1				1		5500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	051	0	1	01	01	H2593_051_0	6	1	1111	2	1				2	1				2	1				2	1				1		4500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	053	0	1	01	01	H2593_053_0	6	1	1111	2	1				2	1				2	1				2	1				1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	054	0	1	01	01	H2593_054_0	6	1	1111	2	1				2	1				2	1				2	1				1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	055	0	1	01	01	H2593_055_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2593	056	0	1	01	01	H2593_056_0	6	1	1111	2	1				2	1				2	1				2	1				1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2610	005	0	1	01	01	H2610_005_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	01000000	20.00	20.00															1	1
H2610	006	0	1	01	01	H2610_006_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	01000000	30.00	30.00															1	1
H2610	011	0	1	01	01	H2610_011_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	01000000	35.00	35.00															1	1
H2610	015	0	1	01	01	H2610_015_0	4	1	1111	2	2	2	6	Periodic, extensive oral and re-evaluation problem focused-two every calendar yearLimited oral-3 every calendar yearComprehensive oral and periodontal evaluation-1 every 3 years.	2	2	2	3		2	2	2	3		2	2	1	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H2610	016	0	1	01	01	H2610_016_0	4	1	1111	2	2	2	6	Periodic, extensive oral and re-evaluation problem focused-two every calendar yearLimited oral-3 every calendar yearComprehensive oral and periodontal evaluation-1 every 3 years.	2	2	2	3		2	2	2	3		2	2	1	3		1		4000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	1
H2610	019	0	1	01	01	H2610_019_0	4	1	1111	2	2	2	6	Periodic, extensive oral and re-evaluation problem focused-two every calendar yearLimited oral-3 every calendar yearComprehensive oral and periodontal evaluation-1 every 3 years.	2	2	2	3		2	2	2	3		2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	1
H2610	021	0	1	01	01	H2610_021_0	5	1	1111	2	2	2	6	Periodic, extensive oral and re-evaluation problem focused-two every calendar yearLimited oral-3 every calendar yearComprehensive oral and periodontal evaluation-1 every 3 years.	2	2	2	3		2	2	2	3		2	2	1	3		1		7000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	1
H2610	023	0	1	01	01	H2610_023_0	5	1	1111	2	2	2	6	Periodic, extensive oral and re-evaluation problem focused-two every calendar yearLimited oral-3 every calendar yearComprehensive oral and periodontal evaluation-1 every 3 years.	2	2	2	3		2	2	2	3		2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H2610	803	0	1	01	01	H2610_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2610	804	0	1	01	01	H2610_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2610	805	0	1	01	01	H2610_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2610	806	0	1	01	01	H2610_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2610	807	0	1	02	01	H2610_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2610	808	0	1	02	01	H2610_808_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2610	809	0	1	02	01	H2610_809_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2610	810	0	1	02	01	H2610_810_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2624	001	0	1	01	01	H2624_001_0	10	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	See notes	1		3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	4	3		2	2	1	6	see notes	2	2	4	2		2	2	4	3		2	2	1	6	see notes	1		1				2					1	10001101							0	20	20	20			20	20	20	20	1	50.00	2																		2	2
H2624	004	0	1	01	01	H2624_004_0	11	1	1111	2	1				2	1				2	1				2	1				1		1100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H2624	802	0	1	01	01	H2624_802_0	5	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H2624	803	0	1	01	01	H2624_803_0	5	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H2663	002	0	1	01	01	H2663_002_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	005	0	1	01	01	H2663_005_0	7	1	1111	2	1				2	1				2	1				2	1				1		3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	006	0	1	02	01	H2663_006_0	9	1	1111	2	1				2	1				2	1				2	1				1		1400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	017	0	1	01	01	H2663_017_0	7	1	1111	2	1				2	1				2	1				2	1				1		2700.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	021	0	1	02	01	H2663_021_0	7	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	022	0	1	02	01	H2663_022_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	023	0	1	02	01	H2663_023_0	7	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	025	0	1	02	01	H2663_025_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	026	0	1	02	01	H2663_026_0	7	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	028	0	1	02	01	H2663_028_0	7	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	029	0	1	02	01	H2663_029_0	4	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	034	0	1	01	01	H2663_034_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below	2	2	4	6	Varies by procedure, see note below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see note below.	1		2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											1	2
H2663	038	0	1	01	01	H2663_038_0	7	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	NOTE NEEDED	2	2	2	6	Plan will cover 1 root canal and the retreatment of 1 root canal per tooth per lifetime.	2	2	4	6	NOTE NEEDED	2	2	1	6	NOTE NEEDED	2	2	6	6	Plan will cover complete or partial dentures once per arch every five years, fixed prosthodontics once per tooth every 5 years, and denture/prosthodontic repairs as needed.	1		2	3000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											1	2
H2663	039	0	1	01	01	H2663_039_0	6	1	1111	2	1				2	1				2	1				2	1				1		3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	040	0	1	01	01	H2663_040_0	7	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	NOTE NEEDED	2	2	2	6	Plan will cover 1 root canal and the retreatment of 1 root canal per tooth per lifetime.	2	2	4	6	NOTE NEEDED	2	2	1	6	note needed	2	2	6	6	Plan will cover complete or partial dentures once per arch every five years, fixed prosthodontics once per tooth every 5 years, and denture/prosthodontic repairs as needed.	1		2	3000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	45.00	45.00			0.00	0.00											1	2
H2663	041	0	1	01	01	H2663_041_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	042	0	1	01	01	H2663_042_0	7	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	note needed	2	2	2	6	Plan will cover 1 root canal and the retreatment of 1 root canal per tooth per lifetime.	2	2	4	6	note needed	2	2	1	6	note needed	2	2	6	6	Plan will cover complete or partial dentures once per arch every five years, fixed prosthodontics once per tooth every 5 years, and denture/prosthodontic repairs as needed.	1		2	3000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	45.00	45.00			0.00	0.00											1	2
H2663	043	0	1	02	01	H2663_043_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	052	0	1	01	01	H2663_052_0	7	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	053	0	1	01	01	H2663_053_0	7	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	054	0	1	01	01	H2663_054_0	7	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	055	0	1	01	01	H2663_055_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	056	0	1	01	01	H2663_056_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	057	0	1	01	01	H2663_057_0	7	1	1111	2	1				2	1				2	1				2	1				1		2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	059	0	1	01	01	H2663_059_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	061	0	1	02	01	H2663_061_0	7	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	062	0	1	02	01	H2663_062_0	7	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	063	0	1	02	01	H2663_063_0	7	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	064	0	1	01	01	H2663_064_0	7	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	065	0	1	01	01	H2663_065_0	7	1	1110	2	2	4	3		2	2	2	3							2	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	2																																											2					2																		2		1	01000000	50.00	50.00															1	2
H2663	066	0	1	01	01	H2663_066_0	7	1	1110	2	2	4	3		2	2	2	3							2	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	2																																											2					2																		2		1	01000000	50.00	50.00															1	2
H2663	067	0	1	01	01	H2663_067_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2663	805	0	1	01	01	H2663_805_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2663	810	0	1	01	01	H2663_810_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2686	001	0	1	04	01	H2686_001_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	5000.00	3		2					2																		2		1	01000000	35.00	35.00															1	2
H2686	002	0	1	04	01	H2686_002_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	6000.00	3		2					2																		2		1	01000000	35.00	35.00															1	2
H2686	003	0	1	04	01	H2686_003_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H2694	001	0	1	04	01	H2694_001_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															2	2
H2694	002	0	1	04	01	H2694_002_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															2	2
H2697	001	0	1	01	01	H2697_001_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	6000.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H2697	002	0	1	01	01	H2697_002_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	7500.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H2697	003	0	1	01	01	H2697_003_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H2697	004	0	1	01	01	H2697_004_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	5000.00	3		2					2																		2		1	01000000	30.00	30.00															1	2
H2697	005	0	1	01	01	H2697_005_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	7500.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H2697	006	0	1	01	01	H2697_006_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H2697	007	0	1	01	01	H2697_007_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	6000.00	3		2					2																		2		1	01000000	30.00	30.00															1	2
H2697	008	0	1	01	01	H2697_008_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	7500.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H2697	009	0	1	01	01	H2697_009_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H2697	010	0	1	01	01	H2697_010_0	13	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	7500.00	3		2					2																		2		2																		1	2
H2697	011	0	1	01	01	H2697_011_0	12	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	5000.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H2715	001	0	1	01	01	H2715_001_0	6	1	1111	2	1				2	1				2	1				2	1				1		700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H2722	002	0	1	02	01	H2722_002_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or  1 full mouth x-ray every 3 years.	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H2722	003	0	1	02	01	H2722_003_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	1		3800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H2722	004	0	1	02	01	H2722_004_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	1		2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H2722	005	0	1	02	01	H2722_005_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H2722	801	0	1	02	01	H2722_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2737	001	0	1	04	01	H2737_001_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	400.00															1	2
H2737	002	0	1	04	01	H2737_002_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	400.00															1	2
H2737	801	0	1	04	01	H2737_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2737	802	0	1	04	01	H2737_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2737	803	0	1	04	01	H2737_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2752	002	0	1	01	01	H2752_002_0	8	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H2752	003	0	1	01	01	H2752_003_0	7	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H2765	001	0	1	02	01	H2765_001_0	6	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	12	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	11111111	20	20	20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															1	2
H2765	002	0	1	02	01	H2765_002_0	8	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	12	3		1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			20	50	20	50	20	50	20	50	20	50	20	50	20	50	2		1	01000000	40.00	40.00															1	2
H2765	003	0	1	02	01	H2765_003_0	8	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	12	3		1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	11111111	20	20	20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															1	2
H2765	004	0	1	02	01	H2765_004_0	7	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	12	3		1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H2775	105	0	1	04	01	H2775_105_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2775	106	0	1	04	01	H2775_106_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS once per tooth	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1	2	2	1000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2775	109	0	1	04	01	H2775_109_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	30.00	30.00	0.00	0.00	0.00	0.00											1	2
H2775	111	0	1	04	01	H2775_111_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H2775	112	0	1	04	01	H2775_112_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS once per tooth	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2775	113	0	1	04	01	H2775_113_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS once per tooth	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2775	114	0	1	04	01	H2775_114_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2775	115	0	1	04	01	H2775_115_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2782	002	0	1	01	01	H2782_002_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	(No charge)Bitewing xrays-limited to 1 series every 6 moIntraoral complete series of radiographic images-limited to 1 series every 24 moPanoramic radiographic image-limited to 1 series every 5 yrs	2	2	1	6	$19-$390Replacement of crowns, inlays &  onlays requires  existing restoration be 5+ yrs oldMin copay to Pin retention per tooth (in addition to restoration Max copay  to titanium/ porcelain crowns	2	1				2	2	2	6	No chargePeriodontal scaling root planing  limited to 4 quadrants during  12  moPeriodontal maintenance-limited to 2 treatments per cyrFull mouth debridement-limited to 1 treatment in  12 cons mon	2	1				2	2	1	6	See notes below	2						2					2																		2		1	11101100	25.00	25.00	0.00	159.00			19.00	390.00	23.00	389.00					35.00	775.00	2	1
H2782	004	0	1	01	01	H2782_004_0	8	2																																																															2																																											2					2																		2		1	01000000	25.00	25.00															2	2
H2782	801	0	1	01	01	H2782_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2782	802	0	1	01	01	H2782_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2782	803	0	1	01	01	H2782_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2782	804	0	1	01	01	H2782_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	001	0	1	02	01	H2802_001_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	007	0	1	02	01	H2802_007_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	008	0	1	02	01	H2802_008_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	010	0	1	02	01	H2802_010_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	012	0	1	02	01	H2802_012_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	016	0	1	02	01	H2802_016_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	018	0	1	02	01	H2802_018_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	024	0	1	02	01	H2802_024_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	025	0	1	02	01	H2802_025_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	027	0	1	02	01	H2802_027_0	4	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2802	028	0	1	02	01	H2802_028_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	029	0	1	02	01	H2802_029_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	030	0	1	02	01	H2802_030_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	031	0	1	02	01	H2802_031_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	032	0	1	02	01	H2802_032_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	033	0	1	02	01	H2802_033_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	034	0	1	02	01	H2802_034_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	035	0	1	02	01	H2802_035_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	041	0	1	02	01	H2802_041_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	044	0	1	02	01	H2802_044_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	048	0	1	02	01	H2802_048_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	049	0	1	02	01	H2802_049_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	050	0	1	02	01	H2802_050_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	052	0	1	02	01	H2802_052_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	053	0	1	02	01	H2802_053_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2802	054	0	1	02	01	H2802_054_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	055	0	1	02	01	H2802_055_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	056	0	1	02	01	H2802_056_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	057	0	1	02	01	H2802_057_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	058	0	1	02	01	H2802_058_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	059	0	1	02	01	H2802_059_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2802	060	0	1	02	01	H2802_060_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	061	0	1	02	01	H2802_061_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	062	0	1	02	01	H2802_062_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H2802	063	0	1	02	01	H2802_063_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H2802	801	0	1	01	01	H2802_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	802	0	1	01	01	H2802_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	803	0	1	01	01	H2802_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	804	0	1	01	01	H2802_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	805	0	1	01	01	H2802_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	806	0	1	01	01	H2802_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	807	0	1	01	01	H2802_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	808	0	1	01	01	H2802_808_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	809	0	1	01	01	H2802_809_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	816	0	1	01	01	H2802_816_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	817	0	1	01	01	H2802_817_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	818	0	1	01	01	H2802_818_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	819	0	1	01	01	H2802_819_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	820	0	1	01	01	H2802_820_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	821	0	1	01	01	H2802_821_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	822	0	1	01	01	H2802_822_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	823	0	1	01	01	H2802_823_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2802	824	0	1	01	01	H2802_824_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H2815	001	0	1	20	08	H2815_001_0	1																																																																																																																																																							
H2815	002	0	1	20	08	H2815_002_0	1																																																																																																																																																							
H2816	013	0	1	09	04	H2816_013_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0110000	2	2	1	6	every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	25.00	25.00	0.00	0.00	0.00	0.00											2	2
H2816	019	0	1	09	04	H2816_019_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0110000	2	2	1	6	every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	35.00	35.00	0.00	0.00	0.00	0.00											2	2
H2816	037	0	1	09	04	H2816_037_0	16	2																																																															2																																											2					2																		2		1	01000000	25.00	25.00															2	2
H2816	038	0	1	09	04	H2816_038_0	16	2																																																															2																																											2					2																		2		1	01000000	30.00	30.00															2	2
H2816	040	0	1	09	04	H2816_040_0	4	2																																																															2																																											2					2																		2		1	01000000	35.00	35.00															2	2
H2819	001	0	1	01	01	H2819_001_0	5	1	1111	2	2	1	1		2	2	2	3		2	2	2	3		2	2	1	6	One per arch per day.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2	2	1	6	Periodicity varies by covered benefit. See Notes for more details	2	2	1	6	Periodicity range: Pulp cap – direct (excluding final restoration): once per calendar year; hemisection (including any root removal), not including root canal therapy: once per lifetime.	2	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2	2	1	6	Periodicity range: Extraction, coronal remnants – primary tooth: once per lifetime; removal of impacted tooth – soft tissue: 3 per calendar year.	2	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2						2					1	01000000	20	20															2		1	10001110							0.00	380.00	0.00	150.00	0.00	295.00			0.00	2100.00	1	1
H2819	002	0	1	01	01	H2819_002_0	6	1	1111	2	2	1	1		2	2	2	3		2	2	2	3		2	2	1	6	One per arch per day.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2	2	1	6	Periodicity range: Pulp cap – direct (excluding final restoration): once per calendar year; hemisection (including any root removal), not including root canal therapy: once per lifetime.	2	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2	2	1	6	Periodicity range: Extraction, coronal remnants – primary tooth: once per lifetime; removal of impacted tooth – soft tissue: 3 per calendar year.	2	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2						2					1	01000000	20	20															2		1	10001110							0.00	380.00	0.00	150.00	0.00	295.00			0.00	2100.00	1	1
H2819	003	0	1	01	01	H2819_003_0	5	1	1111	2	2	1	1		2	2	2	3		2	2	2	3		2	2	1	6	One per arch per day.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2	2	1	6	Periodicity range: Pulp cap – direct (excluding final restoration): once per calendar year; hemisection (including any root removal), not including root canal therapy: once per lifetime.	2	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2	2	1	6	Periodicity range: Extraction, coronal remnants – primary tooth: once per lifetime; removal of impacted tooth – soft tissue: 3 per calendar year.	2	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2						2					1	01000000	20	20															2		1	10001110							0.00	380.00	0.00	150.00	0.00	295.00			0.00	2100.00	1	1
H2835	001	0	1	20	08	H2835_001_0	1																																																																																																																																																							
H2835	002	0	1	20	08	H2835_002_0	1																																																																																																																																																							
H2836	005	0	1	04	01	H2836_005_0	6	1	1111	4	1				4	1				4	1				4	1				1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2836	006	0	1	04	01	H2836_006_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2853	801	0	1	01	01	H2853_801_0	12	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H2879	001	0	1	01	01	H2879_001_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					1	01000000	20	20															2		2																		2	2
H2879	002	0	1	01	01	H2879_002_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1050.00	3		2					2																		2		2																		2	2
H2879	003	0	1	01	01	H2879_003_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1100.00	3		2					2																		2		2																		2	2
H2879	004	0	1	01	01	H2879_004_0	5	2																																																															2																																											2					2																		2		1	01000000	40.00	40.00															2	2
H2879	005	0	1	01	01	H2879_005_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					2																		2		2																		2	2
H2882	003	0	1	20	08	H2882_003_0	1																																																																																																																																																							
H2882	004	0	1	20	08	H2882_004_0	1																																																																																																																																																							
H2915	002	0	1	01	01	H2915_002_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES  3 crowns or bridge units every 12 months, 1 per tooth every 84 months. Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2915	003	0	1	01	01	H2915_003_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2915	007	0	1	01	01	H2915_007_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 months. Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2915	011	0	1	01	01	H2915_011_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2915	013	0	1	01	01	H2915_013_0	15	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2915	016	0	1	01	01	H2915_016_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H2923	001	0	1	01	01	H2923_001_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3500.00	3		2					2																		2		1	01000000	20.00	20.00															1	2
H2926	001	0	1	01	01	H2926_001_0	13	2																																																															1	1001100											2	2	1	3		2	2	2	3												2	2	1	6	Additional one replacement dentures per six years	2						2					2																		2		2																		1	2
H2936	001	0	1	20	08	H2936_001_0	1																																																																																																																																																							
H2936	002	0	1	20	08	H2936_002_0	1																																																																																																																																																							
H2937	001	0	1	20	08	H2937_001_0	1																																																																																																																																																							
H2937	002	0	1	20	08	H2937_002_0	1																																																																																																																																																							
H2941	001	0	1	20	08	H2941_001_0	1																																																																																																																																																							
H2941	002	0	1	20	08	H2941_002_0	1																																																																																																																																																							
H2942	001	0	1	01	01	H2942_001_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	*One full mouth series or panoramic x-ray per 60 months	2	2	1	6	See notes	2	2	1	6	See notes	2	2	1	6	See notes	2	2	1	6	See notes	2	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	2	2	1	6	See notes	1		1				2					2																		2		2																		2	2
H2944	013	0	1	09	04	H2944_013_0	7	1	1111	2	2	3	6	Oral Exams services include emergency diagnostic exam up to 1 per year, periodic oral exam up to 2 per year.	2	2	6	6	Prophylaxis (cleaning) services include periodontal maintenance up to 4 per year, prophylaxis (cleaning) up to 2 per year.	2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	0010000						2	2	1	1																											2						2					2																		2		1	01010000	40.00	40.00			0.00	0.00												
H2960	009	0	1	01	01	H2960_009_0	4	1	1110	2	2	1	3		2	2	2	3							2	2	1	6	INTRAORAL COMPLETE SERIES OR PANORAMIC RADIOGRAPHIC IMAGES: COVERED ONCE EVERY 3 CALENDAR YEARS	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	3		2	2	1	6	Amalgams or resin covered once per surface per tooth every 3 calendar years. Inlay, onlay or crowns covered once per tooth every 5 calendar years.	2	2	1	6	ENDODONTIC THERAPY- ONCE PER TOOTH PER LIFETIME	2	2	1	6	"PERIODONTIC SERVICES- COVERED ONCE PER SITE PER QUADRANT EVERY 24 MONTHS. PERIODONTAL MAINTENANCE COVERED TWICE EVERY CALEANDAR YEAR.FULL MOUTH DEBRIDEMENT COVERED ONCE EVERY 3 CALENDAR YEARS	2	2	1	6	EXTRACTIONS- EXTRACTIONS COVERED ONCE IN A LIFETIME.	2	2	1	6	"ORAL SURGERY SERVICES- INCLUDES SIMPLE AND COMPLICATED EXTRACTIONS.	1		2	1500.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	40.00	40.00															2	2
H2960	012	0	1	01	01	H2960_012_0	6	1	1110	2	2	1	3		2	2	2	3							2	2	1	6	BITEWINGS - SINGLE RADIOGRAPHIC IMAGES , 2 RADIOGRAPHIC IMAGES, 3 RADIOGRAPHIC IMAGES, AND 4 RADIOGRAPHIC IMAGES: COVERED ONCE EVERY CALENDAR YEAR.	2					2				2		2												2		2		2												2	2	2																																											2					2																		2		1	01000000	40.00	40.00															2	2
H2960	018	0	1	01	01	H2960_018_0	6	1	1110	2	2	1	3		2	2	2	3							2	2	1	6	BITEWINGS - SINGLE RADIOGRAPHIC IMAGES , 2 RADIOGRAPHIC IMAGES, 3 RADIOGRAPHIC IMAGES, AND 4 RADIOGRAPHIC IMAGES: COVERED ONCE EVERY CALENDAR YEAR."	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	3		2	2	1	6	Amalgams or resin covered once per surface per tooth every 3 calendar years. Inlay, onlay or crowns covered once per tooth every 5 calendar years.	2	2	1	6	ENDODONTIC THERAPY- ONCE PER TOOTH PER LIFETIME	2	2	1	6	FULL MOUTH DEBRIDEMENT COVERED ONCE EVERY 3 CALENDAR YEARS	2	2	1	6	EXTRACTIONS- EXTRACTIONS COVERED ONCE IN A LIFETIME.	2	2	1	6	"ORAL SURGERY SERVICES- INCLUDES SIMPLE AND COMPLICATED EXTRACTIONS.	1		2	1500.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	15.00	15.00															2	2
H2960	019	0	1	01	01	H2960_019_0	4	1	1110	2	2	1	3		2	2	2	3							2	2	1	6	BITEWINGS - SINGLE RADIOGRAPHIC IMAGES , 2 RADIOGRAPHIC IMAGES, 3 RADIOGRAPHIC IMAGES, AND 4 RADIOGRAPHIC IMAGES: COVERED ONCE EVERY CALENDAR YEAR."	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	3		2	2	1	6	Amalgams or resin covered once per surface per tooth every 3 calendar years. Inlay, onlay or crowns covered once per tooth every 5 calendar years.	2	2	1	6	ENDODONTIC THERAPY- ONCE PER TOOTH PER LIFETIME	2	2	1	6	"PERIODONTIC SERVICES- COVERED ONCE PER SITE PER QUADRANT EVERY 24 MONTHS. PERIODONTAL MAINTENANCE COVERED TWICE EVERY CALEANDAR YEAR.FULL MOUTH DEBRIDEMENT COVERED ONCE EVERY 3 CALENDAR YEARS	2	2	1	6	EXTRACTIONS- EXTRACTIONS COVERED ONCE IN A LIFETIME.	2	2	1	6	"ORAL SURGERY SERVICES- INCLUDES SIMPLE AND COMPLICATED EXTRACTIONS.	1		2	1250.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	0.00	0.00															2	2
H2960	023	0	1	01	01	H2960_023_0	5	1	1110	2	2	1	3		2	2	2	3							2	2	1	6	BITEWINGS - SINGLE RADIOGRAPHIC IMAGES , 2 RADIOGRAPHIC IMAGES, 3 RADIOGRAPHIC IMAGES, AND 4 RADIOGRAPHIC IMAGES: COVERED ONCE EVERY CALENDAR YEAR.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	3		2	2	1	1		2	2	1	6	ENDODONTIC THERAPY- ONCE PER TOOTH PER LIFETIME	2	2	1	6	"PERIODONTIC SERVICES- COVERED ONCE PER SITE PER QUADRANT EVERY 24 MONTHS. PERIODONTAL MAINTENANCE COVERED TWICE EVERY CALEANDAR YEAR.FULL MOUTH DEBRIDEMENT COVERED ONCE EVERY 3 CALENDAR YEARS	2	2	1	6	EXTRACTIONS- EXTRACTIONS COVERED ONCE IN A LIFETIME.	2	2	1	6	"ORAL SURGERY SERVICES- INCLUDES SIMPLE AND COMPLICATED EXTRACTIONS.	1		2	1250.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	35.00	35.00															2	2
H2960	024	0	1	01	01	H2960_024_0	5	1	1110	2	2	1	3		2	2	2	3							2	2	1	6	BITEWINGS - SINGLE RADIOGRAPHIC IMAGES , 2 RADIOGRAPHIC IMAGES, 3 RADIOGRAPHIC IMAGES, AND 4 RADIOGRAPHIC IMAGES: COVERED ONCE EVERY CALENDAR YEAR."	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	3		2	2	1	6	Amalgams or resin covered once per surface per tooth every 3 calendar years. Inlay, onlay or crowns covered once per tooth every 5 calendar years.	2	2	1	6	ENDODONTIC THERAPY- ONCE PER TOOTH PER LIFETIME	2	2	1	6	FULL MOUTH DEBRIDEMENT COVERED ONCE EVERY 3 CALENDAR YEARSOSSEOUS SURGERY COVERED ONCE PER SITE PER QUADRANT EVERY 2 CALENDAR YEARS"	2	2	1	6	EXTRACTIONS- EXTRACTIONS COVERED ONCE IN A LIFETIME.	2	2	1	6	"ORAL SURGERY SERVICES- INCLUDES SIMPLE AND COMPLICATED EXTRACTIONS.	1		2	2000.00	3		2					1	11011111	20	20			0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2
H2960	803	0	1	01	01	H2960_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H2962	001	0	1	01	01	H2962_001_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	0011011						2	2	1	1		2	2	4	3							2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	2	3							2						2					2																		2		2																		1	2
H2962	021	0	1	01	01	H2962_021_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	1		2	2	4	3		2	2	1	3		2	2	7	6	• 1 full mouth debridement every 2 years• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	1	6	$0 copay for:1 simple extraction per year1 surgical extraction per yearUnlimited simple and surgical necessary extractions to fit dentures (see Dentures benefit below)	2	1				2						2					2																		2		2																		1	2
H2962	022	0	1	01	01	H2962_022_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	1		2	2	4	3		2	2	1	3		2	2	7	6	• 1 full mouth debridement every 2 years• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	1	6	$0 copay for:1 simple extraction per year1 surgical extraction per yearUnlimited simple and surgical necessary extractions to fit dentures (see Dentures benefit below)	2	1				2						2					2																		2		2																		1	2
H2962	023	0	1	01	01	H2962_023_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	1		2	2	4	3		2	2	1	3		2	2	7	6	• 1 full mouth debridement every 2 years• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	1	6	$0 copay for:1 simple extraction per year1 surgical extraction per yearUnlimited simple and surgical necessary extractions to fit dentures (see Dentures benefit below)	2	1				2						2					2																		2		2																		1	2
H2962	025	0	1	01	01	H2962_025_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	1		2	2	4	3		2	2	1	3		2	2	7	6	• 1 full mouth debridement every 2 years• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	1	6	$0 copay for:1 simple extraction per year1 surgical extraction per yearUnlimited simple and surgical necessary extractions to fit dentures (see Dentures benefit below)	2	1				2						2					2																		2		2																		1	2
H2962	026	0	1	01	01	H2962_026_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	0011111						2	2	1	1		2	2	4	3		2	2	1	3		2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	2	3							2						2					2																		2		2																		1	2
H2962	028	0	1	01	01	H2962_028_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	0011011						2	2	1	1		2	2	4	3							2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	2	3							2						2					2																		2		2																		1	2
H2962	029	0	1	01	01	H2962_029_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	1		2	2	5	3		2	2	1	3		2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	1	6	$0 copay for:1 simple extraction per year1 surgical extraction per yearUnlimited simple and surgical necessary extractions to fit dentures (see Dentures benefit below)	2	1				2						2					2																		2		2																		1	2
H2962	033	0	1	01	01	H2962_033_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	0011111						2	2	1	1		2	2	4	3		2	2	1	3		2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	2	3							2						2					2																		2		2																		1	2
H2962	035	0	1	01	01	H2962_035_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	1		2	2	4	3		2	2	1	3		2	2	7	6	• 1 full mouth debridement every 2 years• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	1	6	$0 copay for:1 simple extraction per year1 surgical extraction per yearUnlimited simple and surgical necessary extractions to fit dentures (see Dentures benefit below)	2	1				2						2					2																		2		2																		1	2
H2962	036	0	1	01	01	H2962_036_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	1		2	2	4	3		2	2	1	3		2	2	7	6	• 1 full mouth debridement every 2 years• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	1	6	$0 copay for:1 simple extraction per year1 surgical extraction per yearUnlimited simple and surgical necessary extractions to fit dentures (see Dentures benefit below)	2	1				2						2					2																		2		2																		1	2
H2962	045	0	1	01	01	H2962_045_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	0011011						2	2	1	1		2	2	4	3							2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	2	3							2						2					2																		2		2																		1	2
H2962	046	0	1	01	01	H2962_046_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	0011011						2	2	1	1		2	2	4	3							2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	2	3							2						2					2																		2		2																		1	2
H2962	047	0	1	01	01	H2962_047_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	0011011						2	2	1	1		2	2	4	3							2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	2	3							2						2					2																		2		2																		1	2
H2962	050	0	1	01	01	H2962_050_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	0011111						2	2	1	1		2	2	4	3		2	2	1	3		2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	2	3							2						2					2																		2		2																		1	2
H2962	051	0	1	01	01	H2962_051_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	0011111						2	2	1	1		2	2	4	3		2	2	1	3		2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	2	3							2						2					2																		2		2																		1	2
H2962	052	0	1	01	01	H2962_052_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	3		2					2				2		2												2		2		2												2	2	1	0011111						2	2	1	1		2	2	4	3		2	2	1	3		2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2	2	2	3							2						2					2																		2		2																		1	2
H2992	001	0	1	20	08	H2992_001_0	1																																																																																																																																																							
H2992	002	0	1	20	08	H2992_002_0	1																																																																																																																																																							
H2992	003	0	1	20	08	H2992_003_0	1																																																																																																																																																							
H2992	004	0	1	20	08	H2992_004_0	1																																																																																																																																																							
H3015	001	0	1	01	01	H3015_001_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		5000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H3038	001	0	1	01	01	H3038_001_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3038	002	0	1	01	01	H3038_002_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years	2					2				2		2												2		2		2												2	2	1	1101101	2	1									2	1				2	1									2	1				2	1				1		2	500.00	3		2					1	01000000	20	20															2		2																		2	2
H3038	003	0	1	01	01	H3038_003_0	3	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					1	01000000	20	20															2		2																		2	2
H3041	001	0	1	01	01	H3041_001_0	11	1	1111	2	1				2	1				2	1				2	1				1		1750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H3047	001	0	1	04	01	H3047_001_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3047	002	0	1	04	01	H3047_002_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	45.00	45.00	0.00	0.00	0.00	0.00											1	2
H3060	001	0	1	20	08	H3060_001_0	1																																																																																																																																																							
H3060	002	0	1	20	08	H3060_002_0	1																																																																																																																																																							
H3071	002	0	1	01	01	H3071_002_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	4000.00	3		2					2																		2		1	01000000	30.00	30.00															2	2
H3080	001	0	1	01	01	H3080_001_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	6000.00	3		2					2																		2		1	01000000	10.00	10.00															1	2
H3080	002	0	1	01	01	H3080_002_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H3080	003	0	1	01	01	H3080_003_0	12	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime..	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	7500.00	3		2					2																		2		2																		1	2
H3080	004	0	1	01	01	H3080_004_0	12	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	6000.00	3		2					2																		2		2																		1	2
H3080	006	0	1	01	01	H3080_006_0	12	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	7500.00	3		2					2																		2		2																		1	2
H3080	007	0	1	01	01	H3080_007_0	12	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	6000.00	3		2					2																		2		2																		1	2
H3084	001	0	1	20	08	H3084_001_0	1																																																																																																																																																							
H3084	002	0	1	20	08	H3084_002_0	1																																																																																																																																																							
H3113	001	0	1	01	01	H3113_001_0	5	2																																																															2																																											2					1	01000000	0	20															2		2																		1	2
H3113	005	0	1	01	01	H3113_005_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3113	008	0	1	02	01	H3113_008_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		7000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3113	009	0	1	02	01	H3113_009_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3113	010	0	1	02	01	H3113_010_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3113	011	0	1	02	01	H3113_011_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3113	013	0	1	02	01	H3113_013_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3113	014	0	1	02	01	H3113_014_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3138	001	0	1	04	01	H3138_001_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	1	2	1350.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0011110	3					2	1				4	1				4	1				4	1				3					3					1		1				2					1	00001110							30	30	50	50	50	50					2		1	01010000	30.00	30.00			0.00	0.00											2	2
H3138	002	0	1	04	01	H3138_002_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	1	2	1350.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0011110	3					2	1				4	1				4	1				4	1				3					3					1		1				2					1	00001110							30	30	50	50	50	50					2		1	01010000	30.00	30.00			0.00	0.00											2	2
H3146	001	0	1	02	01	H3146_001_0	8	1	1111	2	1				2	1				2	1				2	1				1		2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3146	002	0	1	01	01	H3146_002_0	8	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3146	003	0	1	01	01	H3146_003_0	9	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3146	004	0	1	02	01	H3146_004_0	8	1	1111	2	1				2	1				2	1				2	1				1		2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3146	006	0	1	01	01	H3146_006_0	8	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3146	007	0	1	02	01	H3146_007_0	8	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3146	008	0	1	01	01	H3146_008_0	9	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3146	009	0	1	01	01	H3146_009_0	9	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3146	011	0	1	01	01	H3146_011_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3146	012	0	1	01	01	H3146_012_0	8	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3146	013	0	1	01	01	H3146_013_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3146	014	0	1	02	01	H3146_014_0	8	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	12.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3146	015	0	1	01	01	H3146_015_0	9	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3146	016	0	1	01	01	H3146_016_0	9	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3146	017	0	1	01	01	H3146_017_0	9	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3146	018	0	1	01	01	H3146_018_0	9	1	1110	2	2	4	3		2	2	2	3							2	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	2																																											2					1	01000000	20	20															2		2																		1	2
H3146	019	0	1	01	01	H3146_019_0	9	1	1110	2	2	4	3		2	2	2	3							2	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	2																																											2					1	01000000	20	20															2		2																		1	2
H3146	020	0	1	02	01	H3146_020_0	9	1	1111	2	1				2	1				2	1				2	1				1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3146	801	0	1	01	01	H3146_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3146	802	0	1	01	01	H3146_802_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3152	022	0	1	02	01	H3152_022_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3152	045	0	1	01	01	H3152_045_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3152	048	0	1	02	01	H3152_048_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3152	080	0	1	02	01	H3152_080_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3152	082	0	1	01	01	H3152_082_0	10	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	45.00	45.00															1	2
H3152	084	0	1	01	01	H3152_084_0	9	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															1	2
H3152	088	0	1	01	01	H3152_088_0	9	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															1	2
H3152	801	0	1	01	01	H3152_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3152	804	0	1	01	01	H3152_804_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3170	003	1	1	01	01	H3170_003_1	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		1425.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	2	1	6	Number of visits depends on services, see notes for details.	2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H3170	003	2	1	01	01	H3170_003_2	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		1425.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	2	1	6	Number of visits depends on services received, see notes for details.	2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H3186	001	0	1	04	01	H3186_001_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	2		2	2	1	6	Root canal therapy - 1 per lifetime	2	2	1	1		2	1				2	2	1	6	Oral surgery (alveoloplasty, osseous, osteoperiosteal, or cartilage graft) - 1 per lifetimeCrowns - 1 per 5 years	1	2	2	2000.00	3		2					1	11001011	0	0					0	0			0	0	0	0	0	0	2		2																		2	2
H3186	002	0	1	04	01	H3186_002_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	2		2	2	1	6	Root canal therapy - 1 per lifetime	2	2	1	1		2	1				2	2	1	6	Oral surgery (alveoloplasty, osseous, osteoperiosteal or cartilage graft) - 1 per lifetimeCrowns - 1 per 5 years	1	2	2	1750.00	3		2					2																		2		2																		2	2
H3189	001	0	1	01	01	H3189_001_0	5	1	1111	2	2	2	6	Periodic, extensive oral and re-evaluation problem focused-two every calendar yearLimited oral-3 every calendar yearComprehensive oral and periodontal evaluation-1 every 3 years.	2	2	2	3		2	2	2	3		2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H3189	801	0	1	01	01	H3189_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3189	802	0	1	01	01	H3189_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3189	803	0	1	01	01	H3189_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3189	804	0	1	01	01	H3189_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3192	001	0	1	02	01	H3192_001_0	8	1	1111	2	1				2	1				2	1				2	1				1		3750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3192	002	0	1	02	01	H3192_002_0	9	1	1111	2	1				2	1				2	1				2	1				1		1900.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3192	003	0	1	02	01	H3192_003_0	8	1	1111	2	1				2	1				2	1				2	1				1		2800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3192	004	0	1	02	01	H3192_004_0	8	1	1111	2	1				2	1				2	1				2	1				1		2800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3192	005	0	1	02	01	H3192_005_0	8	1	1111	2	1				2	1				2	1				2	1				1		2900.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3192	006	0	1	02	01	H3192_006_0	8	1	1111	2	1				2	1				2	1				2	1				1		2800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3192	007	0	1	01	01	H3192_007_0	8	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3192	008	0	1	01	01	H3192_008_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3192	009	0	1	01	01	H3192_009_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3192	010	0	1	02	01	H3192_010_0	7	1	1111	2	1				2	1				2	1				2	1				1		1800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3192	011	0	1	02	01	H3192_011_0	7	1	1111	2	1				2	1				2	1				2	1				1		2300.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3192	012	0	1	02	01	H3192_012_0	7	1	1111	2	1				2	1				2	1				2	1				1		1850.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3192	013	0	1	02	01	H3192_013_0	7	1	1111	2	1				2	1				2	1				2	1				1		2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3192	017	0	1	02	01	H3192_017_0	7	1	1111	2	1				2	1				2	1				2	1				1		2350.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3192	020	0	1	02	01	H3192_020_0	7	1	1111	2	1				2	1				2	1				2	1				1		2300.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3192	801	0	1	01	01	H3192_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3192	802	0	1	01	01	H3192_802_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3204	001	0	1	01	01	H3204_001_0	7	1	1111	2	2	2	6	Routine dental coverage that offers limited preventive dental services.	2	2	2	6	-Prophylaxis, scaling in presence of generalized moderate or severe gingival inflammation, full mouth - 2 per 12 months.-Periodontal maintenance procedures (following active therapy) 4 per 12 months.	2	2	2	6	- Topical application of fluoride varnish, topical fluoride - 2 every 12 months.	2	2	1	6	Basic dental x-rays related to routine dental care.	2					2				2		2												2		2		2												2	2	2												3					3					3					3					3											2					2																		2		1	01000000	50.00	50.00															2	1
H3204	007	0	1	01	01	H3204_007_0	7	1	1111	2	2	2	6	Routine dental coverage that offers limited preventive dental services.	2	2	2	6	-Prophylaxis, scaling in presence of generalized moderate or severe gingival inflammation, full mouth - 2 per 12 months.-Periodontal maintenance procedures (following active therapy) 4 per 12 months.	2	2	2	6	Topical application of fluoride varnish, topical fluoride - 2 every 12 months.	2	2	1	6	Basic dental x-rays related to routine dental care.	2					2				2		2												2		2		2												2	2	2												3					3					3					3					3											2					2																		2		1	01000000	45.00	45.00															2	1
H3204	008	0	1	01	01	H3204_008_0	6	1	1111	2	2	2	6	Routine dental coverage that offers limited preventive dental services.	2	2	2	6	-Prophylaxis, scaling in presence of generalized moderate or severe gingival inflammation, full mouth - 2 per 12 months.-Periodontal maintenance procedures (following active therapy) 4 per 12 months.	2	2	2	6	- Topical application of fluoride varnish, topical fluoride - 2 every 12 months.	2	2	1	6	Basic dental x-rays related to routine dental care.	2					2				2		2												2		2		2												2	2	2												3					3					3					3					3											2					2																		2		1	01000000	55.00	55.00															2	1
H3204	013	4	1	01	01	H3204_013_4	8	1	1111	2	2	2	6	Routine dental coverage that offers limited preventive dental services.	2	2	2	6	-Prophylaxis, scaling in presence of generalized moderate or severe gingival inflammation, full mouth - 2 per 12 months.-Periodontal maintenance procedures (following active therapy) 4 per 12 months.	2	2	2	3		2	2	1	6	Basic dental x-rays related to routine dental care.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H3204	013	5	1	01	01	H3204_013_5	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3204	015	0	1	02	01	H3204_015_0	8	1	1111	2	2	2	6	Routine dental coverage that offers limited preventive dental services.	2	2	2	6	-Prophylaxis, scaling in presence of generalized moderate or severe gingival inflammation, full mouth - 2 per 12 months.-Periodontal maintenance procedures (following active therapy) 4 per 12 months.	2	2	2	6	- Topical application of fluoride varnish, topical fluoride - 2 every 12 months.	2	2	1	6	Basic dental x-rays related to routine dental care.	2					2				2		2												2		2		2												2	2	2												3					3					3					3					3											2					2																		2		1	01000000	55.00	55.00															2	1
H3204	801	0	1	01	01	H3204_801_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3204	802	0	1	01	01	H3204_802_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3204	803	0	1	01	01	H3204_803_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3204	808	0	1	02	01	H3204_808_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3204	809	0	1	02	01	H3204_809_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3204	810	0	1	02	01	H3204_810_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3206	001	0	1	04	01	H3206_001_0	9	1	1111	2	2	2	6	Routine dental coverage that offers limited preventive dental services.	2	2	2	6	- Prophylaxis, scaling in presence of generalized moderate or severe gingival inflammation, full mouth - 2 per 12 months.- Periodontal maintenance procedures (following active therapy) 4 per 12 month	2	2	2	6	Topical application of fluoride varnish, topical fluoride - 2 every 12 months.	2	2	1	6	Basic dental x-rays related to routine dental care.	2					2				2		2												2		2		2												2	2	2												3					3					3					3					3											2					2																		2		1	01000000	55.00	55.00															2	1
H3206	003	0	1	04	01	H3206_003_0	5	1	1111	2	2	2	6	Routine dental coverage that offers limited preventive dental services.	2	2	2	6	Prophylaxis, scaling in presence of generalized moderate or severe gingival inflammation, full mouth - 2 per 12 months.Periodontal maintenance procedures (following active therapy) 4 per 12 months.	2	2	2	6	Topical application of fluoride varnish, topical fluoride - 2 every 12 months.	2	2	1	6	Basic dental x-rays related to routine dental care.	2					2				2		2												2		2		2												2	2	2												3					3					3					3					3											2					2																		2		1	01000000	55.00	55.00															2	1
H3206	801	0	1	04	01	H3206_801_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3206	802	0	1	04	01	H3206_802_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3206	803	0	1	04	01	H3206_803_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3219	001	0	1	04	01	H3219_001_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3219	002	0	1	04	01	H3219_002_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3219	003	0	1	04	01	H3219_003_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3219	004	0	1	04	01	H3219_004_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3219	005	0	1	04	01	H3219_005_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3219	007	0	1	04	01	H3219_007_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1450.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3219	008	0	1	04	01	H3219_008_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2550.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3219	801	0	1	04	01	H3219_801_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3219	802	0	1	04	01	H3219_802_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3239	001	0	1	01	01	H3239_001_0	6	1	1111	2	1				2	1				2	1				2	1				1		4500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	002	0	1	01	01	H3239_002_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	003	0	1	01	01	H3239_003_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	005	0	1	01	01	H3239_005_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	006	0	1	01	01	H3239_006_0	6	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	007	0	1	01	01	H3239_007_0	6	1	1111	2	1				2	1				2	1				2	1				1		3750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	008	0	1	01	01	H3239_008_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	010	0	1	01	01	H3239_010_0	6	1	1111	2	1				2	1				2	1				2	1				1		2700.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	011	0	1	01	01	H3239_011_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	012	0	1	01	01	H3239_012_0	6	1	1111	2	1				2	1				2	1				2	1				1		2600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	013	0	1	01	01	H3239_013_0	6	1	1111	2	1				2	1				2	1				2	1				1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	014	0	1	01	01	H3239_014_0	6	1	1111	2	1				2	1				2	1				2	1				1		2550.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	015	0	1	01	01	H3239_015_0	6	1	1111	2	1				2	1				2	1				2	1				1		4500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	016	0	1	01	01	H3239_016_0	6	1	1111	2	1				2	1				2	1				2	1				1		2800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	017	0	1	01	01	H3239_017_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	018	0	1	01	01	H3239_018_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	019	0	1	01	01	H3239_019_0	6	1	1111	2	1				2	1				2	1				2	1				1		2950.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3239	020	0	1	01	01	H3239_020_0	6	1	1111	2	1				2	1				2	1				2	1				1		2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3240	013	0	1	01	01	H3240_013_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3240	017	0	1	02	01	H3240_017_0	6	1	1111	2	1				2	1				2	1				2	1				1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3240	021	0	1	01	01	H3240_021_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3240	022	0	1	01	01	H3240_022_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3240	024	0	1	02	01	H3240_024_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3251	002	0	1	01	01	H3251_002_0	7	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H3251	029	0	1	01	01	H3251_029_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	4000.00	3		2					1	11111111	20	20	0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2
H3251	804	0	1	01	01	H3251_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3256	001	0	1	04	01	H3256_001_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3256	002	0	1	04	01	H3256_002_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3259	001	0	1	01	01	H3259_001_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	3900.00	3		2					1	01000000	20	20															2		2																		2	2
H3259	002	0	1	01	01	H3259_002_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3259	003	0	1	01	01	H3259_003_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3274	001	0	1	01	01	H3274_001_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		1				2					1	01000000	20	20															2		2																		1	2
H3274	002	0	1	01	01	H3274_002_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		1				2					1	01000000	20	20															2		2																		1	2
H3274	003	0	1	01	01	H3274_003_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		1				2					1	01000000	20	20															2		2																		1	2
H3274	004	0	1	01	01	H3274_004_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	One bitewing radiograph is a covered benefit every year.One panoramic radiograph or One complete series is a covered benefit once every three years.Continued in notes.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		2	1000.00	3		2					1	01000000	20	20															2		2																		1	2
H3276	001	0	1	02	01	H3276_001_0	12	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	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	1	1111111	2	1				2	1				2	2	1	6	Restorative: 1 filing per tooth per year	2	2	1	6	Endodontics: 1 per tooth per lifetime	2	2	1	6	Periodontics: 1 every 36 months per quadrant	2	2	1	6	Extractions: 1 per tooth per lifetime	2	2	1	6	Prosthodontics: Oral/Maxillofacial Surgery 1 every 5 years	1		2	3000.00	3		2					1	01000000	20	20															2		2																		1	2
H3276	003	0	1	02	01	H3276_003_0	11	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	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	1	1111111	2	1				2	1				2	2	1	6	Restorative: 1 filing per tooth per year	2	2	1	6	Endodontics: 1 per tooth per lifetime	2	2	1	6	Periodontics: 1 every 36 months per quadrant	2	2	1	6	Extractions: 1 per tooth per lifetime	2	2	1	6	Prosthodontics: Oral/Maxillofacial Surgery 1 every 5 years	1		2	2000.00	3		2					1	01000000	20	20															2		2																		1	2
H3284	001	0	1	20	08	H3284_001_0	1																																																																																																																																																							
H3284	002	0	1	20	08	H3284_002_0	1																																																																																																																																																							
H3288	001	0	1	04	01	H3288_001_0	9	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											1	2
H3288	002	0	1	04	01	H3288_002_0	9	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											1	2
H3288	003	0	1	04	01	H3288_003_0	9	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											1	2
H3288	004	0	1	04	01	H3288_004_0	9	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											1	2
H3288	005	0	1	04	01	H3288_005_0	8	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	3500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	25.00	25.00			0.00	0.00											1	2
H3288	006	0	1	04	01	H3288_006_0	9	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	3500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											1	2
H3288	007	0	1	04	01	H3288_007_0	9	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	4000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											1	2
H3288	008	0	1	04	01	H3288_008_0	11	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	3500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											1	2
H3288	009	0	1	04	01	H3288_009_0	9	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	3500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	25.00	25.00			0.00	0.00											1	2
H3288	011	0	1	04	01	H3288_011_0	9	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	3500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											1	2
H3288	016	0	1	04	01	H3288_016_0	9	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											1	2
H3288	017	0	1	04	01	H3288_017_0	8	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											1	2
H3288	018	0	1	04	01	H3288_018_0	9	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	3000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											1	2
H3288	019	0	1	04	01	H3288_019_0	9	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	3000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											1	2
H3288	020	0	1	04	01	H3288_020_0	9	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3288	021	0	1	04	01	H3288_021_0	9	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	3500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											1	2
H3288	027	0	1	04	01	H3288_027_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3288	031	0	1	04	01	H3288_031_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3288	034	0	1	04	01	H3288_034_0	3	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3288	042	0	1	04	01	H3288_042_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	1650.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3288	045	0	1	04	01	H3288_045_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	850.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3288	046	0	1	04	01	H3288_046_0	9	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	3500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											1	2
H3288	047	0	1	04	01	H3288_047_0	9	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											1	2
H3288	048	0	1	04	01	H3288_048_0	9	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											1	2
H3288	051	0	1	04	01	H3288_051_0	8	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	3000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											1	2
H3288	801	0	1	04	01	H3288_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3288	802	0	1	04	01	H3288_802_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3291	001	0	1	01	01	H3291_001_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3291	002	0	1	01	01	H3291_002_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Refer to the Notes for periodicity details.	1		4200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Refer to the Notes for periodicity details.	2	1				2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	1		1				2					1	01000000	20	20															2		2																		1	2
H3291	003	0	1	01	01	H3291_003_0	7	1	1111	2	2	2	3		2	2	1	4		2	2	2	3		2	2	1	6	Refer to the Notes for periodicity details.	1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Refer to the Notes for periodicity details.	2	1				2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	1		1				2					1	01000000	20	20															2		2																		1	2
H3305	007	0	1	02	01	H3305_007_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	12 to 36 months depending on type of service	1		2000.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	2	1	6	24 to 60 months depending on type of service	2	2	1	6	1 per tooth in a lifetime	2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	2	1				2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H3305	015	0	1	02	01	H3305_015_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	12 to 36 months depending on type of service	1		2000.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	2	1	6	24 to 60 months depending on type of service	2	2	1	6	1 per tooth in a lifetime	2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	2	1				2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H3305	020	0	1	02	01	H3305_020_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	12 to 36 months depending on type of service	1		2000.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	2	1	6	24 to 60 months depending on type of service	2	2	1	6	1 per tooth in a lifetime	2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	2	1				2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H3305	021	0	1	02	01	H3305_021_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	12 to 36 months depending on type of service	1		2000.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	2	1	6	24 to 60 months depending on type of service	2	2	1	6	1 per tooth in a lifetime	2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	2	1				2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H3305	022	0	1	02	01	H3305_022_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	12 to 36 months depending on type of service	1		2000.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	2	1	6	24 to 60 months depending on type of service	2	2	1	6	1 per tooth in a lifetime	2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	2	1				2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H3305	030	0	1	02	01	H3305_030_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	12 to 36 months depending on type of service	1		1500.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	2	1	6	24 to 60 months depending on type of service	2	2	1	6	1 per tooth in a lifetime	2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	2	1				2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H3305	032	0	1	02	01	H3305_032_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	12 to 36 months depending on type of service	1		1250.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	2	1	6	24 to 60 months depending on type of service	2	2	1	6	1 per tooth in a lifetime	2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	2	1				2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H3305	033	0	1	01	01	H3305_033_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H3305	034	0	1	01	01	H3305_034_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H3305	035	0	1	01	01	H3305_035_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H3305	801	0	1	02	01	H3305_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3305	803	0	1	02	01	H3305_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3305	804	0	1	02	01	H3305_804_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3307	002	0	1	02	01	H3307_002_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3307	012	0	1	02	01	H3307_012_0	5	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H3307	015	0	1	02	01	H3307_015_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H3307	018	0	1	02	01	H3307_018_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H3307	023	0	1	02	01	H3307_023_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H3307	802	0	1	01	01	H3307_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3307	804	0	1	01	01	H3307_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3307	805	0	1	01	01	H3307_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3312	002	0	1	01	01	H3312_002_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															1	2
H3312	018	0	1	01	01	H3312_018_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3312	048	0	1	01	01	H3312_048_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3312	062	0	1	02	01	H3312_062_0	8	1	1111	2	1				2	1				2	1				2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3312	064	0	1	01	01	H3312_064_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	45.00	45.00															1	2
H3312	065	0	1	02	01	H3312_065_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3312	069	0	1	01	01	H3312_069_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3312	070	0	1	01	01	H3312_070_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3312	072	0	1	01	01	H3312_072_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	45.00	45.00															1	2
H3312	073	0	1	01	01	H3312_073_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3312	074	0	1	01	01	H3312_074_0	7	1	1111	2	1				2	1				2	1				2	1				1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3312	801	0	1	01	01	H3312_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3312	804	0	1	01	01	H3312_804_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3321	001	0	1	20	08	H3321_001_0	1																																																																																																																																																							
H3321	003	0	1	20	08	H3321_003_0	1																																																																																																																																																							
H3322	001	0	1	20	08	H3322_001_0	1																																																																																																																																																							
H3322	002	0	1	20	08	H3322_002_0	1																																																																																																																																																							
H3329	001	0	1	20	08	H3329_001_0	1																																																																																																																																																							
H3329	002	0	1	20	08	H3329_002_0	1																																																																																																																																																							
H3330	021	1	1	01	01	H3330_021_1	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	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	1	1001111											2	2	1	6	$0: Filings - 1 every 24 months$125: Inlay/Onlay and single crown restoration - 1 every 60 months	2	2	1	6	$0: Root Canal (except molar) – 1 per lifetime$20: Root Canal (molar) – 1 per lifetime	2	2	1	6	$0: Scaling and root planing - 1 every 36 months per quadrant$150: Osseous surgery – 1 every 60 months per quadrant	2	2	1	6	$0: Soft tissue – 1 per lifetime$50: Bony impacted – 1 per lifetime	2	2	1	6	$0: Repair of dentures - 1 per arch per 12 months$150: Complete /partial Dentures – 1 per arch per 60 months	2						2					2																		2		1	10001111							0.00	125.00	0.00	20.00	0.00	150.00	0.00	50.00	0.00	150.00	1	2
H3330	021	2	1	01	01	H3330_021_2	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	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	1	1001111											2	2	1	6	$0: Filings - 1 every 24 months$125: Inlay/Onlay and single crown restoration - 1 every 60 months	2	2	1	6	$0: Root Canal (except molar) – 1 per lifetime$20: Root Canal (molar) – 1 per lifetime	2	2	1	6	$0: Scaling and root planing - 1 every 36 months per quadrant$150: Osseous surgery – 1 every 60 months per quadrant	2	2	1	6	$0: Soft tissue – 1 per lifetime$50: Bony impacted – 1 per lifetime	2	2	1	6	$0: Repair of dentures - 1 per arch per 12 months$150: Complete /partial Dentures – 1 per arch per 60 months	2						2					2																		2		1	10001111							0.00	125.00	0.00	20.00	0.00	150.00	0.00	50.00	0.00	150.00	1	2
H3330	021	3	1	01	01	H3330_021_3	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	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	1	1001111											2	2	1	6	$0: Filings - 1 every 24 months$125: Inlay/Onlay and single crown restoration - 1 every 60 months	2	2	1	6	$0: Root Canal (except molar) – 1 per lifetime$20: Root Canal (molar) – 1 per lifetime	2	2	1	6	$0: Scaling and root planing - 1 every 36 months per quadrant$150: Osseous surgery – 1 every 60 months per quadrant	2	2	1	6	$0: Soft tissue – 1 per lifetime$50: Bony impacted – 1 per lifetime	2	2	1	6	$0: Repair of dentures - 1 per arch per 12 months$150: Complete /partial Dentures – 1 per arch per 60 months	2						2					2																		2		1	10001111							0.00	125.00	0.00	20.00	0.00	150.00	0.00	50.00	0.00	150.00	1	2
H3330	038	0	1	01	01	H3330_038_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	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	1	1001111											2	2	1	6	$0: Filings - 1 every 24 months$125: Inlay/Onlay and single crown restoration - 1 every 60 months	2	2	1	6	$0: Root Canal (except molar) – 1 per lifetime$20: Root Canal (molar) – 1 per lifetime	2	2	1	6	$0: Scaling and root planing - 1 every 36 months per quadrant$150: Osseous surgery – 1 every 60 months per quadrant	2	2	1	6	$0: Soft tissue – 1 per lifetime$50: Bony impacted – 1 per lifetime	2	2	1	6	$0: Repair of dentures - 1 per arch per 12 months$150: Complete /partial Dentures – 1 per arch per 60 months	2						2					2																		2		1	10001111							0.00	125.00	0.00	20.00	0.00	150.00	0.00	50.00	0.00	150.00	1	2
H3330	045	0	1	01	01	H3330_045_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	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	1	1001111											2	2	1	6	$0: Filings - 1 every 24 months$125: Inlay/Onlay and single crown restoration - 1 every 60 months	2	2	1	6	$0: Root Canal (except molar) – 1 per lifetime$20: Root Canal (molar) – 1 per lifetime	2	2	1	6	$0: Scaling and root planing - 1 every 36 months per quadrant$150: Osseous surgery – 1 every 60 months per quadrant	2	2	1	6	$0: Soft tissue – 1 per lifetime$50: Bony impacted – 1 per lifetime	2	2	1	6	$0: Repair of dentures - 1 per arch per 12 months$150: Complete /partial Dentures – 1 per arch per 60 months	2						2					2																		2		1	10001111							0.00	125.00	0.00	20.00	0.00	150.00	0.00	50.00	0.00	150.00	1	2
H3330	814	0	1	01	01	H3330_814_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3330	815	0	1	01	01	H3330_815_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3330	820	0	1	02	01	H3330_820_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3330	821	0	1	02	01	H3330_821_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3331	001	0	1	20	08	H3331_001_0	1																																																																																																																																																							
H3331	002	0	1	20	08	H3331_002_0	1																																																																																																																																																							
H3335	015	0	1	04	01	H3335_015_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1	2	2	1000.00	3		2					2																		2		1	01000000	30.00	30.00															2	2
H3335	018	0	1	04	01	H3335_018_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1	2	2	1000.00	3		2					2																		2		1	01000000	40.00	40.00															2	2
H3335	038	0	1	04	01	H3335_038_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1	2	2	1000.00	3		2					2																		2		1	01000000	30.00	30.00															2	2
H3335	043	0	1	04	01	H3335_043_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1	2	2	1000.00	3		2					2																		2		1	01000000	35.00	35.00															2	2
H3335	044	0	1	04	01	H3335_044_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1	2	2	1000.00	3		2					2																		2		1	01000000	35.00	35.00															2	2
H3335	053	0	1	04	01	H3335_053_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1	2	2	1000.00	3		2					2																		2		1	01000000	35.00	35.00															2	2
H3335	055	0	1	04	01	H3335_055_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1	2	2	1000.00	3		2					2																		2		1	01000000	40.00	40.00															2	2
H3335	056	0	1	04	01	H3335_056_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1	2	2	1000.00	3		2					2																		2		1	01000000	35.00	35.00															2	2
H3335	057	0	1	04	01	H3335_057_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1	2	2	1000.00	3		2					2																		2		1	01000000	35.00	35.00															2	2
H3335	058	0	1	04	01	H3335_058_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1	2	2	1000.00	3		2					2																		2		1	01000000	35.00	35.00															2	2
H3335	801	0	1	04	01	H3335_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3335	811	0	1	04	01	H3335_811_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3335	813	0	1	04	01	H3335_813_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3335	819	0	1	04	01	H3335_819_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3335	820	0	1	04	01	H3335_820_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3335	822	0	1	04	01	H3335_822_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3342	023	1	1	04	01	H3342_023_1	6	2		3					3					3					3																																														2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H3342	023	2	1	04	01	H3342_023_2	6	2		3					3					3					3																																														2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H3344	005	0	1	04	01	H3344_005_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	1	2	1000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	350.00															1	2
H3344	010	0	1	04	01	H3344_010_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	1	2	1000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	30.00	315.00															1	2
H3344	012	0	1	04	01	H3344_012_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	1	2	1000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	40.00	375.00															1	2
H3344	801	0	1	04	01	H3344_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3344	804	0	1	04	01	H3344_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3344	805	0	1	04	01	H3344_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3347	002	0	1	02	01	H3347_002_0	10	1	1110	2	2	1	6	Oral Exams: $0 copayment/ 1 per month/1 every 6 months	2	2	1	4							2	2	1	6	select codes only at $0 copayment/1 every 6 months, $0 copayment / 2 every 6 months, $0 copayment/1 every 36 months, or specific codes at $0 copayment.	2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1001110											2	2	1	6	select codes only at $0 Copayment/ 1 per every 12 months or  60 months, Major Restoratives: Select Codes Only at $0 copayment /1 every 60 months or lifetime, per tooth. Select codes are covered at $0	2	2	1	6	Endodontic ServicesSelect Root Canal Therapy Codes Only at $0 copayment /1 per lifetime, per tooth	2	2	1	6	Periodontics Services Select Codes Only at $0 copayment /1 every 36 months or every 60 months						2	2	1	6	Select Codes Only at $0copayment /1 every 60 months, per tooth; Select Codes Only at $0 copayment /1 per tooth,per lifetime	1		2	1500.00	3		2					1	01000000	20	20															2		1	10001110							0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	2	2
H3347	003	0	1	02	01	H3347_003_0	11	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3347	007	0	1	02	01	H3347_007_0	10	1	0100	2	2	1	4																	2					2				2														2		1	0100					0.00	0.00							2	2	1	1001000											2	2	1	6	Select Codes Only at $0 copayment /1 every 60 months,																2	2	1	6	Select Fixed Partial Denture Pontics and Fixed Partial Denture per arch Retainers Crowns Codes Only at $0 copayment /1 every 60 months, per tooth	2						2					1	01000000	20	20															2		1	10001000							0.00	0.00							0.00	0.00	2	2
H3347	009	0	1	02	01	H3347_009_0	10	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	$0 copay for 1 every 12 or 36 months. Coverage for Preventive Dental is limited to select codes.	2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1001110											2	2	1	6	Select Codes Only at $0 copayment /1 every 6months, 24 months, or 60 months per tooth $50copayment /1 every 60 months per tooth, or$150 copayment /1 every 60 months per tooth	2	2	1	6	Select Codes Only at $0 copayment /1 per lifetime per tooth or $40 copayment /1 per lifetime per tooth	2	2	1	6	$0 copayment / 1 every 36months per quadrant, $40 copayment/1 every 36months per quadrant, Select codes only at $150copayment/1 every 60 months per quadrant						2	2	1	6	See Notes Below	2						2					1	01000000	20	20															2		1	10001110							0.00	150.00	0.00	40.00	0.00	150.00			0.00	150.00	2	2
H3347	015	0	1	02	01	H3347_015_0	9	1	1110	2	2	1	6	Oral Exams: $0 copayment/ 1 per month/1 every 6 months	2	2	1	4							2	2	1	6	select codes only at $0 copayment/1 every 6 months, $0 copayment / 2 every 6 months, $0 copayment/1 every 36 months, or specific codes at $0 copayment.	2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1001110											2	2	1	6	select codes only at $0 Copayment/ 1 per every 12 months or  60 months, Major Restoratives: Select Codes Only at $0 copayment /1 every 60 months or lifetime, per tooth. Select codes are covered at $0	2	2	1	6	Endodontic ServicesSelect Root Canal Therapy Codes Only at $0 copayment /1 per lifetime, per tooth	2	2	1	6	Periodontics Services Select Codes Only at $0 copayment /1 every 36 months or every 60 months						2	2	1	6	Select Codes Only at $0copayment /1 every 60 months, per tooth; Select Codes Only at $0 copayment /1 per tooth,per lifetime	1		2	1500.00	3		2					1	01000000	20	20															2		1	10001110							0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	2	2
H3347	016	0	1	02	01	H3347_016_0	10	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	$0 copay for 1 every 12 or 36 months. Coverage for Preventive Dental limited to select codes.	2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1001110											2	2	1	6	Restorative Services Select Codes Only at $0 copayment /1 every 6 months, 24 months, or 60 months per tooth	2	2	1	6	Endodontic Services Select Codes Only at $0 copayment /1 per lifetime per tooth	2	2	1	6	Periodontic Services Select Codes Only at $0 copayment /1 every 36 months per quadrant/ $0 copayment 1/ every 60 months per quadrant.						2	2	1	6	See Notes Below	1		2	1500.00	3		2					1	01000000	20	20															2		1	10001110							0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	2	2
H3347	018	0	1	02	01	H3347_018_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3351	001	0	1	02	01	H3351_001_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1		2	1000.00	3		2					2																		2		1	01000000	35.00	35.00															2	2
H3351	002	0	1	02	01	H3351_002_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1		2	1000.00	3		2					2																		2		1	01000000	25.00	25.00															2	2
H3351	006	0	1	02	01	H3351_006_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1		2	1000.00	3		2					2																		2		1	01000000	30.00	30.00															2	2
H3351	007	0	1	02	01	H3351_007_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1		2	1000.00	3		2					2																		2		1	01000000	35.00	35.00															2	2
H3351	012	0	1	02	01	H3351_012_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1		2	1000.00	3		2					2																		2		1	01000000	35.00	35.00															2	2
H3351	013	0	1	02	01	H3351_013_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1		2	1000.00	3		2					2																		2		1	01000000	30.00	30.00															2	2
H3351	016	0	1	01	01	H3351_016_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1		2	1000.00	3		2					2																		2		1	01000000	45.00	45.00															2	2
H3351	017	0	1	01	01	H3351_017_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1		2	1000.00	3		2					2																		2		1	01000000	35.00	35.00															2	2
H3351	018	0	1	02	01	H3351_018_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1		2	1000.00	3		2					2																		2		1	01000000	40.00	40.00															2	2
H3351	019	0	1	02	01	H3351_019_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1		2	1000.00	3		2					2																		2		1	01000000	30.00	30.00															2	2
H3351	020	0	1	01	01	H3351_020_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1		2	1000.00	3		2					2																		2		1	01000000	45.00	45.00															2	2
H3351	021	0	1	01	01	H3351_021_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	2	2	3		2	1				2	1				1		2	1000.00	3		2					2																		2		1	01000000	50.00	50.00															2	2
H3351	801	0	1	02	01	H3351_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3351	802	0	1	02	01	H3351_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3351	803	0	1	02	01	H3351_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3351	804	0	1	02	01	H3351_804_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3351	805	0	1	02	01	H3351_805_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3351	806	0	1	02	01	H3351_806_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3359	001	0	1	01	01	H3359_001_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Dental X-rays: 1 set per year	1		2000.00	3		2				2		2												2		2		2												1	2	1	1111111	2	2	1	6	Limits vary by procedure.	2	2	1	6	Limits vary by procedure.	2	2	1	6	Restorative Services: Limits vary by procedure, ranging from once every 24 months to once every 60 months per tooth.	2	2	1	6	Endodontics are limited to one surgery per tooth per lifetime.	2	2	1	6	Limits vary by procedure. Periodontic scaling and root planing is covered once every 24 months, per area.	2	2	1	6	Extractions are limited to one surgery per tooth per lifetime.	2	2	1	6	Prosthodontic limits vary by procedure. Dentures are limited to one set every 5 years. Crowns are limited to once every 5 years for each tooth.	1		1				2					2																		2		2																		1	2
H3359	019	0	1	01	01	H3359_019_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Dental X-rays: 1 set per year	2					2				2		2												2		2		2												1	2	1	1111111	2	2	1	6	Limits vary by procedure.	2	2	1	6	Limits vary by procedure.	2	2	1	6	Restorative Services: Fillings are limited to once every 12 months for the same tooth/tooth surface.	2	2	1	6	Endodontics are limited to one surgery per tooth per lifetime.	2	2	1	6	Periodontics are limited. Periodontic scaling and root planing is only covered once every 24 months, only 2 quadrants will be reimbursed on the same date of service.	2	2	1	6	Extractions are limited to one surgery per tooth per lifetime.	2	2	1	6	Prosthodontic limits vary by procedure. Dentures are limited to one set every 5 years. Crowns are limited to once every 5 years for each tooth.	2						2					2																		2		2																		1	2
H3359	021	0	1	01	01	H3359_021_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Dental X-rays: 1 set per year	2					2				2		2												2		2		2												1	2	1	1111111	2	2	1	6	Limits vary by procedure.	2	2	1	6	Limits vary by procedure.	2	2	1	6	Restorative Services: Fillings are limited to once every 12 months for the same tooth/tooth surface.	2	2	1	6	Endodontics are limited to one surgery per tooth per lifetime.	2	2	1	6	Periodontics are limited. Periodontic scaling and root planing is only covered once every 24 months, only 2 quadrants will be reimbursed on the same date of service.	2	2	1	6	Extractions are limited to one surgery per tooth per lifetime.	2	2	1	6	Prosthodontic limits vary by procedure. Dentures are limited to one set every 5 years. Crowns are limited to once every 5 years for each tooth.	2						2					2																		2		2																		1	2
H3359	034	0	1	01	01	H3359_034_0	11	2																																																															1	1111110	2	2	1	6	Certain services require authorization from Healthfirst dental vendor. Other benefit limitations and exclusions may apply to additional comprehensive services.	2	2	2	6	Bitewings and Cone Beam CT limited to 1 per 6 months. Evaluations are 2 per 12 months. Certain services require authorization. Other benefit limitations and exclusions may apply.	2	2	1	6	Fillings are limited to once every 12 months per tooth per surface. Certain services require authorization from Healthfirst vendor. Other benefit limitations and exclusions may apply.	2	2	1	6	Endodontics are limited to one surgery per tooth per lifetime. Certain services require authorization from Healthfirst dental vendor. Other benefit limitations and exclusions may apply.	2	2	1	6	Periodontics is limited. Gingivectomy, including gingival flap procedures, limited to 1 per 36 months per tooth. Certain services require authorization from Healthfirst dental vendor.						2	2	1	6	Dentures are limited to one set every 5 years. Crowns are limited to once every 5 years per tooth. Certain services require authorization from Healthfirst dental vendor.	2						2					2																		2		2																		1	2
H3359	038	0	1	01	01	H3359_038_0	12	2																																																															2																																											2					2																		2		2																		1	2
H3359	808	0	1	01	01	H3359_808_0	8	2																																																															2																																											2					2																		2		2																		1	2
H3359	809	0	1	01	01	H3359_809_0	8	2																																																															2																																											2					2																		2		2																		1	2
H3362	016	0	1	01	01	H3362_016_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	1		1000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	10.00	100.00															1	2
H3362	017	0	1	01	01	H3362_017_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	1		2000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	20.00	325.00															1	2
H3362	020	0	1	01	01	H3362_020_0	7	2																																																															2																																											2					1	01000000	10	10															2		1	01000000	0.00	100.00															1	2
H3362	033	0	1	01	01	H3362_033_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	1		2000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	30.00	325.00															1	2
H3362	038	0	1	01	01	H3362_038_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	1		2000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	40.00	325.00															1	2
H3362	039	0	1	01	01	H3362_039_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	2																																											2					2																		2		1	01000000	45.00	475.00															1	2
H3362	040	0	1	01	01	H3362_040_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	1		1500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	20.00	350.00															1	2
H3362	801	0	1	01	01	H3362_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3362	807	0	1	02	01	H3362_807_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3362	819	0	1	02	01	H3362_819_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3362	820	0	1	01	01	H3362_820_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3362	822	0	1	02	01	H3362_822_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3379	001	0	1	02	01	H3379_001_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H3379	002	0	1	01	01	H3379_002_0	5	2																																																															2																																											2					1	01000000	0	20															2		2																		1	2
H3379	022	0	1	02	01	H3379_022_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3379	039	0	1	02	01	H3379_039_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3379	040	0	1	02	01	H3379_040_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3379	041	0	1	02	01	H3379_041_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3379	043	0	1	02	01	H3379_043_0	4	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H3379	045	0	1	02	01	H3379_045_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3379	046	0	1	02	01	H3379_046_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H3379	050	0	1	02	01	H3379_050_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H3379	051	0	1	02	01	H3379_051_0	5	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H3384	013	0	1	01	01	H3384_013_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	2	2	3		2	1									1		2	2000.00	3		2					1	00011111					50	50	50	50	50	50	0	50	50	50			2		1	01000000	26.00	26.00															2	2
H3384	019	0	1	01	01	H3384_019_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	2	2	3		2	1									1		2	2000.00	3		2					1	00011111					50	50	50	50	50	50	0	50	50	50			2		1	01000000	25.00	25.00															2	2
H3384	022	0	1	01	01	H3384_022_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	2	2	3		2	1									1		2	2000.00	3		2					1	00011111					50	50	50	50	50	50	0	50	50	50			2		1	01000000	45.00	45.00															2	2
H3384	058	0	1	01	01	H3384_058_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	2	2	3		2	1									1		2	2000.00	3		2					1	00011111					50	50	50	50	50	50	0	50	50	50			2		1	01000000	30.00	30.00															2	2
H3384	059	0	1	01	01	H3384_059_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	2	2	3		2	1									1		2	2000.00	3		2					1	00011111					50	50	50	50	50	50	0	50	50	50			2		1	01000000	35.00	35.00															2	2
H3384	062	0	1	01	01	H3384_062_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	2	2	3		2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	0	50	50	50	50	50	2		1	01000000	30.00	30.00															2	2
H3384	063	0	1	01	01	H3384_063_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	2	2	3		2	1									1		2	2000.00	3		2					1	00011111					50	50	50	50	50	50	0	50	50	50			2		1	01000000	35.00	35.00															2	2
H3384	067	0	1	01	01	H3384_067_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		1000.00	3		2				2		2												2		1	1111	2				20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	2	2	3		2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000010	40.00	40.00									20.00	20.00					2	2
H3384	805	0	1	01	01	H3384_805_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3384	806	0	1	01	01	H3384_806_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3384	811	0	1	02	01	H3384_811_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3384	812	0	1	02	01	H3384_812_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3384	813	0	1	01	01	H3384_813_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3387	013	0	1	01	01	H3387_013_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3387	014	1	1	02	01	H3387_014_1	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3387	014	2	1	02	01	H3387_014_2	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3387	015	1	1	02	01	H3387_015_1	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3387	015	2	1	02	01	H3387_015_2	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3388	001	0	1	01	01	H3388_001_0	3	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															2	2
H3388	002	0	1	01	01	H3388_002_0	6	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															2	1
H3388	004	0	1	01	01	H3388_004_0	5	1	1111	2	1				2	1				2	1				2	1				1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															2	2
H3388	013	0	1	01	01	H3388_013_0	5	1	1111	2	1				2	1				2	1				2	1				1		1450.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	1
H3388	014	0	1	01	01	H3388_014_0	5	1	1111	2	1				2	1				2	1				2	1				1		1225.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															2	1
H3388	018	0	1	01	01	H3388_018_0	7	1	1111	2	1				2	1				2	1				2	1				1		925.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															2	1
H3388	801	0	1	01	01	H3388_801_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3388	803	0	1	01	01	H3388_803_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3388	804	0	1	01	01	H3388_804_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3404	003	1	1	04	01	H3404_003_1	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	See detailed benefit description below.	1	1	2000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	1		1				2					2																		2		1	11001111	15.00	15.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3404	003	2	1	04	01	H3404_003_2	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	See detailed benefit description below.	1	1	2000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	1		1				2					2																		2		1	11001111	25.00	25.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3404	004	0	1	04	01	H3404_004_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3404	801	0	1	04	01	H3404_801_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3404	810	0	1	04	01	H3404_810_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3404	811	0	1	04	01	H3404_811_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3407	001	0	1	01	01	H3407_001_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		1		4000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H3416	001	6	1	04	01	H3416_001_6	4	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001000							0	50							0	50	2		1	01000000	35.00	35.00															2	2
H3416	001	7	1	04	01	H3416_001_7	4	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001000							0	50							0	50	2		1	01000000	35.00	35.00															2	2
H3416	002	4	1	04	01	H3416_002_4	5	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001000							0	50							0	50	2		1	01000000	20.00	20.00															2	2
H3416	002	5	1	04	01	H3416_002_5	5	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001000							0	50							0	50	2		1	01000000	20.00	20.00															2	2
H3416	801	0	1	04	01	H3416_801_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3416	803	0	1	04	01	H3416_803_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3418	001	0	1	04	01	H3418_001_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H3418	002	0	1	04	01	H3418_002_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H3418	003	0	1	04	01	H3418_003_0	5	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H3418	004	0	1	04	01	H3418_004_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3418	005	0	1	04	01	H3418_005_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3418	006	0	1	04	01	H3418_006_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H3418	007	0	1	04	01	H3418_007_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3418	008	0	1	04	01	H3418_008_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3418	009	0	1	04	01	H3418_009_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3418	010	0	1	04	01	H3418_010_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H3419	001	0	1	01	01	H3419_001_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		1				2					1	01000000	20	20															2		2																		1	2
H3419	003	0	1	01	01	H3419_003_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		1				2					1	01000000	20	20															2		2																		1	2
H3419	004	0	1	01	01	H3419_004_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	1		2400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		1				2					1	01000000	20	20															2		2																		1	2
H3430	001	0	1	20	08	H3430_001_0	1																																																																																																																																																							
H3430	002	0	1	20	08	H3430_002_0	1																																																																																																																																																							
H3443	001	0	1	01	01	H3443_001_0	16	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1		2000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H3443	002	0	1	01	01	H3443_002_0	16	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1		2000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H3443	003	0	1	01	01	H3443_003_0	14	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H3443	005	0	1	01	01	H3443_005_0	12	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3					3											2					2																		2		2																		2	2
H3443	006	0	1	01	01	H3443_006_0	13	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1		4000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H3443	801	0	1	01	01	H3443_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3443	802	0	1	01	01	H3443_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3443	803	0	1	01	01	H3443_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3443	804	0	1	01	01	H3443_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3447	001	0	1	01	01	H3447_001_0	8	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	003	0	1	01	01	H3447_003_0	7	1	1111	4	1				4	1				4	1				4	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	004	0	1	01	01	H3447_004_0	6	1	1111	4	1				4	1				4	1				4	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	005	0	1	01	01	H3447_005_0	6	2		3					3					3					3																																														2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	40.00															1	2
H3447	010	0	1	01	01	H3447_010_0	6	1	1111	4	1				4	1				4	1				4	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	011	0	1	01	01	H3447_011_0	6	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	013	0	1	01	01	H3447_013_0	8	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	018	0	1	01	01	H3447_018_0	6	1	1111	2	1				2	1				2	1				2	1				1		5500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	020	0	1	01	01	H3447_020_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	024	0	1	01	01	H3447_024_0	11	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	025	0	1	01	01	H3447_025_0	7	1	1111	4	1				4	1				4	1				4	1				1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	026	0	1	01	01	H3447_026_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	028	0	1	01	01	H3447_028_0	7	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	030	0	1	01	01	H3447_030_0	6	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	033	0	1	01	01	H3447_033_0	6	1	1111	4	1				4	1				4	1				4	1				1		1800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	037	0	1	01	01	H3447_037_0	8	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	038	1	1	01	01	H3447_038_1	7	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	038	2	1	01	01	H3447_038_2	8	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	039	0	1	01	01	H3447_039_0	8	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	042	1	1	01	01	H3447_042_1	9	1	1111	4	1				4	1				4	1				4	1				1		1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	042	2	1	01	01	H3447_042_2	9	1	1111	4	1				4	1				4	1				4	1				1		1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	042	3	1	01	01	H3447_042_3	10	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	042	4	1	01	01	H3447_042_4	9	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	043	0	1	01	01	H3447_043_0	10	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	044	0	1	01	01	H3447_044_0	7	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	045	0	1	01	01	H3447_045_0	6	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	046	0	1	01	01	H3447_046_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	047	0	1	01	01	H3447_047_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	048	0	1	01	01	H3447_048_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3447	804	0	1	01	01	H3447_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	805	0	1	01	01	H3447_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	806	0	2	01	01	H3447_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	807	0	2	01	01	H3447_807_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	809	0	1	01	01	H3447_809_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	811	0	1	01	01	H3447_811_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	812	0	1	01	01	H3447_812_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	813	0	2	01	01	H3447_813_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	814	0	2	01	01	H3447_814_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	816	0	1	01	01	H3447_816_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	818	0	1	01	01	H3447_818_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	819	0	1	01	01	H3447_819_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	820	0	2	01	01	H3447_820_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	821	0	2	01	01	H3447_821_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	823	0	1	01	01	H3447_823_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	825	0	2	01	01	H3447_825_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	826	0	2	01	01	H3447_826_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3447	827	0	2	01	01	H3447_827_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3449	012	0	1	02	01	H3449_012_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	See detailed benefit description below.	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	1	1001111											2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	1		1				2					2																		2		1	11001111	25.00	25.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3449	023	1	1	02	01	H3449_023_1	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	See detailed benefit description below.	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	1	1001111											2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	1		1				2					2																		2		1	11001111	15.00	15.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3449	023	2	1	02	01	H3449_023_2	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	See detailed benefit description below.	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	1	1001111											2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	1		1				2					2																		2		1	11001111	15.00	15.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3449	023	4	1	02	01	H3449_023_4	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	See detailed benefit description below.	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	1	1001111											2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	1		1				2					2																		2		1	11001111	25.00	25.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3449	023	5	1	02	01	H3449_023_5	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	See detailed benefit description below.	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	1	1001111											2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	1		1				2					2																		2		1	11001111	25.00	25.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3449	024	1	1	02	01	H3449_024_1	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	See detailed benefit description below.	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	1	1001111											2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	1		1				2					2																		2		1	11001111	15.00	15.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3449	024	2	1	02	01	H3449_024_2	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	See detailed benefit description below.	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	1	1001111											2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	1		1				2					2																		2		1	11001111	15.00	15.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3449	024	3	1	02	01	H3449_024_3	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	See detailed benefit description below.	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	1	1001111											2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	2	1				2	2	1	6	See detailed benefit description below.	1		1				2					2																		2		1	11001111	15.00	15.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3449	026	0	1	01	01	H3449_026_0	11	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1000010																					2	2	2	3							2	2	1	3		2						2					2																		2		1	11000010	10.00	10.00									0.00	0.00			0.00	0.00	1	2
H3449	027	1	1	01	01	H3449_027_1	10	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1000010																					2	2	2	3							2	2	1	3		2						2					2																		2		1	11000010	45.00	45.00									0.00	0.00			0.00	0.00	1	2
H3449	027	2	1	01	01	H3449_027_2	10	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1000010																					2	2	2	3							2	2	1	3		2						2					2																		2		1	11000010	45.00	45.00									0.00	0.00			0.00	0.00	1	2
H3449	805	0	1	01	01	H3449_805_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3449	814	0	1	01	01	H3449_814_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3449	815	0	1	01	01	H3449_815_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3467	001	0	1	02	01	H3467_001_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		2					2				2		2												2		2		2												2	2	2																																											2					1	01000000	20	20															2		2																		1	2
H3471	001	0	1	01	01	H3471_001_0	7	1	1111	2	1				2	1				2	1				2	1				1		250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															2	2
H3471	002	0	1	01	01	H3471_002_0	6	1	1111	2	1				2	1				2	1				2	1				1		250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															2	2
H3471	003	0	1	01	01	H3471_003_0	5	1	1111	2	1				2	1				2	1				2	1				1		200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															2	2
H3471	004	0	1	01	01	H3471_004_0	6	1	1111	2	1				2	1				2	1				2	1				1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10101111			20	20			20	20	20	20	20	20	20	20	20	50	2		1	01000000	50.00	50.00															2	2
H3471	005	0	1	01	01	H3471_005_0	5	1	1111	2	1				2	1				2	1				2	1				1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10101111			20	20			20	20	20	20	20	20	20	20	20	50	2		1	01000000	50.00	50.00															2	2
H3471	006	0	1	01	01	H3471_006_0	4	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10101111			20	20			20	20	20	20	20	20	20	20	20	50	2		1	01000000	50.00	50.00															2	2
H3471	010	0	1	01	01	H3471_010_0	6	1	1111	2	1				2	1				2	1				2	1				1		250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															2	2
H3471	017	0	1	01	01	H3471_017_0	6	1	1111	2	1				2	1				2	1				2	1				1		225.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															2	2
H3471	018	0	1	02	01	H3471_018_0	6	1	1111	2	1				2	1				2	1				2	1				1		250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															2	2
H3471	019	0	1	02	01	H3471_019_0	6	1	1111	2	1				2	1				2	1				2	1				1		750.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															2	2
H3471	801	0	1	01	01	H3471_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3471	802	0	1	01	01	H3471_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3471	803	0	1	01	01	H3471_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3471	804	0	1	02	01	H3471_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3471	805	0	1	02	01	H3471_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3471	806	0	1	02	01	H3471_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3473	001	0	1	20	08	H3473_001_0	1																																																																																																																																																							
H3473	002	0	1	20	08	H3473_002_0	1																																																																																																																																																							
H3493	001	0	1	20	08	H3493_001_0	1																																																																																																																																																							
H3493	002	0	1	20	08	H3493_002_0	1																																																																																																																																																							
H3499	002	0	1	01	01	H3499_002_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	35.00	35.00															1	2
H3499	005	0	1	01	01	H3499_005_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3499	008	0	1	01	01	H3499_008_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3517	001	0	1	20	08	H3517_001_0	1																																																																																																																																																							
H3517	002	0	1	20	08	H3517_002_0	1																																																																																																																																																							
H3522	001	0	1	20	08	H3522_001_0	1																																																																																																																																																							
H3522	002	0	1	20	08	H3522_002_0	1																																																																																																																																																							
H3528	003	0	1	02	01	H3528_003_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	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	1	1111111	2	1				2	1				2	2	1	6	Restorations: 1 filing per tooth per year	2	2	1	6	Endodontics: 1 per tooth per lifetime	2	2	1	6	Periodontics: 1 every 36 months per quadrant	2	2	1	6	Extractions: 1 per tooth per lifetime	2	2	1	6	Prosthodontics: Oral/Maxillofacial Surgery 1 every 5 years	1		2	3000.00	3		2					1	10111111			20	20	20	20	20	20	50	50	50	50	50	50	50	50	1	100.00	1	01000000	10.00	10.00															1	2
H3528	010	0	1	02	01	H3528_010_0	12	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	45.00	45.00															2	2
H3528	011	1	1	02	01	H3528_011_1	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	50.00	50.00															2	2
H3528	011	2	1	02	01	H3528_011_2	11	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	50.00	50.00															2	2
H3528	014	0	1	02	01	H3528_014_0	12	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	45.00	45.00															2	2
H3528	015	0	1	02	01	H3528_015_0	10	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	35.00	35.00															2	2
H3528	016	0	1	02	01	H3528_016_0	10	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	30.00	30.00															2	2
H3528	801	0	1	01	01	H3528_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3528	805	0	1	01	01	H3528_805_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3528	806	0	1	02	01	H3528_806_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3528	807	0	1	02	01	H3528_807_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3533	002	0	1	01	01	H3533_002_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	root canal&root canal retreatment- 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		2	1000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3533	006	0	1	01	01	H3533_006_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					1	00010000					0	0											2		1	01001010	35.00	35.00					25.00	25.00			25.00	25.00					1	2
H3533	010	0	1	01	01	H3533_010_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		1500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	6	6	Fillings $25 2 per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	2	2	3		4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	50.00	50.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H3533	013	0	1	01	01	H3533_013_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	6	6	Fillings $25 2 per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	2	2	3		2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	30.00	30.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H3533	027	0	1	01	01	H3533_027_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Bitewing X-Rays - 1 set(s) per year, Intraoral X-Rays - 1 set(s) per year,Panoramic Film or Diagnostic X-Rays - 1 every 5 years	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					2	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
H3533	032	1	1	01	01	H3533_032_1	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	6	6	Fillings $25 2 per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	2	2	3		2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	45.00	45.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H3533	032	2	1	01	01	H3533_032_2	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3533	033	0	1	01	01	H3533_033_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H3533	034	1	1	01	01	H3533_034_1	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0011010						2	2	1	1		2	1									2	2	2	1												1		1				2					1	01000000	20	20															2		1	00011010					0.00	0.00	0.00	0.00			0.00	0.00					1	2
H3533	034	2	1	01	01	H3533_034_2	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010						2	2	1	1		2	1									2	2	2	1												1		1				2					1	01000000	20	20															2		1	00011010					0.00	0.00	0.00	0.00			0.00	0.00					1	2
H3533	802	0	1	01	01	H3533_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3533	803	0	1	01	01	H3533_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3533	805	0	1	01	01	H3533_805_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3533	806	0	1	01	01	H3533_806_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3536	002	0	1	01	01	H3536_002_0	9	1	1111	4	1				4	1				4	1				4	1				1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3536	004	0	1	01	01	H3536_004_0	8	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3536	006	0	1	01	01	H3536_006_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3536	801	0	1	01	01	H3536_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3536	802	0	1	01	01	H3536_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3536	803	0	2	01	01	H3536_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3536	804	0	2	01	01	H3536_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3536	806	0	1	01	01	H3536_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3536	808	0	2	01	01	H3536_808_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3551	001	0	1	01	01	H3551_001_0	8	1	1111	2	1				2	1				2	1				2	1				1		4500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															2	2
H3551	002	0	1	01	01	H3551_002_0	8	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															2	2
H3551	003	0	1	02	01	H3551_003_0	6	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H3554	002	0	1	04	01	H3554_002_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	1	2	2000.00	3		2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001011											2	2	1	3							2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	2	1				2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1		1				2					1	10001011							20	20			20	20	20	20	20	20	2		1	01000000	30.00	30.00															2	2
H3554	007	0	1	04	01	H3554_007_0	4	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	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	1	1001111											2	2	2	3		2	2	1	3		2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	2	1				2	2	2	6	Periodicities for covered services range from every year to every five years depending on the service.	1		1				2					1	10001111							20	20	20	20	20	20	20	20	20	20	2		1	01000000	30.00	30.00															2	2
H3554	011	0	1	04	01	H3554_011_0	2	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	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	1	1001111											2	2	2	3		2	2	1	3		2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	2	1				2	2	2	6	Periodicities for covered services range from every year to every five years depending on the service.	1		1				2					1	10001111							20	20	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H3554	801	0	1	04	01	H3554_801_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3554	802	0	1	04	01	H3554_802_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3554	803	0	1	04	01	H3554_803_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3554	804	0	1	04	01	H3554_804_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3557	001	0	1	04	01	H3557_001_0	9	1	1111	2	2	1	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing X-rays - 1 set per calendar yearIndividual X-rays - 4 per calendar yearFull mouth series or Panorex - 1 per 60 month period	1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H3557	801	0	1	04	01	H3557_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3557	802	0	1	04	01	H3557_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3557	803	0	1	04	01	H3557_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3561	001	0	1	01	01	H3561_001_0	17	2																																																															1	1001000											2	2	1	6	Every 5 years																2	2	1	6	Every 2 to 5 years	2						2					1	01000000	20	20															2		1	10001000							0.00	0.00							0.00	0.00	1	2
H3561	007	0	1	01	01	H3561_007_0	17	2																																																															1	1001000											2	2	1	6	Every 5 years																2	2	1	6	Every 2 to 5 years	2						2					1	01000000	20	20															2		1	10001000							0.00	0.00							0.00	0.00	1	2
H3561	008	0	1	01	01	H3561_008_0	17	2																																																															1	1001000											2	2	1	6	Every 5 years																2	2	1	6	Every 2 to 5 years	2						2					1	01000000	20	20															2		1	10001000							0.00	0.00							0.00	0.00	1	2
H3561	009	0	1	01	01	H3561_009_0	17	2																																																															1	1001000											2	2	1	6	Every 5 years																2	2	1	6	Every 2 to 5 years	2						2					1	01000000	20	20															2		1	10001000							0.00	0.00							0.00	0.00	1	2
H3563	001	0	1	20	08	H3563_001_0	1																																																																																																																																																							
H3563	002	0	1	20	08	H3563_002_0	1																																																																																																																																																							
H3597	001	0	1	01	01	H3597_001_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3597	007	0	1	01	01	H3597_007_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3597	009	0	1	01	01	H3597_009_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3597	011	0	1	02	01	H3597_011_0	8	1	1111	2	1				2	1				2	1				2	1				1		2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3597	012	0	1	02	01	H3597_012_0	8	1	1111	2	1				2	1				2	1				2	1				1		2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3597	014	0	1	01	01	H3597_014_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3597	801	0	1	01	01	H3597_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3597	802	0	1	01	01	H3597_802_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3613	001	0	1	20	08	H3613_001_0	1																																																																																																																																																							
H3613	002	0	1	20	08	H3613_002_0	1																																																																																																																																																							
H3653	004	0	1	02	01	H3653_004_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		7500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	2	6	N/A	2	2	1	6	Amalgam and Resin based composites are limited to one procedure per tooth every 3 years.	2	2	1	6	Select endodontics procedures will only be eligible for retreatment every 4 years per the details in the evidence of coverage.	2	2	1	6	Periodontics Scaling and root planning procedures requires submission of supporting documentation and subject to utilization review. Must contain 4 teeth with 4+MM pockets, covered every 3 years.	2	2	1	6	Extractions	2	1				1		1				2					1	11111111	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2
H3653	015	0	1	02	01	H3653_015_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		7500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	2	6	N/A	2	2	1	6	Amalgam and Resin based composites are limited to one procedure per tooth every 3 years.	2	2	1	6	Select endodontics procedures will only be eligible for retreatment every 4 years per the details in the evidence of coverage.	2	2	1	6	Periodontics Scaling and root planning procedures requires submission of supporting documentation and subject to utilization review. Must contain 4 teeth with 4+MM pockets, covered every 3 years.	2	2	1	6	Extractions	2	1				1		1				2					1	11111111	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2
H3653	018	0	1	02	01	H3653_018_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		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	1	1111111	2	1				2	2	2	6	Diagnostic intraoral evaluations are limited to two evaluations within any consecutive 12-month benefit plan year period. Complete series of radiographic images covered are limited to 1 per 5 years.	2	2	1	6	Amalgam and Resin based composites are limited to one procedure per tooth every 3 years.	2	2	1	6	Endodontic therapy is limited to one procedure per tooth per lifetime.	2	2	1	6	Periodontic scaling and root planing procedures requires submission of supporting documentation and subject to Utilization Review. Must contain 4 teeth with 4+MM pockets. These procedures are covered	2	2	1	6	Extractions	2	1				1		1				2					1	11111111	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2
H3653	022	0	1	02	01	H3653_022_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		7500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	2	6	N/A	2	2	1	6	Amalgam and Resin based composites are limited to one procedure per tooth every 3 years.	2	2	1	6	Select endodontics procedures will only be eligible for retreatment every 4 years per the details in the evidence of coverage.	2	2	1	6	Periodontics Scaling and root planning procedures requires submission of supporting documentation and subject to utilization review. Must contain 4 teeth with 4+MM pockets, covered every 3 years. Peri	2	2	1	3		2	1				1		1				2					1	11111111	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2
H3653	024	0	1	02	01	H3653_024_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		7500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	2	6	N/A	2	2	1	6	Amalgam and Resin based composites are limited to one procedure per tooth every 3 years.	2	2	1	6	Select endodontics procedures will only be eligible for retreatment every 4 years per the details in the evidence of coverage.	2	2	1	6	Periodontics Scaling and root planning procedures requires submission of supporting documentation and subject to utilization review. Must contain 4 teeth with 4+MM pockets, covered every 3 years.	2	2	1	6	Extractions	2	1				1		1				2					1	11111111	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2
H3653	026	0	1	02	01	H3653_026_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		7500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	2	6	N/A	2	2	1	6	Amalgam and Resin based composites are limited to one procedure per tooth every 3 years.	2	2	1	6	Select endodontics procedures will only be eligible for retreatment every 4 years per the details in the evidence of coverage.	2	2	1	6	Periodontics Scaling and root planning procedures requires submission of supporting documentation and subject to utilization review. Must contain 4 teeth with 4+MM pockets, covered every 3 years.	2	2	1	6	Extractions	2	1				1		1				2					1	11111111	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2
H3653	027	0	1	02	01	H3653_027_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		7500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	2	6	N/A	2	2	1	6	Amalgam and Resin based composites are limited to one procedure per tooth every 3 years.	2	2	1	6	Select endodontics procedures will only be eligible for retreatment every 4 years per the details in the evidence of coverage.	2	2	1	6	Periodontics Scaling and root planning procedures requires submission of supporting documentation and subject to utilization review. Must contain 4 teeth with 4+MM pockets, covered every 3 years.	2	2	1	6	Extractions	2	1				1		1				2					1	11111111	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2
H3653	803	0	1	01	01	H3653_803_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3653	806	0	2	01	01	H3653_806_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3653	809	0	1	01	01	H3653_809_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3655	033	0	1	01	01	H3655_033_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3655	034	0	1	01	01	H3655_034_0	10	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3655	041	0	1	01	01	H3655_041_0	9	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3655	042	0	1	01	01	H3655_042_0	9	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3655	045	1	1	01	01	H3655_045_1	10	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3655	045	2	1	01	01	H3655_045_2	10	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3655	045	3	1	01	01	H3655_045_3	9	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3655	045	4	1	01	01	H3655_045_4	14	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3655	047	0	1	01	01	H3655_047_0	10	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3655	048	0	1	01	01	H3655_048_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3655	801	0	1	01	01	H3655_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3655	803	0	1	01	01	H3655_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3655	805	0	2	01	01	H3655_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3655	806	0	2	01	01	H3655_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3655	808	0	1	01	01	H3655_808_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3655	810	0	2	01	01	H3655_810_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3660	028	0	1	02	01	H3660_028_0	7	1	1111	4	2	2	3		4	2	2	3		4	2	1	3		4	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	1		2000.00	3		2				2		2												2		2		2												2	2	1	1011101						4	1				4	1				4	1				3					4	1				4	1				1		1				2					1	10001101							50	70	50	50			50	50	70	70	2		2																		2	2
H3660	029	0	1	02	01	H3660_029_0	7	1	1111	4	2	2	3		4	2	2	3		4	2	1	3		4	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	1		2000.00	3		2				2		2												2		2		2												2	2	1	1011101						4	1				4	1				4	1				3					4	1				4	1				1		1				2					1	10001101							50	70	50	50			50	50	70	70	2		2																		2	2
H3660	044	0	1	01	01	H3660_044_0	7	1	1111	4	2	2	3		4	2	2	3		4	2	1	3		4	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011101						4	1				4	1				4	1				3					4	1				3					1		1				2					1	00011101					50	50	50	50	50	50			50	50			2		2																		2	2
H3660	050	0	1	01	01	H3660_050_0	9	1	1111	4	2	2	3		4	2	2	3		4	2	1	3		4	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1011101						4	1				4	1				4	1				3					4	1				4	1				1		1				2					1	10001000							0	20							20	20	2		2																		2	2
H3660	052	1	1	01	01	H3660_052_1	7	1	1111	4	2	2	3		4	2	2	3		4	2	1	3		4	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	1		2000.00	3		2				2		2												2		2		2												2	2	1	1011101						4	1				4	1				4	1				3					4	1				4	1				1		1				2					1	10001000							0	50							50	50	2		2																		2	2
H3660	052	2	1	01	01	H3660_052_2	7	1	1111	4	2	2	3		4	2	2	3		4	2	1	3		4	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	1		2000.00	3		2				2		2												2		2		2												2	2	1	1011101						4	1				4	1				4	1				3					4	1				4	1				1		1				2					1	10001000							0	50							50	50	2		2																		2	2
H3660	053	1	1	01	01	H3660_053_1	9	1	1111	4	2	2	3		4	2	2	3		4	2	1	3		4	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	1		2000.00	3		2				2		2												2		2		2												2	2	1	1011111						4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					1	10001000							0	40							0	40	2		2																		2	2
H3660	053	2	1	01	01	H3660_053_2	9	1	1111	4	2	2	3		4	2	2	3		4	2	1	3		4	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	1		2000.00	3		2				2		2												2		2		2												2	2	1	1011111						4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					1	10001000							0	40							0	40	2		2																		2	2
H3660	056	1	1	01	01	H3660_056_1	9	1	1111	4	2	2	3		4	2	2	3		4	2	1	3		4	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1011101						4	1				4	1				4	1				3					4	1				4	1				1		1				2					1	10001000							0	20							20	20	2		2																		2	2
H3660	056	2	1	01	01	H3660_056_2	10	1	1111	4	2	2	3		4	2	2	3		4	2	1	3		4	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1011101						4	1				4	1				4	1				3					4	1				4	1				1		1				2					1	10001000							0	20							20	20	2		2																		2	2
H3660	801	0	1	01	01	H3660_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3660	802	0	1	01	01	H3660_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3660	805	0	1	02	01	H3660_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3660	806	0	1	02	01	H3660_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3664	014	0	1	02	01	H3664_014_0	10	1	1111	2	1				2	1				2	1				2	1				1		1100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H3664	017	0	1	02	01	H3664_017_0	13	1	1111	2	1				2	1				2	1				2	1				1		1150.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H3664	020	0	1	02	01	H3664_020_0	13	1	1111	2	1				2	1				2	1				2	1				1		850.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H3664	021	0	1	02	01	H3664_021_0	13	1	1111	2	1				2	1				2	1				2	1				1		600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H3664	023	0	1	02	01	H3664_023_0	13	1	1111	2	1				2	1				2	1				2	1				1		600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H3664	801	0	1	02	01	H3664_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3664	802	0	1	02	01	H3664_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3664	803	0	1	02	01	H3664_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3664	805	0	2	02	01	H3664_805_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3664	806	0	2	02	01	H3664_806_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3664	807	0	1	02	01	H3664_807_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3668	013	0	1	01	01	H3668_013_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	30.00	30.00			0.00	0.00											2	2
H3668	018	1	1	01	01	H3668_018_1	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	30.00	30.00			0.00	0.00											2	2
H3668	018	2	1	01	01	H3668_018_2	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	30.00	30.00			0.00	0.00											2	2
H3668	019	1	1	01	01	H3668_019_1	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	35.00	35.00			0.00	0.00											2	2
H3668	019	2	1	01	01	H3668_019_2	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	35.00	35.00			0.00	0.00											2	2
H3668	020	0	1	01	01	H3668_020_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	35.00	35.00			0.00	0.00											2	2
H3668	022	0	1	01	01	H3668_022_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	35.00	35.00			0.00	0.00											2	2
H3668	023	0	1	01	01	H3668_023_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	35.00	35.00			0.00	0.00											2	2
H3668	025	0	1	01	01	H3668_025_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	30.00	30.00			0.00	0.00											2	2
H3668	026	0	1	01	01	H3668_026_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	25.00	25.00			0.00	0.00											2	2
H3668	029	0	1	01	01	H3668_029_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	25.00	25.00			0.00	0.00											2	2
H3668	030	0	1	01	01	H3668_030_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011001						2	1				2	1														2	1									1		1				2					1	00001001							50	50					50	50			2		1	01010000	40.00	40.00			0.00	0.00											2	2
H3668	031	0	1	01	01	H3668_031_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011001						2	1				2	1														2	1									1		1				2					1	00001001							50	50					50	50			2		1	01010000	40.00	40.00			0.00	0.00											2	2
H3668	802	0	1	01	01	H3668_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3668	803	0	1	01	01	H3668_803_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3668	804	0	1	01	01	H3668_804_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3668	811	0	1	01	01	H3668_811_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3668	812	0	1	01	01	H3668_812_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3672	013	0	1	01	01	H3672_013_0	13	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	1 set of bitewing x-rays every year. 1 full mouth radiographic image (x-ray) every three years	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral evaluations 2 every yr. 1 set of bitewing x-rays every yr. 1 full mouth radiographic image (x-ray) every three yrs. Bitewing x-rays covered up to 4 every yr. depending on number of images.	4	2	1	6	Restorative Services: Fillings- 0% - 50% coinsurance for Fillings-1 per tooth every 3 years, 0% - 50% coinsurance for Crowns -1 per tooth every 5 years	4	1				4	2	1	6	Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs.	4	2	1	6	Extractions: Unlimited.	4	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1		2	1500.00	3		2					1	10001111							0	50	0	50	0	50	0	50	0	50	2		2																		1	2
H3672	014	0	1	01	01	H3672_014_0	13	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	1 set of bitewing x-rays every year. 1 full mouth radiographic image (x-ray) every three years	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral evaluations 2 every year. 1 set of bitewing x-rays every year. 1 full mouth radiographic image (x-ray) every three years. Bitewing x-rays covered up to 4 every year depending on number of images.	4	2	1	6	Restorative Services: Fillings- 0% - 50% coinsurance for Fillings-1 per tooth every 3 years, 0% - 50% coinsurance for Crowns -1 per tooth every 5 years.	4	1				4	2	1	6	Scaling & root planning 1 site every 3 yrs. Maintenance 2 every yrs. Full mouth debridement 1 every 3 yrs.	4	1				4	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1		2	1000.00	3		2					1	10001111							0	50	0	50	0	50	0	50	0	50	2		2																		1	2
H3672	019	0	1	01	01	H3672_019_0	13	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	1 set of bitewing x-rays every year. 1 full mouth radiographic image (x-ray) every three years	1		4000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Diagnostic Services: oral evaluation 2 per calendar year. Images 1-4 every 1-3 calendar years. Depending on the service.	2	2	1	6	Restorative Services: 1 per tooth every 1-5 years. Depending on services.	2	2	1	6	Endodontics: 1 per tooth per calendar year.	2	2	1	6	Periodontics: 1-2 every 1-3 calendar years. Depending on services.	2	2	1	6	Extractions: 1 service per tooth per lifetime, excision of lesion - unlimited.	2	2	1	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services: Unlimited except: Palliative 2 every year, Consultation 1 every 6 months.	1		1				2					2																		2		2																		1	2
H3672	020	0	1	01	01	H3672_020_0	13	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	1 set of bitewing x-rays every year. 1 full mouth radiographic image (x-ray) every three years	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral evaluations 2 every yr. 1 set of bitewing x-rays every yr. 1 full mouth radiographic image (x-ray) every three yrs. Bitewing x-rays covered up to 4 every yr depending on number of images.	4	2	1	6	Restorative Services: Fillings- 0% - 50% coinsurance for Fillings-1 per tooth every 3 years, 0% - 50% coinsurance for Crowns -1 per tooth every 5 years.	4	1				4	2	1	6	Scaling and root planning 1 site every 3 yrs. Maintenance 2 every yrs. Full mouth debridement 1 every 3 yrs.	4	1				4	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1		2	1500.00	3		2					1	10001111							0	50	0	50	0	50	0	50	0	50	2		2																		1	2
H3672	021	0	1	01	01	H3672_021_0	13	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	1 set of bitewing x-rays every year. 1 full mouth radiographic image (x-ray) every three years	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral evaluations 2 every year. 1 set of bitewing x-rays every year. 1 full mouth radiographic image (x-ray) every three years. Bitewing x-rays covered up to 4 every year depending on number of images.	4	2	1	6	Restorative Services: Fillings- 0% - 50% coinsurance for Fillings-1 per tooth every 3 years, 0% - 50% coinsurance for Crowns -1 per tooth every 5 years.	4	1				4	2	1	6	Scaling and root planning 1 site every 3 yrs. Maintenance 2 every years. Full mouth debridement 1 every 3 yrs.	4	1				4	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1		2	1000.00	3		2					1	10001111							0	50	0	50	0	50	0	50	0	50	2		2																		1	2
H3672	023	0	1	01	01	H3672_023_0	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	1 set of bitewing x-rays every year. 1 full mouth radiographic image (x-ray) every three years	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral evaluations 2 every year. 1 set of bitewing x-rays every year. 1 full mouth radiographic image (x-ray) every three years. Bitewing x-rays covered up to 4 every year depending on number of images.	4	2	1	6	Restorative Services: Fillings- 0% - 50% coinsurance for Fillings-1 per tooth every 3 years, 0% - 50% coinsurance for Crowns -1 per tooth every 5 years.	4	1				4	2	1	6	Scaling and root planning 1 site every 3 yrs. Maintenance 2 every yrs. Full mouth debridement 1 every 3 yrs.	4	1				4	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1		2	1500.00	3		2					1	10001111							0	50	0	50	0	50	0	50	0	50	2		2																		1	2
H3672	024	0	1	01	01	H3672_024_0	13	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	1 set of bitewing x-rays every year. 1 full mouth radiographic image (x-ray) every three years	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral evaluations 2 every year. 1 set of bitewing x-rays every year. 1 full mouth radiographic image (x-ray) every three years. Bitewing x-rays covered up to 4 every year depending on number of images.	4	2	1	6	Restorative Services: Fillings- 0% - 50% coinsurance for Fillings-1 per tooth every 3 years, 0% - 50% coinsurance for Crowns -1 per tooth every 5 years.	4	1				4	2	1	6	Scaling and root planning 1 site every 3 yrs.  Maintenance 2 every years. Full mouth debridement 1 every 3 yrs.	4	1				4	2	1	6	Dentures one set every 60 months, rebase dentures one every 24 months, reline one every 24 months. Anesthesia and sedations - unlimited.	1		2	1000.00	3		2					1	10001111							0	50	0	50	0	50	0	50	0	50	2		2																		1	2
H3672	805	0	1	01	01	H3672_805_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3706	001	0	1	01	01	H3706_001_0	5	1	1111	2	2	1	6	Limited exams - three every 12 monthsRoutine exams - two every 12 monthsComprehensive exams - one every 36 months	2	2	2	6	Standard cleaning - two every 12 monthsPeriodontal maintenance (cleaning) - four every 12 months.	2	2	2	3		2	2	1	6	Bitewing (1-4) - one every 12 monthsPanoramic radiographic image, intraoral complete series, 7-8 vertical bitewings, - one every 36 monthsIntraoral occlusal - two every 24 months	1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	1				2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	2	1				2	1				1		1				2					1	10101111			20	20			0	20	20	20	0	20	20	20	0	20	2		1	01000000	40.00	40.00															1	1
H3706	009	0	1	02	01	H3706_009_0	2	1	1111	2	2	1	6	Limited exams limited to three every 12 monthsRoutine exams limited to two every 12 monthsComprehensive exams limited to one every 36 months	2	2	2	6	Standard cleaning limited to two every 12 monthsPeriodontal maintenance (cleaning) limited to four every 12 months.	2	2	2	3		2	2	1	6	Bitewing (1-4) - one every 12 monthsPanoramic radiographic image, intraoral complete series, 7-8 vertical bitewings, - one every 36 monthsIntraoral occlusal - two every 24 months	1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	1				2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	2	1				2	1				1		1				2					1	10101111			20	20			0	20	20	20	0	20	20	20	0	20	2		1	01000000	35.00	35.00															1	1
H3706	023	0	1	01	01	H3706_023_0	5	1	1111	2	2	1	6	Limited exams limited to three every 12 monthsRoutine exams limited to two every 12 monthsComprehensive exams limited to one every 36 months	2	2	2	6	Standard cleaning limited to two every 12 monthsPeriodontal maintenance (cleaning) limited to four every 12 months	2	2	2	3		2	2	1	6	Bitewing (1-4) - one every 12 monthsPanoramic radiographic image, intraoral complete series, 7-8 vertical bitewings, - one every 36 monthsIntraoral occlusal - two every 24 months	1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	1				2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	2	1				2	1				1		1				2					1	10101111			20	20			0	20	20	20	0	20	20	20	0	20	2		1	01000000	30.00	30.00															1	1
H3706	024	0	1	01	01	H3706_024_0	4	1	1111	2	2	1	6	Limited exams limited to three every 12 monthsRoutine exams limited to two every 12 monthsComprehensive exams limited to one every 36 months	2	2	2	6	Standard cleaning limited to two every 12 monthsPeriodontal maintenance (cleaning) limited to four every 12 months	2	2	2	3		2	2	1	6	Bitewing (1-4) - one every 12 monthsPanoramic radiographic image, intraoral complete series, 7-8 vertical bitewings, - one every 36 monthsIntraoral occlusal - two every 24 months	1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	1				2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	2	1				2	1				1		1				2					1	10101111			20	20			0	20	20	20	0	20	20	20	0	20	2		1	01000000	20.00	20.00															1	1
H3706	025	0	1	01	01	H3706_025_0	6	1	1111	2	2	1	6	Limited exams limited to three every 12 monthsRoutine exams limited to two every 12 monthsComprehensive exams limited to one every 36 months	2	2	2	6	Standard cleaning limited to two every 12 monthsPeriodontal maintenance (cleaning) limited to four every 12 months.	2	2	2	3		2	2	1	6	Bitewing (1-4) - one every 12 monthsPanoramic radiographic image, intraoral complete series, 7-8 vertical bitewings, - one every 36 monthsIntraoral occlusal - two every 24 months	1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	1				2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	2	1				2	1				1		1				2					1	10101111			20	20			0	20	20	20	0	20	20	20	0	20	2		1	01000000	35.00	35.00															1	1
H3706	028	0	1	01	01	H3706_028_0	6	1	1111	2	2	1	6	Limited exams limited to three every 12 monthsRoutine exams limited to two every 12 monthsComprehensive exams limited to one every 36 months	2	2	2	6	Standard cleaning limited to two every 12 monthsPeriodontal maintenance (cleaning) limited to four every 12 months	2	2	2	3		2	2	1	6	Bitewing (1-4) - one every 12 monthsPanoramic radiographic image, intraoral complete series, 7-8 vertical bitewings, - one every 36 monthsIntraoral occlusal - two every 24 months	1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	1				2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	1
H3706	029	0	1	01	01	H3706_029_0	5	1	1111	2	2	1	6	Limited exams limited to three every 12 monthsRoutine exams limited to two every 12 monthsComprehensive exams limited to one every 36 months	2	2	2	6	Standard cleaning limited to two every 12 monthsPeriodontal maintenance (cleaning) limited to four every 12 months.	2	2	2	3		2	2	1	6	Bitewing (1-4) - one every 12 monthsPanoramic radiographic image, intraoral complete series, 7-8 vertical bitewings, - one every 36 monthsIntraoral occlusal - two every 24 months	1		6000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	1				2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	1
H3706	803	0	1	01	01	H3706_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3708	001	0	1	01	01	H3708_001_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3727	001	1	1	01	01	H3727_001_1	5	1	1110	2	1				2	1									2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H3727	001	2	1	01	01	H3727_001_2	5	1	1110	2	1				2	1									2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H3727	001	3	1	01	01	H3727_001_3	5	1	1110	2	1				2	1									2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H3727	002	1	1	01	01	H3727_002_1	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H3727	002	2	1	01	01	H3727_002_2	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H3727	002	3	1	01	01	H3727_002_3	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H3727	004	1	1	01	01	H3727_004_1	5	1	1110	2	1				2	1									2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	1				2	1									1		1				2					2																		2		2																		2	2
H3727	004	2	1	01	01	H3727_004_2	5	1	1110	2	1				2	1									2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	1				2	1									1		1				2					2																		2		2																		2	2
H3727	004	3	1	01	01	H3727_004_3	5	1	1110	2	1				2	1									2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	1				2	1									1		1				2					2																		2		2																		2	2
H3727	005	1	1	01	01	H3727_005_1	5	1	1110	2	1				2	1									2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	1				2	1									1		1				2					2																		2		2																		2	2
H3727	005	2	1	01	01	H3727_005_2	5	1	1110	2	1				2	1									2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	1				2	1									1		1				2					2																		2		2																		2	2
H3727	005	3	1	01	01	H3727_005_3	5	1	1110	2	1				2	1									2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	1				2	1									1		1				2					2																		2		2																		2	2
H3748	001	0	1	02	01	H3748_001_0	7	1	1111	2	1				2	1				2	1				2	1				1		1100.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3748	003	0	1	02	01	H3748_003_0	7	1	1111	2	1				2	1				2	1				2	1				1		875.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3748	004	0	1	02	01	H3748_004_0	7	1	1111	2	1				2	1				2	1				2	1				1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3748	006	0	1	02	01	H3748_006_0	7	1	1111	2	1				2	1				2	1				2	1				1		2100.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3748	007	0	1	02	01	H3748_007_0	7	1	1111	2	1				2	1				2	1				2	1				1		1700.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3748	008	0	1	02	01	H3748_008_0	7	1	1111	2	1				2	1				2	1				2	1				1		1700.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3748	009	0	1	02	01	H3748_009_0	7	1	1111	2	1				2	1				2	1				2	1				1		2100.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3748	010	0	1	02	01	H3748_010_0	7	1	1110	2	2	4	3		2	2	2	3							2	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	2																																											2					2																		2		1	01000000	45.00	45.00															1	2
H3748	013	0	1	02	01	H3748_013_0	7	1	1111	2	1				2	1				2	1				2	1				1		1800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3748	801	0	1	01	01	H3748_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3748	802	0	1	01	01	H3748_802_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3749	001	0	1	02	01	H3749_001_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3749	017	0	1	02	01	H3749_017_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3749	018	0	1	02	01	H3749_018_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3749	020	0	1	02	01	H3749_020_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3749	801	0	1	01	01	H3749_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3749	803	0	1	01	01	H3749_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3749	804	0	1	01	01	H3749_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3755	001	0	1	01	01	H3755_001_0	4	1	1111	2	2	2	3		2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2	2	1	3		2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2	2	1	6	Root canals are limited to 1 per lifetime per tooth. Therapeutic pulpotomoy and pulpal debridement are limited to 1 per lifetime per tooth.	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months. Periodontal maintenance is limited to 4 every 12 months.	2	2	1	6	Extractions are limited to 1 per tooth per lifetime.  Coronectomy is limited to 1 per tooth per lifetime	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months.  Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1		2	1500.00	3		2					2																		2		1	01000000	30.00	30.00															1	2
H3755	002	0	1	01	01	H3755_002_0	5	1	1111	2	2	2	3		2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2	2	1	6	Bitewings (1-4 films) are limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series are limited to 1 per 36 months.	2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2	2	1	6	Root canals are limited to 1 per lifetime per tooth. Therapeutic pulpotomoy and pulpal debridement are limited to 1 per lifetime per tooth.	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months. Periodontal maintenance is limited to 4 every 12 months.	2	2	1	6	Extractions are limited to 1 per tooth per lifetime. Coronectomy is limited to 1 per tooth per lifetime	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months. Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1		2	1500.00	3		2					2																		2		1	01000000	5.00	5.00															1	2
H3755	004	0	1	01	01	H3755_004_0	5	1	1111	2	2	2	6	Periodic, detailed and extensive problem focused, re-evaluation exams are limited to 2 per 12 months.	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2	2	2	6	Bitewings (1-4 films) are limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series are limited to 1 per 36 months.	2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2	2	1	6	Root canals are limited to 1 per lifetime per tooth. Therapeutic pulpotomoy and pulpal debridement are limited to 1 per lifetime per tooth.	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months.	2	2	1	6	Extractions are limited to 1 per tooth per lifetime. Coronectomy is limited to 1 per tooth per lifetime	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months.  Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1		2	1500.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H3755	005	0	1	01	01	H3755_005_0	4	1	1111	2	2	2	6	Periodic, detailed and extensive problem focused, re-evaluation exams are limited to 2 per 12 months. Limited oral evaluation problem focused is limited to 3 per 12 months.	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2	2	1	6	Bitewings (1-4 films) limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series limited to 1 per 36 months.	2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2	2	1	6	Root canals are limited to 1 per lifetime per tooth. Therapeutic pulpotomoy and pulpal debridement are limited to 1 per lifetime per tooth.	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months.	2	2	1	6	Extractions are limited to 1 per tooth per lifetime. Coronectomy is limited to 1 per tooth per lifetime	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months. Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1		2	1500.00	3		2					2																		2		1	01000000	35.00	35.00															1	2
H3755	801	0	1	01	01	H3755_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3777	001	2	1	01	01	H3777_001_2	9	1	1111	2	1				2	1				2	1				2	1				1		500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1500.00	3		2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3777	001	3	1	01	01	H3777_001_3	9	1	1111	2	1				2	1				2	1				2	1				1		500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1500.00	3		2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3777	001	4	1	01	01	H3777_001_4	9	1	1111	2	1				2	1				2	1				2	1				1		500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1500.00	3		2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3794	002	0	1	02	01	H3794_002_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3794	004	0	1	02	01	H3794_004_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3800	001	0	1	01	01	H3800_001_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H3805	001	0	1	02	01	H3805_001_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3805	015	0	1	02	01	H3805_015_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H3805	017	0	1	02	01	H3805_017_0	4	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H3805	032	0	1	02	01	H3805_032_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H3805	033	0	1	02	01	H3805_033_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3805	034	0	1	02	01	H3805_034_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3805	035	0	1	02	01	H3805_035_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3805	037	0	1	02	01	H3805_037_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	1
H3805	039	1	1	02	01	H3805_039_1	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3805	039	2	1	02	01	H3805_039_2	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H3805	801	0	1	01	01	H3805_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3805	803	0	1	01	01	H3805_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3805	804	0	1	01	01	H3805_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3805	805	0	1	01	01	H3805_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3805	806	0	1	01	01	H3805_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3805	807	0	1	01	01	H3805_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3809	001	0	1	20	08	H3809_001_0	2																																																																																																																																																							
H3809	002	0	1	20	08	H3809_002_0	2																																																																																																																																																							
H3810	001	0	1	01	01	H3810_001_0	4	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															1	1
H3810	003	0	1	01	01	H3810_003_0	11	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															1	1
H3810	021	0	1	01	01	H3810_021_0	4	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															1	1
H3810	022	0	1	01	01	H3810_022_0	8	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															1	1
H3810	023	0	1	01	01	H3810_023_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3810	024	0	1	01	01	H3810_024_0	7	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															1	1
H3811	001	0	1	01	01	H3811_001_0	3	1	1111	2	1				2	1				2	1				2	1				1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H3811	002	0	1	01	01	H3811_002_0	8	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H3811	003	0	1	01	01	H3811_003_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3811	009	0	1	01	01	H3811_009_0	8	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H3813	001	0	1	04	01	H3813_001_0	8	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	12	3		1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															1	2
H3813	010	0	1	04	01	H3813_010_0	6	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	12	3		1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	30.00	30.00															2	2
H3813	012	0	1	04	01	H3813_012_0	7	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	12	3		1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															1	2
H3813	013	0	1	04	01	H3813_013_0	8	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	12	3		1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	30.00	30.00															2	2
H3813	014	0	1	04	01	H3813_014_0	7	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	12	3		1	2	500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															1	2
H3813	016	0	1	04	01	H3813_016_0	6	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	12	3		1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	40.00	40.00															1	2
H3813	017	0	1	04	01	H3813_017_0	6	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	12	3		1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	40.00	40.00															1	2
H3813	018	0	1	04	01	H3813_018_0	7	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	12	3		1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		1				2					1	10101111			20	20			20	20	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															1	2
H3813	019	0	1	04	01	H3813_019_0	7	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	12	3		1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		1				2					1	10101111			20	20			20	20	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															1	2
H3813	804	0	1	04	01	H3813_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3814	007	0	1	01	01	H3814_007_0	8	1	1111	2	1				2	1				2	1				2	1				1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H3814	030	0	1	01	01	H3814_030_0	10	1	1111	2	1				2	1				2	1				2	1				1		375.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H3814	031	0	1	01	01	H3814_031_0	9	1	1111	2	1				2	1				2	1				2	1				1		850.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H3815	001	0	1	01	01	H3815_001_0	16	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H3815	007	0	1	01	01	H3815_007_0	19	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												1	1	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	2	2
H3815	008	0	1	01	01	H3815_008_0	19	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	2	2
H3815	010	0	1	01	01	H3815_010_0	16	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	1	1
H3815	011	0	1	01	01	H3815_011_0	14	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												1	1	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	2	2
H3815	013	0	1	01	01	H3815_013_0	15	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	1	1
H3815	016	0	1	02	01	H3815_016_0	17	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H3815	019	0	1	01	01	H3815_019_0	16	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	1	1
H3815	020	0	1	01	01	H3815_020_0	16	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	1	1
H3815	021	0	1	01	01	H3815_021_0	16	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	1	1
H3815	023	0	1	01	01	H3815_023_0	16	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	1	1
H3815	026	0	1	02	01	H3815_026_0	14	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												1	1	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	2	2
H3815	028	0	1	01	01	H3815_028_0	15	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												1	1	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	2	2
H3815	030	0	1	01	01	H3815_030_0	15	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	300.00	5		2					1	01000000	20	20															2		2																		2	2
H3815	031	0	1	01	01	H3815_031_0	14	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	2	2
H3815	033	0	1	01	01	H3815_033_0	11	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	2	2
H3815	034	0	1	01	01	H3815_034_0	16	2																																																															2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		2	2
H3815	035	0	1	01	01	H3815_035_0	16	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												1	1	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	2	2
H3815	036	0	1	01	01	H3815_036_0	17	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1011111	3					4	1				4	1				4	1				4	1				4	1				4	1				1		2	600.00	3		2					2																		2		2																		2	2
H3815	037	0	1	01	01	H3815_037_0	15	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												1	1	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	2	2
H3815	038	0	1	01	01	H3815_038_0	15	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	2	2
H3815	039	0	1	01	01	H3815_039_0	16	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	500.00	5		2					1	01000000	20	20															2		2																		2	2
H3815	040	0	1	01	01	H3815_040_0	15	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10001111							20.00	350.00	15.00	295.00	15.00	375.00	25.00	140.00	20.00	425.00	2	2
H3815	801	0	1	01	01	H3815_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3815	802	0	1	01	01	H3815_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3815	803	0	1	01	01	H3815_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3815	804	0	1	01	01	H3815_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3817	008	1	1	04	01	H3817_008_1	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1	2	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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											2	2
H3817	008	2	1	04	01	H3817_008_2	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1	2	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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											2	2
H3817	008	4	1	04	01	H3817_008_4	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1	2	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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											2	2
H3817	009	1	1	04	01	H3817_009_1	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	25.00	25.00			0.00	0.00											2	2
H3817	009	2	1	04	01	H3817_009_2	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	25.00	25.00			0.00	0.00											2	2
H3817	010	0	1	04	01	H3817_010_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											2	2
H3817	011	1	1	04	01	H3817_011_1	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											2	2
H3817	011	2	1	04	01	H3817_011_2	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											2	2
H3817	011	3	1	04	01	H3817_011_3	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											2	2
H3817	801	0	1	04	01	H3817_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3817	802	0	1	04	01	H3817_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3817	803	0	1	04	01	H3817_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3817	804	0	1	04	01	H3817_804_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3822	001	0	1	01	01	H3822_001_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1		2	2000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H3822	002	0	1	01	01	H3822_002_0	6	2																																																															2																																											2					2																		2		1	01000000	35.00	35.00															2	2
H3822	007	0	1	02	01	H3822_007_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1		2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H3822	008	0	1	02	01	H3822_008_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	45.00	45.00															2	2
H3822	012	0	1	01	01	H3822_012_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	25.00	25.00															2	2
H3822	014	0	1	01	01	H3822_014_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H3822	801	0	1	01	01	H3822_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3822	802	0	1	01	01	H3822_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3822	805	0	1	01	01	H3822_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3822	806	0	1	01	01	H3822_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3822	809	0	1	01	01	H3822_809_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3822	810	0	1	01	01	H3822_810_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3822	813	0	1	01	01	H3822_813_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3822	814	0	1	01	01	H3822_814_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3822	815	0	1	01	01	H3822_815_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3822	816	0	1	01	01	H3822_816_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3822	817	0	1	01	01	H3822_817_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3822	818	0	1	01	01	H3822_818_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3828	001	0	1	04	01	H3828_001_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Benefit is either two series of bitewing per year, or one full mouth every 36 consecutive months. Benefit is combined in and out-of-network for all covered services (includes all preventive services).	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	35.00	35.00			0.00	0.00											2	2
H3828	801	0	1	04	01	H3828_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3828	802	0	1	04	01	H3828_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3832	007	0	1	04	01	H3832_007_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	4	6	The plan provides 2 topical fluoride treatments per calendar year, and 2 treatments of caries arresting medicament per tooth, per calendar year	2	2	1	6	The plan provides one set of bitewing X-rays every year. The plan provides one set of set of full mouth X-rays every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0001001											2	2	2	3												2	2	4	3							2						2					2																		2		1	01001001	50.00	50.00					0.00	0.00					0.00	0.00			2	2
H3832	008	0	1	04	01	H3832_008_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	4	6	The plan provides 2 topical fluoride treatments per calendar year, and 2 treatments of caries arresting medicament per tooth, per calendar year	2	2	1	6	The plan provides one set of bitewing X-rays every year. The plan provides one set of full mouth X-rays every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1001101											2	2	2	3		2	2	1	3							2	2	4	3		2	2	1	6	The plan provides 1 crown per calendar year following root canal procedure on the same tooth	2						2					2																		2		1	11001101	40.00	40.00					0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	2	2
H3832	009	0	1	04	01	H3832_009_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	4	6	The plan provides 2 topical fluoride treatments per calendar year, and 2 treatments of caries arresting medicament per tooth, per calendar year.	2	2	1	6	The plan provides one set of bitewing X-rays every year. The plan provides one set of set of full mouth X-rays every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0001001											2	2	2	3												2	2	4	3							2						2					2																		2		1	01001001	50.00	50.00					0.00	0.00					0.00	0.00			2	2
H3832	010	0	1	04	01	H3832_010_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	4	6	The plan provides 2 topical fluoride treatments per calendar year, and 2 treatments of caries arresting medicament per tooth, per calendar year.	2	2	1	6	The plan provides one set of bitewing X-rays every year. The plan provides one set of full mouth X-rays every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1001101											2	2	2	3		2	2	1	3							2	2	4	3		2	2	1	6	The plan provides 1 crown per calendar year following root canal procedure on the same tooth	2						2					2																		2		1	11001101	30.00	30.00					0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	2	2
H3832	011	0	1	04	01	H3832_011_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3832	801	0	1	04	01	H3832_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3832	802	0	1	04	01	H3832_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3832	805	0	1	04	01	H3832_805_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3832	807	0	1	04	01	H3832_807_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3864	002	0	1	02	01	H3864_002_0	4	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	40.00	40.00															1	2
H3864	006	0	1	01	01	H3864_006_0	5	1	1111	2	1				2	1				2	1				2	1				1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	25.00	25.00															1	2
H3864	014	0	1	02	01	H3864_014_0	6	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															1	2
H3864	024	0	1	02	01	H3864_024_0	5	1	1111	2	1				2	1				2	1				2	1				1		1750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															1	2
H3864	027	0	1	01	01	H3864_027_0	6	1	1111	2	1				2	1				2	1				2	1				1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	50.00	50.00															1	2
H3864	029	0	1	02	01	H3864_029_0	5	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	40.00	40.00															1	2
H3864	030	0	1	02	01	H3864_030_0	4	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	30.00	30.00															1	2
H3864	032	0	1	02	01	H3864_032_0	6	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	50.00	50.00															1	2
H3864	034	0	1	02	01	H3864_034_0	5	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	40.00	40.00															1	2
H3864	036	0	1	02	01	H3864_036_0	6	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	40.00	40.00															1	2
H3864	040	0	1	01	01	H3864_040_0	5	1	1111	2	1				2	1				2	1				2	1				1		1750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															1	2
H3864	041	0	1	01	01	H3864_041_0	6	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	35.00	35.00															1	2
H3864	043	0	1	01	01	H3864_043_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3864	801	0	1	01	01	H3864_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3864	803	0	1	01	01	H3864_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3864	805	0	1	02	01	H3864_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3864	806	0	1	02	01	H3864_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3890	001	0	1	04	01	H3890_001_0	9	1	1111	2	2	2	6	See notes for benefit details.	2	2	2	6	Prophylaxis Cleaning - 2 every year	2	2	2	6	Fluoride Treatment - 2 every year	2	2	2	6	See notes for benefit details.	2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	See notes for benefit details.	2	2	1	6	• Root canals and retreatment, apicoectomy, retrograde filling - once per tooth per lifetime	2	2	1	6	• Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 36 months	2	2	1	6	• Extractions, coronectomy - once per tooth	2	2	1	6	See notes for benefit details.	1	2	2	1000.00	3		2					2																		2		2																		1	2
H3890	002	0	1	04	01	H3890_002_0	10	1	1110	2	2	2	6	See notes for benefit details.	2	2	2	3							2	2	2	6	See notes for benefit details.	2					2				2		2												2		2		2												2	2	2												3					3					3					3					3											2					1	01000000	20	20															2		2																		2	2
H3890	004	0	1	04	01	H3890_004_0	10	1	1111	2	2	2	6	Members must see a DentaQuest provider to utilize this benefit in-network. Exclusions may apply. See notes for more details.	2	2	2	6	Prophylaxis Cleaning - 2 every year	2	2	2	6	Fluoride Treatment - 2 every year	2	2	2	6	See notes for more details.	2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	See notes for more details.	2	2	1	6	• Root canals and retreatment, apicoectomy, retrograde filling - once per tooth per lifetime	2	2	1	6	• Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 36 months • Full mouth debridement - once per 36 months	2	2	1	6	• Extractions, coronectomy - once per tooth	2	2	1	6	See notes for more details.	1	2	2	1500.00	3		2					2																		2		2																		1	2
H3890	005	0	1	04	01	H3890_005_0	10	1	1111	2	2	2	6	Members must see a DentaQuest provider to utilize this benefit in-network. Exclusions may apply. See notes for details.	2	2	2	6	Prophylaxis Cleaning - 2 every year	2	2	2	6	Fluoride Treatment - 2 every year	2	2	2	6	See notes for details	2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	See notes for details	2	2	1	6	• Root canals and retreatment, apicoectomy, retrograde filling - once per tooth per lifetime	2	2	1	6	See notes for details.	2	2	1	6	• Extractions, coronectomy - once per tooth	2	2	1	6	See notes for details.	1	2	2	2000.00	3		2					2																		2		2																		1	2
H3890	801	0	1	04	01	H3890_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3907	002	0	1	01	01	H3907_002_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	3000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	45.00	45.00															2	2
H3907	006	0	1	01	01	H3907_006_0	11	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every year. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		1	1100	2				15.00	15.00					15.00	15.00	2	2	2																																											2					2																		2		1	01000000	25.00	25.00															2	2
H3907	029	0	1	01	01	H3907_029_0	11	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every year. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	5000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	25.00	25.00															2	2
H3907	037	0	1	01	01	H3907_037_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	2250.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															2	2
H3907	046	0	1	01	01	H3907_046_0	10	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	4000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	30.00	30.00															2	2
H3907	050	0	1	01	01	H3907_050_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	4000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	30.00	30.00															2	2
H3907	052	0	1	01	01	H3907_052_0	11	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	4000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	30.00	30.00															2	2
H3907	057	1	1	01	01	H3907_057_1	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	5000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															2	2
H3907	057	2	1	01	01	H3907_057_2	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	5000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															2	2
H3907	057	3	1	01	01	H3907_057_3	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	5000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															2	2
H3907	057	4	1	01	01	H3907_057_4	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	5000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															2	2
H3907	057	5	1	01	01	H3907_057_5	13	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	5000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															2	2
H3907	801	0	1	01	01	H3907_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3907	802	0	1	01	01	H3907_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3907	803	0	1	01	01	H3907_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3908	001	0	1	20	08	H3908_001_0	1																																																																																																																																																							
H3908	002	0	1	20	08	H3908_002_0	1																																																																																																																																																							
H3909	001	0	1	04	01	H3909_001_0	6	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime and crowns 1 every 5 years per tooth.	2	2	1	6	#16b5, Periodontics: Includes scaling and root planing covered at 1 per 36 months, per mouth quadrant (there are 4 mouth quadrants).	2	1				2	2	1	6	Subject to limitations described in note	1	2	2	1500.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	35.00	35.00															2	2
H3909	007	0	1	04	01	H3909_007_0	6	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime and crowns 1 every 5 years per tooth.	2	2	1	6	#16b5, Periodontics: Includes scaling and root planing covered at 1 per 36 months, per mouth quadrant (there are 4 mouth quadrants).	2	1				2	2	1	6	Subject to limitations described in note	1	2	2	1500.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	35.00	35.00															2	2
H3909	009	0	1	04	01	H3909_009_0	6	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime and crowns 1 every 5 years per tooth.	2	2	1	6	#16b5, Periodontics: Includes scaling and root planing covered at 1 per 36 months, per mouth quadrant (there are 4 mouth quadrants).	2	1				2	2	1	6	Subject to limitations described in note	1	2	2	1500.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	35.00	35.00															2	2
H3909	014	0	1	04	01	H3909_014_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime and crowns 1 every 5 years per tooth.	2	2	1	6	#16b5, Periodontics: Includes scaling and root planing covered at 1 per 36 months, per mouth quadrant (there are 4 mouth quadrants).	2	1				2	2	1	6	Subject to limitations described in note.	1	2	2	2000.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	30.00	30.00															2	2
H3909	015	0	1	04	01	H3909_015_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime and crowns 1 every 5 years per tooth.	2	2	1	6	#16b5, Periodontics: Includes scaling and root planing covered at 1 per 36 months, per mouth quadrant (there are 4 mouth quadrants).	2	1				2	2	1	6	Subject to limitations described in note.	1	2	2	2000.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	30.00	30.00															2	2
H3909	016	0	1	04	01	H3909_016_0	6	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime and crowns 1 every 5 years per tooth.	2	2	1	6	#16b5, Periodontics: Includes scaling and root planing covered at 1 per 36 months, per mouth quadrant (there are 4 mouth quadrants).	2	1				2	2	1	6	Subject to limitations described in note.	1	2	2	1500.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	50.00	50.00															2	2
H3909	017	0	1	04	01	H3909_017_0	6	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime and crowns 1 every 5 years per tooth.	2	2	1	6	#16b5, Periodontics: Includes scaling and root planing covered at 1 per 36 months, per mouth quadrant (there are 4 mouth quadrants).	2	1				2	2	1	6	Subject to limitations described in note	1	2	2	3000.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	30.00	30.00															2	2
H3909	801	0	1	04	01	H3909_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3909	802	0	1	04	01	H3909_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3916	001	0	1	04	01	H3916_001_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	25.00	25.00															1	2
H3916	002	0	1	04	01	H3916_002_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	25.00	25.00															1	2
H3916	005	0	1	04	01	H3916_005_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	30.00	30.00															1	2
H3916	012	0	1	04	01	H3916_012_0	5	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	35.00	35.00															1	2
H3916	015	0	1	04	01	H3916_015_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	35.00	35.00															1	2
H3916	018	0	1	04	01	H3916_018_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	40.00	40.00															1	2
H3916	022	0	1	04	01	H3916_022_0	8	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	30.00	30.00															1	2
H3916	024	0	1	04	01	H3916_024_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	30.00	30.00															1	2
H3916	032	0	1	04	01	H3916_032_0	8	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	40.00	40.00															1	2
H3916	033	0	1	04	01	H3916_033_0	8	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	40.00	40.00															1	2
H3916	034	1	1	04	01	H3916_034_1	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			10	10	10	10	10	10	10	10	10	10	10	10	10	10	2		1	01000000	15.00	15.00															1	2
H3916	034	3	1	04	01	H3916_034_3	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			10	10	10	10	10	10	10	10	10	10	10	10	10	10	2		1	01000000	15.00	15.00															1	2
H3916	034	4	1	04	01	H3916_034_4	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			10	10	10	10	10	10	10	10	10	10	10	10	10	10	2		1	01000000	15.00	15.00															1	2
H3916	034	5	1	04	01	H3916_034_5	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			10	10	10	10	10	10	10	10	10	10	10	10	10	10	2		1	01000000	5.00	5.00															1	2
H3916	035	1	1	04	01	H3916_035_1	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			10	10	10	10	10	10	10	10	10	10	10	10	10	10	2		1	01000000	10.00	10.00															1	2
H3916	035	2	1	04	01	H3916_035_2	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			10	10	10	10	10	10	10	10	10	10	10	10	10	10	2		1	01000000	10.00	10.00															1	2
H3916	035	4	1	04	01	H3916_035_4	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			10	10	10	10	10	10	10	10	10	10	10	10	10	10	2		1	01000000	10.00	10.00															1	2
H3916	036	0	1	04	01	H3916_036_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			10	10	10	10	10	10	10	10	10	10	10	10	10	10	2		1	01000000	15.00	15.00															1	2
H3916	037	1	1	04	01	H3916_037_1	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	25.00	25.00															1	2
H3916	037	2	1	04	01	H3916_037_2	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	25.00	25.00															1	2
H3916	037	3	1	04	01	H3916_037_3	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	20.00	20.00															1	2
H3916	037	4	1	04	01	H3916_037_4	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	25.00	25.00															1	2
H3916	038	0	1	04	01	H3916_038_0	7	1	1111	2	2	1	4		2	2	1	4		2	1				2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	20.00	20.00															1	2
H3916	039	0	1	04	01	H3916_039_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	25.00	25.00															1	2
H3916	041	1	1	04	01	H3916_041_1	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	20.00	20.00															1	2
H3916	041	2	1	04	01	H3916_041_2	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	20.00	20.00															1	2
H3916	042	1	1	04	01	H3916_042_1	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	10.00	10.00															1	2
H3916	042	2	1	04	01	H3916_042_2	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	10.00	10.00															1	2
H3916	043	0	1	04	01	H3916_043_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	10.00	10.00															1	2
H3916	044	1	1	04	01	H3916_044_1	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		2																		1	2
H3916	044	2	1	04	01	H3916_044_2	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		2																		1	2
H3916	044	3	1	04	01	H3916_044_3	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		2																		1	2
H3916	045	1	1	04	01	H3916_045_1	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		2																		1	2
H3916	045	2	1	04	01	H3916_045_2	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		2																		1	2
H3916	045	3	1	04	01	H3916_045_3	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		2																		1	2
H3916	045	4	1	04	01	H3916_045_4	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		2																		1	2
H3916	046	0	1	04	01	H3916_046_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		2																		1	2
H3916	801	0	1	04	01	H3916_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3916	802	0	1	04	01	H3916_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3916	804	0	1	04	01	H3916_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3916	805	0	1	04	01	H3916_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3916	806	0	1	04	01	H3916_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3916	807	0	1	04	01	H3916_807_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3916	808	0	1	04	01	H3916_808_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3916	809	0	1	04	01	H3916_809_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3916	810	0	1	04	01	H3916_810_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3917	001	0	1	20	08	H3917_001_0	1																																																																																																																																																							
H3917	002	0	1	20	08	H3917_002_0	1																																																																																																																																																							
H3918	001	0	1	20	08	H3918_001_0	1																																																																																																																																																							
H3918	002	0	1	20	08	H3918_002_0	1																																																																																																																																																							
H3919	001	0	1	20	08	H3919_001_0	2																																																																																																																																																							
H3919	002	0	1	20	08	H3919_002_0	2																																																																																																																																																							
H3923	013	0	1	04	01	H3923_013_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	1111111	2	1				2	2	1	6	1 procedure per year	2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	2	2	2	6	Periodontal maintenance only - up to 2 per year. A member may have 2 perio maintenance per year OR 2 cleanings per year (not both).	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	2	2	1	6	Complete or Partial(upper&lower)Dentures-1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement; Bridges-1 every 5 years; Oral Surgery-not covered	1	2	2	2000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	30.00	30.00															2	2
H3923	017	0	1	04	01	H3923_017_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	1111111	2	1				2	2	1	6	1 procedure per year	2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	2	2	2	6	Periodontal maintenance only - up to 2 per year. A member may have 2 perio maintenance per year OR 2 cleanings per year (not both).	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	2	2	1	6	Complete or Partial(upper&lower)Dentures-1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement; Bridges-1 every 5 years; Oral Surgery-not covered	1	2	2	2000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	25.00	25.00															2	2
H3923	028	0	1	04	01	H3923_028_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	1111111	2	1				2	2	1	6	1 procedure per year	2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	2	2	2	6	Periodontal maintenance only - up to 2 per year. A member may have 2 perio maintenance per year OR 2 cleanings per year (not both).	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	2	2	1	6	Complete or Partial(upper&lower)Dentures-1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement; Bridges-1 every 5 years; Oral Surgery-not covered	1	2	2	2750.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	40.00	40.00															2	2
H3923	029	0	1	04	01	H3923_029_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	1111111	2	1				2	2	1	6	1 procedure per year	2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	2	2	2	6	Periodontal maintenance only - up to 2 per year. A member may have 2 perio maintenance per year OR 2 cleanings per year (not both).	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	2	2	1	6	Complete or Partial(upper&lower)Dentures-1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement; Bridges-1 every 5 years; Oral Surgery-not covered	1	2	2	2750.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	40.00	40.00															2	2
H3923	030	0	1	04	01	H3923_030_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	1111111	2	1				2	2	1	6	1 procedure per year	2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	2	2	2	6	Periodontal maintenance only - up to 2 per year. A member may have 2 perio maintenance per year OR 2 cleanings per year (not both).	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	2	2	1	6	Complete or Partial(upper&lower)Dentures-1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement; Bridges-1 every 5 years; Oral Surgery-not covered	1	2	2	3500.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	25.00	25.00															2	2
H3923	031	0	1	04	01	H3923_031_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	0001001											2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement											2	2	1	6	Simple extractions only - 1 per tooth per lifetime						1	2	2	600.00	3		2					1	00001001							50	50					50	50			2		1	01000000	45.00	45.00															2	2
H3923	032	0	1	04	01	H3923_032_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	0001001											2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement											2	2	1	6	Simple extractions only - 1 per tooth per lifetime						1	2	2	600.00	3		2					1	00001001							50	50					50	50			2		1	01000000	45.00	45.00															2	2
H3923	033	0	1	04	01	H3923_033_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	0001001											2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement											2	2	1	6	Simple extractions only - 1 per tooth per lifetime						1	2	2	600.00	3		2					1	00001001							50	50					50	50			2		1	01000000	45.00	45.00															2	2
H3923	034	0	1	04	01	H3923_034_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	1111111	2	1				2	2	1	6	1 procedure per year	2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	2	2	2	6	Periodontal maintenance only - up to 2 per year. A member may have 2 perio maintenance per year OR 2 cleanings per year (not both).	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	2	2	1	6	Complete or Partial(upper&lower)Dentures-1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement; Bridges-1 every 5 years; Oral Surgery-not covered	1	2	2	3500.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	25.00	25.00															2	2
H3923	035	0	1	04	01	H3923_035_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	1111111	2	1				2	2	1	6	1 procedure per year	2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	2	2	2	6	Periodontal maintenance only - up to 2 per year. A member may have 2 perio maintenance per year OR 2 cleanings per year (not both).	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	2	2	1	6	Complete or Partial(upper&lower)Dentures-1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement; Bridges-1 every 5 years; Oral Surgery-not covered	1	2	2	3500.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	25.00	25.00															2	2
H3923	801	0	1	04	01	H3923_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3923	802	0	1	04	01	H3923_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3923	817	0	1	04	01	H3923_817_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3923	818	0	1	04	01	H3923_818_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3923	819	0	1	04	01	H3923_819_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3923	820	0	1	04	01	H3923_820_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3923	832	0	1	04	01	H3923_832_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3924	059	21	1	04	01	H3924_059_21	5	2		3					3										3																																														2												3					3					3					3					3											2					2																		2		1	01000000	25.00	25.00															1	2
H3924	059	22	1	04	01	H3924_059_22	5	2		3					3										3																																														2												3					3					3					3					3											2					2																		2		1	01000000	25.00	25.00															1	2
H3924	062	21	1	04	01	H3924_062_21	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H3924	062	22	1	04	01	H3924_062_22	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H3924	062	23	1	04	01	H3924_062_23	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H3924	062	24	1	04	01	H3924_062_24	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H3924	062	25	1	04	01	H3924_062_25	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H3924	065	0	1	04	01	H3924_065_0	5	2		3					3										3																																														2												3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															1	2
H3924	804	0	1	04	01	H3924_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3925	001	0	1	20	08	H3925_001_0	1																																																																																																																																																							
H3925	002	0	1	20	08	H3925_002_0	1																																																																																																																																																							
H3928	001	0	1	01	01	H3928_001_0	6	1	1111	2	1				2	1				2	1				2	1				1		2650.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3928	801	0	1	01	01	H3928_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3928	803	0	1	01	01	H3928_803_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3931	004	0	1	02	01	H3931_004_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	064	0	1	02	01	H3931_064_0	7	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	070	0	1	02	01	H3931_070_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	091	0	1	02	01	H3931_091_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	092	0	1	02	01	H3931_092_0	7	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	094	0	1	02	01	H3931_094_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	095	0	1	02	01	H3931_095_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	096	0	1	02	01	H3931_096_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	097	0	1	02	01	H3931_097_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	098	0	1	02	01	H3931_098_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	099	0	1	02	01	H3931_099_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	100	0	1	02	01	H3931_100_0	7	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	101	0	1	02	01	H3931_101_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	102	0	1	02	01	H3931_102_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	105	0	1	02	01	H3931_105_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	107	0	1	02	01	H3931_107_0	7	1	1111	2	1				2	1				2	1				2	1				1		2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	108	0	1	01	01	H3931_108_0	7	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Plan will cover 1 filling per tooth per year, recement once per tooth per year, crown repair once per tooth per year, and 1 crown per tooth every 5 years.	2	2	2	6	Plan will cover 1 root canal and the retreatment of 1 root canal per tooth per lifetime.	2	2	4	6	Plan will cover scaling and root planing once per quadrant every 2 years and periodontal maintenance 2 times per year.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see notes.	1		2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	50.00	50.00			0.00	0.00											1	2
H3931	109	0	1	02	01	H3931_109_0	7	1	1111	2	1				2	1				2	1				2	1				1		2100.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	124	0	1	02	01	H3931_124_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	126	0	1	02	01	H3931_126_0	7	1	1111	2	1				2	1				2	1				2	1				1		900.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	129	0	1	02	01	H3931_129_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	143	0	1	02	01	H3931_143_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	145	0	1	02	01	H3931_145_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	146	0	1	02	01	H3931_146_0	7	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	147	0	1	02	01	H3931_147_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	148	0	1	02	01	H3931_148_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	149	0	1	02	01	H3931_149_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	151	0	1	02	01	H3931_151_0	6	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	152	0	1	02	01	H3931_152_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	153	0	1	02	01	H3931_153_0	8	1	1111	2	1				2	1				2	1				2	1				1		2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	154	0	1	02	01	H3931_154_0	8	1	1111	2	1				2	1				2	1				2	1				1		2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	156	0	1	02	01	H3931_156_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	157	0	1	02	01	H3931_157_0	6	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	158	0	1	02	01	H3931_158_0	8	1	1111	2	1				2	1				2	1				2	1				1		2900.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	159	0	1	01	01	H3931_159_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	160	0	1	02	01	H3931_160_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	161	0	1	02	01	H3931_161_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	162	0	1	02	01	H3931_162_0	8	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	165	0	1	02	01	H3931_165_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	166	0	1	02	01	H3931_166_0	7	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	167	0	1	02	01	H3931_167_0	7	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	168	0	1	02	01	H3931_168_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	169	0	1	02	01	H3931_169_0	7	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3931	801	0	1	01	01	H3931_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3931	804	0	1	01	01	H3931_804_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3933	001	0	1	20	08	H3933_001_0	1	2																																																																																																																																																						
H3933	002	0	1	20	08	H3933_002_0	1	2																																																																																																																																																						
H3942	001	0	1	20	08	H3942_001_0	1																																																																																																																																																							
H3942	002	0	1	20	08	H3942_002_0	1																																																																																																																																																							
H3949	009	0	1	01	01	H3949_009_0	8	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H3949	024	0	1	01	01	H3949_024_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	20.00	20.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H3949	026	0	1	01	01	H3949_026_0	5	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	25.00	25.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H3949	030	0	1	01	01	H3949_030_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	35.00	35.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H3949	031	0	1	01	01	H3949_031_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	20.00	20.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H3949	032	0	1	01	01	H3949_032_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	40.00	40.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H3949	034	0	1	01	01	H3949_034_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	35.00	35.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H3949	035	0	1	01	01	H3949_035_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	40.00	40.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H3949	045	0	1	01	01	H3949_045_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	35.00	35.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H3949	046	0	1	01	01	H3949_046_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	30.00	30.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H3949	047	0	1	01	01	H3949_047_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	25.00	25.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H3949	048	0	1	01	01	H3949_048_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	25.00	25.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H3949	049	0	1	01	01	H3949_049_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	30.00	30.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H3949	050	0	1	01	01	H3949_050_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	25.00	25.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H3949	051	0	1	01	01	H3949_051_0	5	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	35.00	35.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H3949	804	0	1	01	01	H3949_804_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H3952	008	0	1	01	01	H3952_008_0	5	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	2																																											2					2																		2		1	01000000	40.00	40.00															2	2
H3952	020	0	1	01	01	H3952_020_0	8	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	2																																											2					2																		2		1	01000000	40.00	40.00															2	2
H3952	044	0	1	01	01	H3952_044_0	5	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	2																																											2					2																		2		1	01000000	40.00	40.00															2	2
H3952	045	0	1	01	01	H3952_045_0	8	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	2																																											2					2																		2		1	01000000	40.00	40.00															2	2
H3952	048	0	1	01	01	H3952_048_0	5	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime and crowns 1 every 5 years per tooth.	2	2	1	6	#16b5, Periodontics: Includes scaling and root planning covered at 1 per 36 months, per mouth quadrant (there are 4 mouth quadrants).	2	1				2	2	1	6	Subject to limitations described in note	1		2	2000.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	40.00	40.00															2	2
H3952	049	0	1	01	01	H3952_049_0	8	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime and crowns 1 every 5 years per tooth.	2	2	1	6	#16b5, Periodontics: Includes scaling and root planning covered at 1 per 36 months, per mouth quadrant (there are 4 mouth quadrants).	2	1				2	2	1	6	Subject to limitations described in note	1		2	2000.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	40.00	40.00															2	2
H3952	050	0	1	01	01	H3952_050_0	5	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime and crowns 1 every 5 years per tooth.	2	2	1	6	#16b5, Periodontics: Includes scaling and root planning covered at 1 per 36 months, per mouth quadrant (there are 4 mouth quadrants).	2	1				2	2	1	6	Subject to limitations described in note	1		2	2000.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	40.00	40.00															2	2
H3952	051	0	1	01	01	H3952_051_0	8	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime and crowns 1 every 5 years per tooth.	2	2	1	6	#16b5, Periodontics: Includes scaling and root planning covered at 1 per 36 months, per mouth quadrant (there are 4 mouth quadrants).	2	1				2	2	1	6	Subject to limitations described in note	1		2	2000.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	40.00	40.00															2	2
H3952	053	0	1	02	01	H3952_053_0	9	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental x-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime and crowns 1 every 5 years per tooth.	2	2	1	6	#16b5, Periodontics: Includes scaling and root planing covered at 1 per 36 months, per mouth quadrant (there are 4 mouth quadrants).	2	1				2	2	1	6	Subject to limitations described in note.	1		2	2000.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	40.00	40.00															2	2
H3952	054	0	1	02	01	H3952_054_0	9	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental x-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime and crowns 1 every 5 years per tooth.	2	2	1	6	#16b5, Periodontics: Includes scaling and root planing covered at 1 per 36 months, per mouth quadrant (there are 4 mouth quadrants).	2	1				2	2	1	6	Subject to limitations described in note.	1		2	2000.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	40.00	40.00															2	2
H3952	055	0	1	01	01	H3952_055_0	9	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime and crowns 1 every 5 years per tooth.	2	2	1	6	#16b5, Periodontics: Includes scaling and root planing covered at 1 per 36 months, per mouth quadrant (there are 4 mouth quadrants).	2	1				2	2	1	6	Subject to limitations described in note	1		2	2500.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	35.00	35.00															2	2
H3952	056	0	1	01	01	H3952_056_0	10	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime and crowns 1 every 5 years per tooth.	2	2	1	6	#16b5, Periodontics: Includes scaling and root planing covered at 1 per 36 months, per mouth quadrant (there are 4 mouth quadrants).	2	1				2	2	1	6	Subject to limitations described in note	1		2	2500.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	35.00	35.00															2	2
H3952	059	0	1	01	01	H3952_059_0	5	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	#16a4, Dental x-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime and crowns 1 every 5 years per tooth.	2	2	1	6	#16b5, Periodontics: Includes scaling and root planing covered at 1 per 36 months, per mouth quadrant (there are 4 mouth quadrants).	2	1				2	2	1	6	Subject to limitations described in note.	1		2	2000.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	40.00	40.00															2	2
H3952	802	0	1	01	01	H3952_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3952	804	0	1	01	01	H3952_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3954	097	0	1	01	01	H3954_097_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		1		4500.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H3954	157	21	1	01	01	H3954_157_21	6	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		1250.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H3954	157	22	1	01	01	H3954_157_22	6	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		1250.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H3954	157	23	1	01	01	H3954_157_23	6	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		1250.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H3954	158	13	1	01	01	H3954_158_13	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		750.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H3954	158	14	1	01	01	H3954_158_14	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		750.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H3954	160	0	1	01	01	H3954_160_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		850.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H3954	161	0	1	01	01	H3954_161_0	4	2																																																															2																																											2					2																		2		1	01000000	40.00	40.00															1	2
H3954	162	0	1	01	01	H3954_162_0	2	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		1250.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H3954	163	0	1	01	01	H3954_163_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		100.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H3954	801	0	1	01	01	H3954_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3954	802	0	1	01	01	H3954_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3954	805	0	1	01	01	H3954_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3957	031	0	1	02	01	H3957_031_0	9	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	40.00	40.00															1	2
H3957	039	0	1	01	01	H3957_039_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays every 6 months and full mouth x-rays every five years.	1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		2																		1	2
H3957	042	1	1	01	01	H3957_042_1	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		2																		1	2
H3957	042	2	1	01	01	H3957_042_2	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		2																		1	2
H3957	042	4	1	01	01	H3957_042_4	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		2																		1	2
H3957	042	5	1	01	01	H3957_042_5	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		2																		1	2
H3957	043	1	1	02	01	H3957_043_1	6	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	30.00	30.00															1	2
H3957	043	2	1	02	01	H3957_043_2	6	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	30.00	30.00															1	2
H3957	044	1	1	02	01	H3957_044_1	8	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	40.00	40.00															1	2
H3957	044	4	1	02	01	H3957_044_4	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	40.00	40.00															1	2
H3957	045	1	1	02	01	H3957_045_1	8	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	30.00	30.00															1	2
H3957	045	2	1	02	01	H3957_045_2	8	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	30.00	30.00															1	2
H3957	046	1	1	02	01	H3957_046_1	8	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	25.00	25.00															1	2
H3957	046	2	1	02	01	H3957_046_2	8	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	25.00	25.00															1	2
H3957	047	1	1	01	01	H3957_047_1	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H3957	047	2	1	01	01	H3957_047_2	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H3957	047	3	1	01	01	H3957_047_3	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H3957	048	0	1	01	01	H3957_048_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years.	1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		2																		1	2
H3957	805	0	1	01	01	H3957_805_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3957	806	0	1	01	01	H3957_806_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3957	808	0	1	01	01	H3957_808_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3957	810	0	1	01	01	H3957_810_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3957	811	0	1	01	01	H3957_811_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3957	812	0	1	01	01	H3957_812_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3957	813	0	1	02	01	H3957_813_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3957	814	0	1	02	01	H3957_814_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3957	815	0	1	02	01	H3957_815_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3957	816	0	1	01	01	H3957_816_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3957	817	0	1	02	01	H3957_817_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3957	818	0	1	01	01	H3957_818_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3959	001	0	1	02	01	H3959_001_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	002	0	1	02	01	H3959_002_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	010	0	1	02	01	H3959_010_0	6	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	011	0	1	02	01	H3959_011_0	7	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	032	0	1	02	01	H3959_032_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	033	0	1	02	01	H3959_033_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	035	0	1	01	01	H3959_035_0	6	1	1111	2	1				2	1				2	1				2	1				1		6000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	036	0	1	01	01	H3959_036_0	6	1	1111	2	1				2	1				2	1				2	1				1		7000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	037	0	1	02	01	H3959_037_0	6	1	1111	2	1				2	1				2	1				2	1				1		3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	039	0	1	02	01	H3959_039_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	041	0	1	02	01	H3959_041_0	3	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	045	0	1	02	01	H3959_045_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	046	0	1	02	01	H3959_046_0	8	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	047	0	1	02	01	H3959_047_0	8	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	049	0	1	02	01	H3959_049_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	051	0	1	02	01	H3959_051_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	052	0	1	02	01	H3959_052_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	053	0	1	02	01	H3959_053_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	055	0	1	02	01	H3959_055_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	056	0	1	02	01	H3959_056_0	4	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	057	0	1	02	01	H3959_057_0	3	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	063	0	1	01	01	H3959_063_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	066	0	1	01	01	H3959_066_0	9	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3959	068	0	1	02	01	H3959_068_0	6	1	1110	2	2	4	3		2	2	2	3							2	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	2																																											2					2																		2		1	01000000	50.00	50.00															1	2
H3959	803	0	1	01	01	H3959_803_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3959	804	0	1	01	01	H3959_804_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H3962	001	0	1	01	01	H3962_001_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	1111111	2	1				2	2	1	6	1 procedure per year	2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	2	2	2	6	Periodontal maintenance only - up to 2 per year. A member may have 2 perio maintenance per year OR 2 cleanings per year (not both).	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	2	2	1	6	Complete or Partial(upper&lower)Dentures-1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement; Bridges-1 every 5 years; Oral Surgery-not covered	1		2	3000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	20.00	20.00															2	2
H3962	004	0	1	01	01	H3962_004_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	1111111	2	1				2	2	1	6	1 procedure per year	2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	2	2	2	6	Periodontal maintenance only - up to 2 per year. A member may have 2 perio maintenance per year OR 2 cleanings per year (not both).	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	2	2	1	6	Complete or Partial(upper&lower)Dentures-1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement; Bridges-1 every 5 years; Oral Surgery-not covered	1		2	2500.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	25.00	25.00															2	2
H3962	007	0	1	01	01	H3962_007_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	1111111	2	1				2	2	1	6	1 procedure per year	2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	2	2	2	6	Periodontal maintenance only - up to 2 per year. A member may have 2 perio maintenance per year OR 2 cleanings per year (not both).	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	2	2	1	6	Complete or Partial(upper&lower)Dentures-1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement; Bridges-1 every 5 years; Oral Surgery-not covered	1		2	2500.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	30.00	30.00															2	2
H3962	021	0	1	01	01	H3962_021_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	1111111	2	1				2	2	1	6	1 procedure per year	2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	2	2	2	6	Periodontal maintenance only - up to 2 per year. A member may have 2 perio maintenance per year OR 2 cleanings per year (not both).	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	2	2	1	6	Complete or Partial(upper&lower)Dentures-1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement; Bridges-1 every 5 years; Oral Surgery-not covered	1		2	2500.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	30.00	30.00															2	2
H3962	801	0	1	01	01	H3962_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3962	802	0	1	01	01	H3962_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3962	813	0	1	01	01	H3962_813_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3962	817	0	1	01	01	H3962_817_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3962	828	0	1	01	01	H3962_828_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3975	001	0	1	04	01	H3975_001_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	40.00	40.00															1	2
H3975	002	0	1	04	01	H3975_002_0	15	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1000.00	3		2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3975	004	0	1	04	01	H3975_004_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months..	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H3979	001	0	1	01	01	H3979_001_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	40.00	40.00															2	2
H3979	801	0	1	01	01	H3979_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3979	803	0	1	01	01	H3979_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3979	805	0	1	01	01	H3979_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H3991	001	0	1	20	08	H3991_001_0	1																																																																																																																																																							
H3991	002	0	1	20	08	H3991_002_0	1																																																																																																																																																							
H4003	009	0	1	01	01	H4003_009_0	7	1	1111	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	4		2	2	1	4		2	2	6	6	PERIODICITY VARIES BY SERVICE.	2					2				2		2												2		2		2												1	2	1	1011111						2	2	1	4		2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	1		2	2500.00	3		2					2																		2		2																		1	2
H4003	017	0	1	01	01	H4003_017_0	7	2																																																															1	1001000											2	2	1	6	PERIODICITY VARIES BY SERVICE.																2	2	1	6	PERIODICITY VARIES BY SERVICE.	1		2	3500.00	3		2					2																		2		2																		1	2
H4003	019	0	1	02	01	H4003_019_0	5	1	1111	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	4		2	2	1	4		2	2	6	6	PERIODICITY VARIES BY SERVICE.	2					2				2		2												2		2		2												1	2	1	1011111						2	2	1	4		2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	1		2	3500.00	3		2					2																		2		2																		1	2
H4003	034	0	1	02	01	H4003_034_0	6	1	1111	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	4		2	2	1	4		2	2	6	6	PERIODICITY VARIES BY SERVICE.	2					2				2		2												2		2		2												1	2	1	1011111						2	2	1	4		2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	1		2	2500.00	3		2					2																		2		2																		1	2
H4003	049	0	1	01	01	H4003_049_0	6	2																																																															1	1001000											2	2	1	6	PERIODICITY VARIES BY SERVICE.																2	2	1	6	PERIODICITY VARIES BY SERVICE.	1		2	2000.00	3		2					2																		2		2																		1	2
H4003	054	0	1	02	01	H4003_054_0	5	1	1111	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	4		2	2	1	4		2	2	6	6	PERIODICITY VARIES BY SERVICE.	2					2				2		2												2		2		2												1	2	1	1011111						2	2	1	4		2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY PLAN.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	1		2	2000.00	3		2					2																		2		2																		1	2
H4003	055	0	1	02	01	H4003_055_0	6	1	1111	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	4		2	2	1	4		2	2	6	6	PERIODICITY VARIES BY SERVICE.	2					2				2		2												2		2		2												1	2	1	1011111						2	2	1	4		2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	1		2	1000.00	3		2					2																		2		2																		1	2
H4003	058	0	1	01	01	H4003_058_0	6	2																																																															1	1001000											2	2	1	6	PERIODICITY VARIES BY SERVICE.																2	2	1	6	PERIODICITY VARIES BY SERVICE.	1		2	1500.00	3		2					2																		2		2																		1	2
H4003	806	0	1	02	01	H4003_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4003	807	0	1	02	01	H4003_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4003	820	0	1	02	01	H4003_820_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4003	821	0	1	02	01	H4003_821_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4003	822	0	1	02	01	H4003_822_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4003	823	0	1	02	01	H4003_823_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4003	824	0	1	02	01	H4003_824_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4003	825	0	1	02	01	H4003_825_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4003	826	0	1	02	01	H4003_826_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4003	827	0	1	02	01	H4003_827_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4003	828	0	1	02	01	H4003_828_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4003	829	0	1	02	01	H4003_829_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4004	048	0	1	01	01	H4004_048_0	6	2																																																															1	1001000											2	2	1	6	PERIODICITY VARIES BY SERVICE.																2	2	1	6	PERIODICITY VARIES BY SERVICE.	1		2	2000.00	3		2					2																		2		2																		1	2
H4004	056	0	1	02	01	H4004_056_0	5	1	1111	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	4		2	2	1	4		2	2	6	6	PERIODICITY VARIES BY SERVICE.	2					2				2		2												2		2		2												1	2	1	1011111						2	2	1	4		2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	1		2	1500.00	3		2					2																		2		2																		1	2
H4004	062	0	1	01	01	H4004_062_0	6	2																																																															1	1001000											2	2	1	6	PERIODICITY VARIES BY SERVICE.																2	2	1	6	PERIODICITY VARIES BY SERVICE.	1		2	2000.00	3		2					2																		2		2																		1	2
H4004	063	0	1	02	01	H4004_063_0	5	1	1111	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	4		2	2	1	4		2	2	6	6	PERIODICITY VARIES BY SERVICE.	2					2				2		2												2		2		2												1	2	1	1011111						2	2	1	4		2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	1		2	1500.00	3		2					2																		2		2																		1	2
H4004	065	0	1	02	01	H4004_065_0	5	1	1111	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	4		2	2	1	4		2	2	6	6	PERIODICITY VARIES BY SERVICE.	2					2				2		2												2		2		2												1	2	1	1011111						2	2	1	4		2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	1		2	2000.00	3		2					2																		2		2																		1	2
H4004	066	0	1	02	01	H4004_066_0	4	1	1111	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	4		2	2	1	4		2	2	6	6	PERIODICITY VARIES BY SERVICE.	2					2				2		2												2		2		2												1	2	1	1011111						2	2	1	4		2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	2	2	1	6	PERIODICITY VARIES BY SERVICE.	1		2	500.00	3		2					2																		2		2																		1	2
H4004	067	0	1	01	01	H4004_067_0	6	2																																																															1	1001000											2	2	1	6	PERIODICITY VARIES BY SERVICE.																2	2	1	6	PERIODICITY VARIES BY SERVICE.	1		2	1000.00	3		2					2																		2		2																		1	2
H4004	817	0	1	02	01	H4004_817_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4004	818	0	1	02	01	H4004_818_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4004	819	0	1	02	01	H4004_819_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4004	820	0	1	02	01	H4004_820_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4004	822	0	1	02	01	H4004_822_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4004	823	0	1	02	01	H4004_823_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4004	824	0	1	02	01	H4004_824_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4004	825	0	1	02	01	H4004_825_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4004	826	0	1	02	01	H4004_826_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4004	827	0	1	02	01	H4004_827_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4004	828	0	1	02	01	H4004_828_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4004	829	0	1	02	01	H4004_829_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4005	001	0	1	04	01	H4005_001_0	4	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	1	2	2	2000.00	3		2					2																		2		2																		1	2
H4005	004	0	1	04	01	H4005_004_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	1	2	2	1700.00	3		2					2																		2		2																		1	2
H4005	007	0	1	04	01	H4005_007_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	1	2	2	3250.00	3		2					2																		2		2																		1	2
H4005	801	0	1	04	01	H4005_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4005	802	0	1	04	01	H4005_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4005	804	0	1	04	01	H4005_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4005	807	0	1	04	01	H4005_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4005	808	0	1	04	01	H4005_808_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4007	012	0	1	01	01	H4007_012_0	5	1	1110	2	2	2	3		2	2	4	3							2	2	8	6	Dental X-Rays include bitewing x-rays up to 1 set(s) every 2 years, intraoral x-rays up to 6 per year, panoramic film up to 1 every 3 years.	2					2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	1011111						2	2	1	1		2	2	2	6	Restorative services include amalgam and/or composite filling up to 1 per tooth every 3 years, crown up to 1 per tooth every 5 years.	2	1				2	2	1	3		2	1				2	2	8	6	to dentures unlimited per year, implant svcs up to 1/tooth per life, implant supported prosth. 1/tooth every 5 years, partial/complete dentures up to 1 set/5 years, bridges up to 1/5 years	1		2	2000.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	0.00	0.00															1	2
H4007	016	0	1	01	01	H4007_016_0	10	1	1110	2	2	2	3		2	2	4	3							2	2	8	6	Dental X-Rays services include bitewing x-rays up to 1 set(s) every 2 years, intraoral x-rays up to 6 per year, panoramic film up to 1 every 3 years.	2					2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	1011111						2	2	4	6	Diagnostic Services services include comprehensive oral exam and cone beam CT imaging up to 1 every 3 years, pulp vitality test up to 2 per quadrant per year.	2	2	2	6	Amalgam or composite filling up to 1 per tooth every 3 years, crown up to 1 per tooth every 5 years. $2,500 maximum benefit per year that only applies to crowns	2	1				2	2	2	6	Periodontics services include periodontal surgery up to 1 per quadrant every 3 years, scaling and root planing (deep cleaning) up to 1 per quadrant per year.	2	1				2	2	9	6	Dent. adjstmnts unlmtd/yr;brdges, comp. dent., comp. or part. dent. reline, and part. dent. 1/5 yrs; comp. or part. dent. rpair 3/yr; implnt srvces 1/tooth/lfetme; implnt spprted prosth. 1/tooth/5 yrs	1		2	2500.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	0.00	0.00															1	2
H4007	018	0	1	01	01	H4007_018_0	5	1	1110	2	2	2	3		2	2	4	3							2	2	8	6	Dental X-Rays include bitewing x-rays up to 1 set(s) every 2 years, intraoral x-rays up to 6 per year, panoramic film up to 1 every 3 years.	2					2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	1011111						2	2	4	6	Diagnostic Services services include comprehensive oral exam and cone beam CT imaging up to 1 every 3 years, pulp vitality test up to 2 per quadrant per year.	2	2	2	6	Restorative services include amalgam or composite filling up to 1 per tooth every 3 years, crown up to 1 per tooth every 5 years, $2,500 maximum benefit per year that only applies to crowns.	2	1				2	2	2	6	Periodontics services include periodontal surgery up to 1 per quadrant every 3 years, scaling and root planing (deep cleaning) up to 1 per quadrant per year.	2	1				2	2	9	6	Denture adj. unlimited/yr, bridges, complete and partial dentures and denture reline 1/5 years, complete or partial denture repair 3/yr, implant svcs 1/tooth/life, implant prost. 1/tooth/5 yrs	1		2	2500.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	0.00	0.00															1	2
H4007	019	0	1	01	01	H4007_019_0	5	1	1110	2	2	2	3		2	2	4	3							2	2	8	6	Dental X-Rays services include bitewing x-rays up to 1 set(s) every 2 years, intraoral x-rays up to 6 per year, panoramic film up to 1 every 3 years.	2					2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	1011111						2	2	4	6	Diagnostic Services services include comprehensive oral exam and cone beam CT imaging up to 1 every 3 years, pulp vitality test up to 2 per quadrant per year.	2	2	2	6	Restorative services include amalgam or composite filling up to 1 per tooth every 3 years, crown up to 1 per tooth every 5 years, $2,000 maximum benefit per year that only applies to crowns.	2	1				2	2	2	6	Periodontics services include periodontal surgery up to 1 per quadrant every 3 years, scaling and root planing (deep cleaning) up to 1 per quadrant per year.	2	1				2	2	9	6	Denture adj. unlimited/yr, bridges, complete and partial dentures and denture reline 1/5 years, complete or partial denture repair 3/yr, implant svcs 1/tooth/life, implant prost. 1/tooth/5 yrs	1		2	2000.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	0.00	0.00															1	2
H4007	020	0	1	01	01	H4007_020_0	6	1	1110	2	2	2	3		2	2	4	3							2	2	8	6	Dental X-Rays include bitewing x-rays up to 1 set(s) every 2 years, intraoral x-rays up to 6 per year, panoramic film up to 1 every 3 years.	2					2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	1011111						2	2	4	1		2	2	2	6	Restorative services include fillings 0% up to 1 per tooth every 3 years, crown 0% up to 1 per tooth every 5 years, $1500 maximum benefit per year that only applies to crowns.	2	1				2	2	1	3		2	1				2	2	5	6	Prosths, Oral/Maxillo Surgery, bridges-crown up to 1 every 5 years, bridges-pontic up to 1every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.Dentures, unlimited	1		2	1500.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	3.00	3.00															1	2
H4007	021	0	1	01	01	H4007_021_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	8	6	Dental X-Rays include bitewing x-rays up to 1 set(s) every 2 years, intraoral x-rays up to 6 per year, panoramic film up to 1 every 3 years.	2					2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	1011111						2	2	2	1		2	2	2	6	Restorative services include fillings 0% up to 1 per tooth every 3 years, crown 0% up to 1 per tooth every 5 years, $7500 maximum benefit per year that only applies to crowns.	2	1				2	2	1	3		2	1				2	2	5	6	Dentures adjustment unlimited/year, implant svcs 1/ tooth/lifetime, implant supported prosthetic (abutment crown) 1 per tooth/5 years, complete and partial denture 1 set(s)/5 years, bridges 1/5 years	1		2	7500.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	0.00	0.00															1	2
H4007	024	0	1	01	01	H4007_024_0	5	1	1110	2	2	2	3		2	2	4	3							2	2	8	6	Dental X-Rays services include bitewing x-rays up to 1 set(s) every 2 years, intraoral x-rays up to 6 per year, panoramic film up to 1 every 3 years.	2					2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	1011111						2	2	4	6	Diagnostic Services services include comprehensive oral exam and cone beam CT imaging up to 1 every 3 years, pulp vitality test up to 2 per quadrant per year.	2	2	2	6	Restorative services include amalgam and/or composite filling up to 1 per tooth every 3 years, crown up to 1 per tooth every 5 years. $7500 maximum benefit per year that only applies to crowns.	2	1				2	2	2	6	Periodontics services include periodontal surgery up to 1 per quadrant every 3 years, scaling and root planing (deep cleaning) up to 1 per quadrant per year.	2	1				2	2	9	6	Adj. to dentures-unlimited. Bridges,comp./part. dentures,denture reline-1/5 years. Comp./part. denture repair-3/year. Implant services-1 per tooth/life. Implant supported prosth.-1 per tooth/5 years	1		2	7500.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	0.00	0.00															1	2
H4007	025	0	1	01	01	H4007_025_0	4	1	1110	2	2	2	3		2	2	4	3							2	2	8	6	Dental X-Rays include bitewing x-rays up to 1 set(s) every 2 years, intraoral x-rays up to 6 per year, panoramic film up to 1 every 3 years.	2					2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	1011111						2	2	4	6	Diagnostic Services services include comprehensive oral exam and cone beam CT imaging up to 1 every 3 years, pulp vitality test up to 2 per quadrant per year.	2	2	2	6	Restorative services include amalgam and/or composite filling up to 1 per tooth every 3 years, crown up to 1 per tooth every 5 years. $7500 maximum benefit per year that only applies to crowns.	2	1				2	2	2	6	Periodontics services include periodontal surgery up to 1 per quadrant every 3 years, scaling and root planing (deep cleaning) up to 1 per quadrant per year.	2	1				2	2	9	6	Adj. to dentures-unlimited. Bridges,comp./part. dentures,denture reline-1/5 years. Comp./part. denture repair-3/year. Implant services-1 per tooth/life. Implant supported prosth.-1 per tooth/5 years	1		2	7500.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	0.00	0.00															1	2
H4007	026	0	1	01	01	H4007_026_0	5	1	1110	2	2	2	3		2	2	4	3							2	2	8	6	Dental X-Rays services include bitewing x-rays up to 1 set(s) every 2 years, intraoral x-rays up to 6 per year, panoramic film up to 1 every 3 years.	2					2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	1011111						2	2	4	6	Diagnostic Services services include comprehensive oral exam and cone beam CT imaging up to 1 every 3 years, pulp vitality test up to 2 per quadrant per year.	2	2	2	6	Restorative services include amalgam or composite filling up to 1 per tooth every 3 years, crown up to 1 per tooth every 5 years, $5,000 maximum benefit per year that only applies to crowns.	2	1				2	2	2	6	Periodontics services include periodontal surgery up to 1 per quadrant every 3 years, scaling and root planing (deep cleaning) up to 1 per quadrant per year.	2	1				2	2	9	6	Denture adj. unlimited/yr, bridges, complete and partial dentures and denture reline 1/5 years, complete or partial denture repair 3/yr, implant svcs 1/tooth/life, implant prost. 1/tooth/5 yrs	1		2	5000.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	0.00	0.00															1	2
H4007	027	0	1	01	01	H4007_027_0	5	1	1110	2	2	2	3		2	2	4	3							2	2	8	6	Dental X-Rays include bitewing x-rays up to 1 set(s) every 2 years, intraoral x-rays up to 6 per year, panoramic film up to 1 every 3 years.	2					2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	1011111						2	2	4	6	Diagnostic Services services include comprehensive oral exam and cone beam CT imaging up to 1 every 3 years, pulp vitality test up to 2 per quadrant per year.	2	2	2	6	Restorative services include amalgam or composite filling up to 1 per tooth every 3 years, crown up to 1 per tooth every 5 years, $2,500 maximum benefit per year that only applies to crowns.	2	1				2	2	2	6	Periodontics services include periodontal surgery up to 1 per quadrant every 3 years, scaling and root planing (deep cleaning) up to 1 per quadrant per year.	2	1				2	2	9	6	Denture adj unlimited/year, bridges, comp./partial dentures, comp./partial denture reline, 1/5 years, comp./partial denture repair 3/year, implant svcs 1/tooth/life, implant prost. 1/tooth/5 years	1		2	2500.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	0.00	0.00															1	2
H4007	028	0	1	02	01	H4007_028_0	5	1	1110	2	2	2	3		2	2	4	3							2	2	8	6	Dental X-Rays include bitewing x-rays up to 1 set(s) every 2 years, intraoral x-rays up to 6 per year, panoramic film up to 1 every 3 years.	2					2				1	1110	2				0	0	0	0			0	0	2		2		2												2	1	1	1011111						2	2	4	6	Comprehensive oral exam and cone beam CT imaging up to 1 every 3 years, pulp vitality test up to 2 per quadrant per year.	2	2	2	6	Restorative services include fillings up to 1 per tooth every 3 years, crown up to 1 per tooth every 5 years	2	1				2	2	2	6	Periodontal surgery up to 1 per quadrant every 3 years, scaling and root planing (deep cleaning) up to 1 per quadrant per year.	2	1				2	2	9	6	Dent adj. unlimited/per year.Bridges, comp/part dent, and comp/part dent reline 1/5 yrs. Comp/part dent repair 3/yr. Implant srvces 1/tooth/lifetime. Implant supported prosts. 1/per tooth/every 5 yrs.	1		2	10000.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	0.00	0.00															1	1
H4007	029	0	1	01	01	H4007_029_0	5	1	1110	2	2	2	3		2	2	4	3							2	2	8	6	Bitewing x-rays up to 1 set(s) every 2 years, intraoral x-rays up to 6 per year, panoramic film up to 1 every 3 years.	2					2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	1011111						2	2	4	6	Comprehensive oral exam and cone beam CT imaging up to 1 every 3 years, pulp vitality test up to 2 per quadrant per year.	2	2	2	6	Amalgam and/or composite fillings 1 per tooth every 3 years, crowns 1 per tooth every 5 years	2	1				2	2	2	6	Periodontal surgery up to 1 per quadrant every 3 years, scaling and root planing (deep cleaning) up to 1 per quadrant per year.	2	1				2	2	9	6	Dent. adjstmnts unlimited/yr.Bridges, comp./part.dent., comp./part. and dent. reline 1/5 yrs, comp/part. dent. repair 3/yr.Implant services 1/tooth/lifetime.Implant supported prosthetics 1/tooth/5 yrs	1		2	5000.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	0.00	0.00															1	2
H4007	030	0	1	01	01	H4007_030_0	5	1	1110	2	2	2	3		2	2	4	3							2	2	8	6	Dental X-Rays include bitewing x-rays up to 1 set(s) every 2 years, intraoral x-rays up to 6 per year, panoramic film up to 1 every 3 years.	2					2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	1011111						2	2	4	6	Diagnostic Services include comprehensive oral exam and cone beam CT imaging up to 1 every 3 years, pulp vitality test up to 2 per quadrant per year.	2	2	2	6	Restorative services include amalgam or composite filling up to 1 per tooth every 3 years, crown up to 1 per tooth every 5 years, $2,000 maximum benefit per year that only applies to crowns.	2	1				2	2	2	6	Periodontics services include periodontal surgery up to 1 per quadrant every 3 years, scaling and root planing (deep cleaning) up to 1 per quadrant per year.	2	1				2	2	9	6	Denture adj. unlimited/yr, bridges, complete and partial dentures and denture reline 1/5 years, complete or partial denture repair 3/yr, implant svcs 1/tooth/life, implant prost. 1/tooth/5 yrs	1		2	2000.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	0.00	0.00															1	2
H4007	801	0	1	01	01	H4007_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4007	802	0	1	01	01	H4007_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4007	819	0	1	01	01	H4007_819_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4007	820	0	1	01	01	H4007_820_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4007	829	0	1	01	01	H4007_829_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4007	830	0	1	01	01	H4007_830_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4007	833	0	1	02	01	H4007_833_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4007	834	0	1	02	01	H4007_834_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4007	835	0	1	02	01	H4007_835_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4007	836	0	1	02	01	H4007_836_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4007	837	0	1	02	01	H4007_837_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4007	838	0	1	02	01	H4007_838_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4036	008	0	1	04	01	H4036_008_0	6	1	1111	4	2	2	3		4	2	2	3		4	2	1	3		4	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H4036	017	0	1	04	01	H4036_017_0	10	1	1111	4	1				4	1				4	1				4	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4036	020	0	1	04	01	H4036_020_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					1	10101111			50	50			50	50	70	70	70	70	50	50	70	70	2		1	01010000	0.00	0.00			0.00	0.00											1	2
H4036	022	0	1	04	01	H4036_022_0	9	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4036	024	0	1	04	01	H4036_024_0	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4036	025	0	1	04	01	H4036_025_0	9	1	1111	4	1				4	1				4	1				4	1				1	2	1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4036	026	0	1	04	01	H4036_026_0	10	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					1	10101111			50	50			50	50	70	70	70	70	50	50	70	70	2		1	01010000	0.00	0.00			0.00	0.00											1	2
H4036	028	0	1	04	01	H4036_028_0	8	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4036	029	0	1	04	01	H4036_029_0	8	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4036	030	0	1	04	01	H4036_030_0	6	1	1111	4	1				4	1				4	1				4	1				1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4036	031	0	1	04	01	H4036_031_0	6	1	1111	4	1				4	1				4	1				4	1				1	2	1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4036	032	0	1	04	01	H4036_032_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4036	033	0	1	04	01	H4036_033_0	6	1	1111	4	1				4	1				4	1				4	1				1	2	1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4036	034	0	1	04	01	H4036_034_0	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4036	035	0	1	04	01	H4036_035_0	7	1	1111	4	1				4	1				4	1				4	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4036	036	0	1	04	01	H4036_036_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					1	10101111			50	50			50	50	70	70	70	70	50	50	70	70	2		1	01010000	0.00	0.00			0.00	0.00											1	2
H4036	801	0	1	04	01	H4036_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	802	0	1	04	01	H4036_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	805	0	1	04	01	H4036_805_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	806	0	2	04	01	H4036_806_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	807	0	1	04	01	H4036_807_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	809	0	2	04	01	H4036_809_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	810	0	2	04	01	H4036_810_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	812	0	1	04	01	H4036_812_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	813	0	1	04	01	H4036_813_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	814	0	1	04	01	H4036_814_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	819	0	1	04	01	H4036_819_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	820	0	1	04	01	H4036_820_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	821	0	2	04	01	H4036_821_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	822	0	2	04	01	H4036_822_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	823	0	1	04	01	H4036_823_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	824	0	1	04	01	H4036_824_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	825	0	2	04	01	H4036_825_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	826	0	2	04	01	H4036_826_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	827	0	1	04	01	H4036_827_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	828	0	1	04	01	H4036_828_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	829	0	2	04	01	H4036_829_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4036	830	0	2	04	01	H4036_830_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4045	001	0	1	01	01	H4045_001_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4053	001	0	1	20	08	H4053_001_0	1																																																																																																																																																							
H4053	002	0	1	20	08	H4053_002_0	1																																																																																																																																																							
H4054	001	0	1	01	01	H4054_001_0	5	1	1111	2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		1		5000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H4073	001	0	1	01	01	H4073_001_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	25.00	25.00															1	2
H4073	002	0	1	01	01	H4073_002_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4073	003	0	1	01	01	H4073_003_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	25.00	25.00															1	2
H4074	001	0	1	20	08	H4074_001_0	1																																																																																																																																																							
H4074	002	0	1	20	08	H4074_002_0	2																																																																																																																																																							
H4091	001	0	1	04	01	H4091_001_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4091	002	0	1	04	01	H4091_002_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	2400.00	3		2				2		2												2		2		2												2	2	1	1001100											2	1				2	1														2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H4091	003	0	1	04	01	H4091_003_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	3		1	2	750.00	3		2				2		2												2		2		2												2	2	1	1001101											2	1				2	1									2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H4093	001	0	1	01	01	H4093_001_0	5	1	1111	2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H4093	004	0	1	01	01	H4093_004_0	5	1	1111	2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H4094	001	0	1	02	01	H4094_001_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4105	001	0	1	20	08	H4105_001_0	1																																																																																																																																																							
H4105	002	0	1	20	08	H4105_002_0	1																																																																																																																																																							
H4118	001	0	1	20	08	H4118_001_0	1																																																																																																																																																							
H4118	002	0	1	20	08	H4118_002_0	1																																																																																																																																																							
H4140	001	0	1	01	01	H4140_001_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years	2					2				2		2												2		2		2												2	2	1	1001111											2	2	5	3		2	2	1	3		2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2	2	4	3		2	2	3	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years. Plan covers 1 dental implant per year.	2						2					2																		2		2																		1	2
H4140	002	0	1	01	01	H4140_002_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years	2					2				2		2												2		2		2												2	2	1	1001111											2	2	7	3		2	2	1	3		2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2	2	4	3		2	2	3	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years. Plan covers 1 dental implant per year.	2						2					2																		2		2																		1	2
H4140	004	0	1	01	01	H4140_004_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years	2					2				2		2												2		2		2												2	2	1	1001111											2	2	5	3		2	2	1	3		2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2	2	4	3		2	2	3	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years. Plan covers 1 dental implant per year.	2						2					2																		2		2																		1	2
H4140	005	0	1	01	01	H4140_005_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years	2					2				2		2												2		2		2												2	2	1	1001011											2	2	1	3							2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2	2	2	3		2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years.	2						2					2																		2		2																		1	2
H4140	009	0	1	01	01	H4140_009_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years	2					2				2		2												2		2		2												2	2	1	1001111											2	2	6	3		2	2	1	3		2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2	2	4	3		2	2	3	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years. Plan covers 1 dental implant per year.	2						2					2																		2		2																		1	2
H4140	010	0	1	01	01	H4140_010_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years	2					2				2		2												2		2		2												2	2	1	1001111											2	2	3	3		2	2	1	3		2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2	2	2	3		2	2	3	6	Plan covers 1 full upper and 1 full lower denture per 5 years or Plan covers 1 upper partial and 1 lower partial denture per 5 years. Plan covers one implant per year.	2						2					2																		2		2																		1	2
H4140	011	0	1	01	01	H4140_011_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years	2					2				2		2												2		2		2												2	2	1	0001111											2	2	3	3		2	2	1	3		2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2	2	2	3							2						2					2																		2		2																		1	2
H4140	012	0	1	01	01	H4140_012_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years	2					2				2		2												2		2		2												2	2	1	1001111											2	2	3	3		2	2	1	3		2	2	1	3		2	2	4	3		2	2	3	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years. Plan covers 1 dental implant per year.	2						2					2																		2		2																		1	2
H4140	013	0	1	01	01	H4140_013_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years	2					2				2		2												2		2		2												2	2	1	1001111											2	2	7	3		2	2	1	3		2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2	2	4	3		2	2	3	6	Plan covers 1 full upper and 1 full lower denture per 5 years or Plan covers 1 upper partial and 1 lower partial denture per 5 years. Plan covers 1 dental implant per year.	2						2					2																		2		2																		1	2
H4141	003	0	1	01	01	H4141_003_0	8	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Partial and complete denture up to 1 every 5 years, oral surgery up to 2 per year, denture adj., reline, repair, rebase, tissue conditioning up to 1 per year, occlusal adjustment up to 1 every 3 years	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4141	015	0	1	01	01	H4141_015_0	10	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	partial dentures complete dentures up to 1 every 5 years, oral surgery up to 2 per year, denture adjustment /reline/repair rebase and conditioning up to 1 per year, adjustments up to 1 every 3 years.	1		1				2					2																		2		1	11111111	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4141	017	3	1	01	01	H4141_017_3	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	2	6	Restorative services include amalgam and/or composite filling up to unlimited per year, crown and other restorative services - core buildup and prefabricated post/core up to 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Partial dentures and complete dentures up to 1 every 5 years, oral surgery up to 2 per year, denture care up to 1 every year, occlusal adjustments up to 1 every 3 years.	1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4141	017	5	1	01	01	H4141_017_5	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4141	021	0	1	01	01	H4141_021_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services services include adjustments to dentures, denture rebase, denture reline, denture repair and tissue conditioning up to 1 per year, comp	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4141	801	0	1	01	01	H4141_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4141	802	0	1	01	01	H4141_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4141	805	0	1	01	01	H4141_805_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4141	806	0	1	01	01	H4141_806_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4142	001	0	1	20	08	H4142_001_0	1																																																																																																																																																							
H4142	002	0	1	20	08	H4142_002_0	1																																																																																																																																																							
H4152	004	0	1	01	01	H4152_004_0	6	1	1111	2	2	1	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing X-rays - 1 set per calendar yearIndividual X-rays - 4 per calendar yearFull mouth series or Panorex - 1 per 60 month period	1		1500.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H4152	005	0	1	01	01	H4152_005_0	7	1	1111	2	2	1	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing X-rays - 1 set per calendar yearIndividual X-rays - 4 per calendar yearFull mouth series or Panorex - 1 per 60 month period	1		1500.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H4152	007	0	1	02	01	H4152_007_0	7	1	1111	2	2	1	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing X-rays - 1 set per calendar yearIndividual X-rays - 4 per calendar yearFull mouth series or Panorex - 1 per 60 month period	1		1500.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H4152	013	0	1	01	01	H4152_013_0	7	1	1111	2	2	1	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing X-rays - 1 set per calendar yearIndividual X-rays - 4 per calendar yearFull mouth series or Panorex - 1 per 60 month period	1		1500.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H4152	018	0	1	02	01	H4152_018_0	7	1	1111	2	2	1	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing X-rays - 1 set per calendar yearIndividual X-rays - 4 per calendar yearFull mouth series or Panorex - 1 per 60 month period	1		1500.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H4152	020	0	1	02	01	H4152_020_0	8	1	1111	2	2	1	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing X-rays - 1 set per calendar yearIndividual X-rays - 4 per calendar yearFull mouth series or Panorex - 1 per 60 month period	1		1500.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H4152	021	0	1	01	01	H4152_021_0	9	1	1111	2	2	1	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing X-rays - 1 set per calendar yearIndividual X-rays - 4 per calendar yearFull mouth series or Panorex - 1 per 60 month period	1		3000.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H4152	815	0	1	02	01	H4152_815_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4152	817	0	1	01	01	H4152_817_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4161	002	0	1	01	01	H4161_002_0	7	1	1111	4	1				4	1				4	1				4	1				1		2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4161	003	0	1	01	01	H4161_003_0	7	1	1111	2	1				2	1				2	1				2	1				1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4161	004	0	1	01	01	H4161_004_0	7	1	1111	4	2	1	3		4	2	1	3		4	1				4	1				2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		2	500.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H4161	005	0	1	01	01	H4161_005_0	7	1	1111	4	2	1	3		4	2	1	3		4	1				4	1				2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		2	500.00	3		2					2																		2		1	01000000	10.00	10.00															1	2
H4161	006	0	1	01	01	H4161_006_0	8	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4161	007	0	1	01	01	H4161_007_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4161	009	0	1	01	01	H4161_009_0	7	1	1111	4	1				4	1				4	1				4	1				1		1600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4161	010	0	1	01	01	H4161_010_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4161	011	0	1	01	01	H4161_011_0	7	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4161	012	0	1	01	01	H4161_012_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4161	013	0	1	01	01	H4161_013_0	7	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4172	001	0	1	01	01	H4172_001_0	4	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Refer to the Notes for periodicity details.	1		1650.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Refer to the Notes for periodicity details.	2	1				2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	1		1				2					1	01000000	20	20															2		2																		1	2
H4172	003	0	1	01	01	H4172_003_0	5	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Refer to the Notes for periodicity details.	1		1650.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Refer to the Notes for periodicity details.	2	1				2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	1		1				2					1	01000000	20	20															2		2																		1	2
H4185	001	0	1	20	08	H4185_001_0	1																																																																																																																																																							
H4185	002	0	1	20	08	H4185_002_0	1																																																																																																																																																							
H4198	007	0	1	01	01	H4198_007_0	4	1	1111	2	2	2	6	Periodic, detailed and extensive problem focused, re-evaluation exams are limited to 2 per 12 months. Limited oral evaluation problem focused is limited to 3 per 12 months.	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2	2	1	6	Bitewings (1-4 films) are limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series are limited to 1 per 36 months.	2					2				2		2												2		2		2												2	2	1	1001111											2	1				2	2	1	6	Root canals are limited to 1 per lifetime per tooth. Therapeutic pulpotomoy and pulpal debridement are limited to 1 per lifetime per tooth.	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months. Periodontal maintenance is limited to 4 every 12 months.	2	2	1	6	Extractions are limited to 1 per tooth per lifetime. Coronectomy is limited to 1 per tooth per lifetime	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months. Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1		2	1500.00	3		2					2																		2		1	01000000	35.00	35.00															1	2
H4198	008	0	1	01	01	H4198_008_0	4	1	1111	2	2	2	6	Periodic, detailed and extensive problem focused, re-evaluation exams are limited to 2 per 12 months. Limited oral evaluation problem focused is limited to 3 per 12 months.	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2	2	1	6	Bitewings (1-4 films) are limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series are limited to 1 per 36 months.	2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2	2	1	6	Root canals are limited to 1 per lifetime per tooth. Therapeutic pulpotomoy and pulpal debridement are limited to 1 per lifetime per tooth.	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months. Periodontal maintenance is limited to 4 every 12 months.	2	2	1	6	Extractions are limited to 1 per tooth per lifetime. Coronectomy is limited to 1 per tooth per lifetime	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months. Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1		2	1500.00	3		2					2																		2		1	01000000	40.00	40.00															1	2
H4198	009	0	1	01	01	H4198_009_0	5	1	1111	2	2	2	6	Periodic, detailed and extensive problem focused, re-evaluation exams are limited to 2 per 12 months. Limited oral evaluation problem focused is limited to 3 per 12 months.	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2	2	1	6	Bitewings (1-4 films) are limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series are limited to 1 per 36 months.	2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2	2	1	6	Root canals are limited to 1 per lifetime per tooth. Therapeutic pulpotomoy and pulpal debridement are limited to 1 per lifetime per tooth.	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months. Periodontal maintenance is limited to 4 every 12 months.	2	2	1	6	Extractions are limited to 1 per tooth per lifetime. Coronectomy is limited to 1 per tooth per lifetime	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months. Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1		2	1500.00	3		2					2																		2		1	01000000	35.00	35.00															1	2
H4198	803	0	1	01	01	H4198_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4203	001	0	1	20	08	H4203_001_0	1																																																																																																																																																							
H4203	002	0	1	20	08	H4203_002_0	1																																																																																																																																																							
H4213	016	1	1	09	04	H4213_016_1	2	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	1	2	2000.00	3		2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001011											2	2	1	3							2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	2	1				2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1		1				2					1	10001011							20	20			20	20	20	20	20	20	2		1	01000000	50.00	50.00															2	2
H4213	016	3	1	09	04	H4213_016_3	2	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	1	2	2000.00	3		2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001011											2	2	1	3							2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	2	1				2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1		1				2					1	10001011							20	20			20	20	20	20	20	20	2		1	01000000	50.00	50.00															2	2
H4213	016	4	1	09	04	H4213_016_4	2	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	1	2	2000.00	3		2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001011											2	2	1	3							2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	2	1				2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1		1				2					1	10001011							20	20			20	20	20	20	20	20	2		1	01000000	50.00	50.00															2	2
H4213	017	1	1	09	04	H4213_017_1	3	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	1	2	2000.00	3		2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001011											2	2	1	3							2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	2	1				2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1		1				2					1	10001011							20	20			20	20	20	20	20	20	2		1	01000000	50.00	50.00															2	2
H4213	017	5	1	09	04	H4213_017_5	3	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	1	2	2000.00	3		2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001011											2	2	1	3							2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	2	1				2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1		1				2					1	10001011							20	20			20	20	20	20	20	20	2		1	01000000	50.00	50.00															2	2
H4213	017	6	1	09	04	H4213_017_6	3	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	1	2	2000.00	3		2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001011											2	2	1	3							2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	2	1				2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1		1				2					1	10001011							20	20			20	20	20	20	20	20	2		1	01000000	50.00	50.00															2	2
H4227	001	0	1	01	01	H4227_001_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	4	6	1 every 5 years per member per year.	2					2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Prior authorization required. Pre and post-op radiographs required. Prior authorization required.	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. 1 per 24 mo. Per quadrant. Debridement once per year. Subject to the $3000 combined limit every year.	2	1				2	2	1	6	Periodicity varies by procedure, see full note below.	1		2	3000.00	3		2					2																		2		2																		1	2
H4227	002	0	1	01	01	H4227_002_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	4	6	1 every 5 years per member per year.	2					2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Prior authorization required. Pre and post-op radiographs required. Prior authorization required.	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. 1 per 24 mo. Per quadrant. Debridement once per year. Subject to the $3000 combined limit every year.	2	1				2	2	1	6	Periodicity varies by procedure, see full note below.	1		2	3000.00	3		2					2																		2		2																		1	2
H4232	001	0	1	01	01	H4232_001_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4232	003	0	1	01	01	H4232_003_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4235	001	0	1	20	08	H4235_001_0	1																																																																																																																																																							
H4235	002	0	1	20	08	H4235_002_0	1																																																																																																																																																							
H4256	001	0	1	20	08	H4256_001_0	2																																																																																																																																																							
H4256	002	0	1	20	08	H4256_002_0	2																																																																																																																																																							
H4277	001	0	1	04	01	H4277_001_0	5	1	1111	2	2	2	6	Periodic, detailed and extensive problem focused, re-evaluation exams are limited to 2 per 12 months. Limited oral evaluation problem focused is limited to 3 per 12 months.	2	2	2	6	Limited to 2 (two) treatments per 12 month period.Dental services must be provided by a participating dental provider.	2	2	2	6	Limited to 2 (two) treatments per 12 month period.Dental services must be provided by a participating dental provider.	2	2	1	6	Dental services must be obtained from a participating dental provider.	2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2	2	1	6	Dental services must be provided by a participating dental provider.	2	2	1	6	Dental services must be provided by a participating dental provider.	2	2	1	6	Dental services must be provided by a participating dental provider.	2	2	1	6	Dental services must be provided by a participating dental provider.	1	1	2	1500.00	3		2					2																		2		1	01000000	40.00	40.00															1	2
H4279	001	0	1	01	01	H4279_001_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	8250.00	3		2					1	01000000	20	20															2		2																		2	2
H4279	004	0	1	01	01	H4279_004_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	5000.00	3		2					1	01000000	20	20															2		2																		2	2
H4286	001	0	1	01	01	H4286_001_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	4		1		7000.00	3		2				2		2												2		2		2												1	1	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H4286	002	0	1	01	01	H4286_002_0	11	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	4		1		5000.00	3		2				2		2												2		2		2												1	1	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H4286	003	0	1	01	01	H4286_003_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	4		1		5000.00	3		2				2		2												2		2		2												1	1	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H4305	001	0	1	20	08	H4305_001_0	1																																																																																																																																																							
H4305	002	0	1	20	08	H4305_002_0	1																																																																																																																																																							
H4326	001	0	1	20	08	H4326_001_0	1																																																																																																																																																							
H4326	002	0	1	20	08	H4326_002_0	1																																																																																																																																																							
H4343	001	0	1	01	01	H4343_001_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H4343	003	0	1	01	01	H4343_003_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	5000.00	3		2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4346	001	0	1	01	01	H4346_001_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4346	005	0	1	01	01	H4346_005_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4346	006	0	1	01	01	H4346_006_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4346	009	0	1	01	01	H4346_009_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4346	010	0	1	01	01	H4346_010_0	7	1	1111	4	1				4	1				4	1				4	1				1		1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4346	012	0	1	01	01	H4346_012_0	7	2		3					3					3					3																																														2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H4346	014	0	1	01	01	H4346_014_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	1	6	Restorative Fillings - 1 per tooth every 3 yearsRestorative Crowns - 1 per tooth every 5 years	2	1				2	2	1	6	Periodontal Root Planning and Scaling - 1 per quadrant every 2 years	2	2	1	6	Extractions: 1 per tooth per lifetime	2	2	1	6	Prosthodontics (Dentures) - 1 set every 5 years	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4346	017	0	1	01	01	H4346_017_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4346	019	0	1	01	01	H4346_019_0	7	1	1111	4	1				4	1				4	1				4	1				1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4346	025	0	1	01	01	H4346_025_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4346	026	0	1	01	01	H4346_026_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4346	029	0	1	01	01	H4346_029_0	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	2	1	6	Restorative: Fillings - 1 per tooth every 3 yearsRestorative Crowns - 1 per tooth every 5 years	4	1				4	2	1	6	Periodontal Root Planning and Scaling - 1 per quadrant every 2 years	4	1				4	2	1	6	Prosthodontics (Dentures) - 1 set every 5 years	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4346	805	0	1	01	01	H4346_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4346	806	0	2	01	01	H4346_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4346	809	0	1	01	01	H4346_809_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4346	810	0	2	01	01	H4346_810_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4346	812	0	1	01	01	H4346_812_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4346	821	0	2	01	01	H4346_821_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4346	823	0	1	01	01	H4346_823_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4346	824	0	1	01	01	H4346_824_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4346	826	0	1	01	01	H4346_826_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4346	827	0	2	01	01	H4346_827_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4346	828	0	2	01	01	H4346_828_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4346	830	0	2	01	01	H4346_830_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4393	001	0	1	20	08	H4393_001_0	1																																																																																																																																																							
H4393	002	0	1	20	08	H4393_002_0	1																																																																																																																																																							
H4402	001	0	1	20	08	H4402_001_0	1																																																																																																																																																							
H4402	002	0	1	20	08	H4402_002_0	1																																																																																																																																																							
H4407	004	0	1	01	01	H4407_004_0	9	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H4407	011	0	1	01	01	H4407_011_0	6	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H4407	027	0	1	01	01	H4407_027_0	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H4407	028	0	1	01	01	H4407_028_0	7	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H4407	029	0	1	01	01	H4407_029_0	8	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H4407	030	1	1	01	01	H4407_030_1	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H4407	030	2	1	01	01	H4407_030_2	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H4407	030	3	1	01	01	H4407_030_3	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H4439	001	0	1	01	01	H4439_001_0	5	1	1111	2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H4439	002	0	1	01	01	H4439_002_0	7	1	1111	2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H4461	004	0	1	01	01	H4461_004_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4461	022	0	1	01	01	H4461_022_0	9	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4461	025	0	1	01	01	H4461_025_0	5	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4461	029	0	1	01	01	H4461_029_0	8	1	1111	2	1				2	1				2	1				2	1				1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4461	035	0	1	01	01	H4461_035_0	5	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4461	038	0	1	01	01	H4461_038_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4461	039	0	1	01	01	H4461_039_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	3		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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative srvc: amalgam and/or composite filling unlimited/year, bridge/crown recementation up to 1 every 5 years, crown/other services-core buildup, prefab post, core up to 1/ tooth/ lifetime.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges-crown up to 2/5 years, bridges-pontic up to 1/5 years, occlusal adjustment up to 1/3 years, oral surgery up to 2/ year.	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4461	040	0	1	01	01	H4461_040_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4461	041	0	1	01	01	H4461_041_0	5	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4461	042	0	1	01	01	H4461_042_0	7	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4461	806	0	1	01	01	H4461_806_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4461	807	0	1	01	01	H4461_807_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4461	810	0	1	01	01	H4461_810_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4461	811	0	1	01	01	H4461_811_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4471	001	0	1	01	01	H4471_001_0	7	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4471	002	0	1	01	01	H4471_002_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4471	003	0	1	01	01	H4471_003_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4471	004	0	1	01	01	H4471_004_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4471	005	0	1	01	01	H4471_005_0	6	1	1111	2	1				2	1				2	1				2	1				1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4471	006	0	1	01	01	H4471_006_0	6	1	1111	2	1				2	1				2	1				2	1				1		2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4471	007	0	1	01	01	H4471_007_0	6	1	1111	2	1				2	1				2	1				2	1				1		1400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4471	009	0	1	01	01	H4471_009_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4490	001	0	1	01	01	H4490_001_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4490	003	0	1	01	01	H4490_003_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4497	001	1	1	04	01	H4497_001_1	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3																2					2																		2		1	01000000	40.00	40.00															2	2
H4497	001	2	1	04	01	H4497_001_2	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3																2					2																		2		1	01000000	45.00	45.00															2	2
H4497	001	3	1	04	01	H4497_001_3	15	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3																2					2																		2		1	01000000	40.00	40.00															2	2
H4497	002	1	1	04	01	H4497_002_1	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3																2					2																		2		1	01000000	40.00	40.00															2	2
H4497	002	2	1	04	01	H4497_002_2	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3																2					2																		2		1	01000000	40.00	40.00															2	2
H4497	002	3	1	04	01	H4497_002_3	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3																2					2																		2		1	01000000	40.00	40.00															2	2
H4497	003	1	1	04	01	H4497_003_1	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	0111111	2	1				2	1				2	1				2	1				2	1				2	1									1	2	2	1000.00	3		2					1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		1	01000000	30.00	30.00															2	2
H4497	003	2	1	04	01	H4497_003_2	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	0111111	2	1				2	1				2	1				2	1				2	1				2	1									1	2	2	1000.00	3		2					1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		1	01000000	35.00	35.00															2	2
H4497	003	3	1	04	01	H4497_003_3	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	0111111	2	1				2	1				2	1				2	1				2	1				2	1									1	2	2	1000.00	3		2					1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		1	01000000	30.00	30.00															2	2
H4497	005	3	1	04	01	H4497_005_3	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				2	1				1		1				2					1	10111111			30	30	30	30	30	30	50	50	50	50	30	30	50	50	2		1	01000000	30.00	30.00															2	2
H4497	005	4	1	04	01	H4497_005_4	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	1500.00	3		2				2		2												2		2		2												2	2	1	0111111	4	1				4	1				4	1				4	1				4	1				4	1									1		1				2					1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		1	01000000	40.00	40.00															2	2
H4497	801	0	1	04	01	H4497_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4497	802	0	1	04	01	H4497_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4497	803	0	1	04	01	H4497_803_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4506	003	0	1	01	01	H4506_003_0	21	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4506	010	0	1	01	01	H4506_010_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4506	029	0	1	02	01	H4506_029_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4513	009	0	1	01	01	H4513_009_0	5	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H4513	026	0	1	01	01	H4513_026_0	8	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H4513	027	0	1	01	01	H4513_027_0	9	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H4513	030	0	1	01	01	H4513_030_0	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H4513	033	0	1	01	01	H4513_033_0	6	1	1111	2	1				2	1				2	1				2	1				1		2600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H4513	034	0	1	01	01	H4513_034_0	8	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H4513	035	0	1	01	01	H4513_035_0	8	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H4513	036	0	1	02	01	H4513_036_0	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H4513	037	0	1	01	01	H4513_037_0	7	1	1111	2	1				2	1				2	1				2	1				1		2100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H4513	038	0	1	01	01	H4513_038_0	7	1	1111	2	1				2	1				2	1				2	1				1		1200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H4513	039	0	1	01	01	H4513_039_0	8	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H4513	045	0	1	01	01	H4513_045_0	5	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H4513	046	1	1	01	01	H4513_046_1	7	1	1111	2	1				2	1				2	1				2	1				1		750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H4513	046	2	1	01	01	H4513_046_2	7	1	1111	2	1				2	1				2	1				2	1				1		400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H4513	047	0	1	01	01	H4513_047_0	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H4513	048	0	1	01	01	H4513_048_0	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H4513	049	1	1	01	01	H4513_049_1	7	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H4513	049	2	1	01	01	H4513_049_2	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H4513	049	3	1	01	01	H4513_049_3	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H4513	049	4	1	01	01	H4513_049_4	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H4513	049	5	1	01	01	H4513_049_5	7	1	1111	2	1				2	1				2	1				2	1				1		1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H4513	050	0	1	01	01	H4513_050_0	7	1	1111	2	1				2	1				2	1				2	1				1		1200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H4513	051	0	1	01	01	H4513_051_0	7	1	1111	2	1				2	1				2	1				2	1				1		1400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H4513	052	0	1	01	01	H4513_052_0	7	1	1111	2	1				2	1				2	1				2	1				1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H4513	053	0	1	01	01	H4513_053_0	8	1	1111	2	1				2	1				2	1				2	1				1		1200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H4513	055	0	1	01	01	H4513_055_0	8	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H4513	059	0	1	01	01	H4513_059_0	7	1	1111	2	1				2	1				2	1				2	1				1		2100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H4513	060	1	1	01	01	H4513_060_1	9	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H4513	060	2	1	01	01	H4513_060_2	9	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H4513	060	3	1	01	01	H4513_060_3	9	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H4513	060	4	1	01	01	H4513_060_4	9	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H4513	060	5	1	01	01	H4513_060_5	9	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H4513	061	1	1	01	01	H4513_061_1	8	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H4513	061	2	1	01	01	H4513_061_2	8	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H4513	061	3	1	01	01	H4513_061_3	8	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H4513	061	4	1	01	01	H4513_061_4	8	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H4513	061	5	1	01	01	H4513_061_5	8	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	25.00	25.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H4513	063	0	1	01	01	H4513_063_0	10	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H4513	064	0	1	01	01	H4513_064_0	8	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H4513	068	1	1	01	01	H4513_068_1	7	1	1111	2	1				2	1				2	1				2	1				1		750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H4513	068	2	1	01	01	H4513_068_2	7	1	1111	2	1				2	1				2	1				2	1				1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H4513	068	3	1	01	01	H4513_068_3	7	1	1111	2	1				2	1				2	1				2	1				1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H4513	073	0	1	01	01	H4513_073_0	8	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H4513	074	0	1	01	01	H4513_074_0	8	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H4513	075	0	1	01	01	H4513_075_0	9	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H4513	076	1	1	01	01	H4513_076_1	7	1	1111	2	1				2	1				2	1				2	1				1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	5.00	5.00															1	2
H4513	076	2	1	01	01	H4513_076_2	7	1	1111	2	1				2	1				2	1				2	1				1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H4513	077	1	1	01	01	H4513_077_1	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H4513	077	2	1	01	01	H4513_077_2	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H4513	077	3	1	01	01	H4513_077_3	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H4513	078	0	1	01	01	H4513_078_0	6	1	1111	2	1				2	1				2	1				2	1				1		2600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H4513	079	0	1	01	01	H4513_079_0	8	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H4513	080	0	1	01	01	H4513_080_0	8	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H4513	081	0	1	01	01	H4513_081_0	9	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H4513	082	0	1	01	01	H4513_082_0	6	1	1111	2	1				2	1				2	1				2	1				1		2600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H4513	083	1	1	01	01	H4513_083_1	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	45.00	45.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H4513	083	2	1	01	01	H4513_083_2	7	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H4513	083	3	1	01	01	H4513_083_3	7	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H4513	083	4	1	01	01	H4513_083_4	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	45.00	45.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H4513	083	5	1	01	01	H4513_083_5	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	45.00	45.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H4513	083	6	1	01	01	H4513_083_6	7	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H4513	083	7	1	01	01	H4513_083_7	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	45.00	45.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H4513	084	0	1	02	01	H4513_084_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	35.00	35.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H4513	085	0	1	01	01	H4513_085_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	25.00	25.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H4513	086	0	1	01	01	H4513_086_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	40.00	40.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H4513	804	0	1	01	01	H4513_804_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4513	815	0	1	01	01	H4513_815_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4513	817	0	1	01	01	H4513_817_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4513	819	0	1	01	01	H4513_819_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4513	821	0	1	01	01	H4513_821_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4514	007	0	1	02	01	H4514_007_0	5	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H4514	013	1	1	02	01	H4514_013_1	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4514	013	2	1	02	01	H4514_013_2	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4514	013	3	1	02	01	H4514_013_3	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4514	014	0	1	02	01	H4514_014_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4514	015	0	1	02	01	H4514_015_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4514	016	0	1	02	01	H4514_016_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4514	017	0	1	02	01	H4514_017_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4514	018	0	1	02	01	H4514_018_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4514	019	0	1	02	01	H4514_019_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4514	021	0	1	02	01	H4514_021_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4514	801	0	1	01	01	H4514_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4514	803	0	1	01	01	H4514_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4514	806	0	1	01	01	H4514_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4517	001	0	1	20	08	H4517_001_0	1																																																																																																																																																							
H4517	002	0	1	20	08	H4517_002_0	1																																																																																																																																																							
H4518	001	0	1	20	08	H4518_001_0	1																																																																																																																																																							
H4518	002	0	1	20	08	H4518_002_0	1																																																																																																																																																							
H4523	001	0	1	01	01	H4523_001_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below	2	2	4	6	Varies by procedure, see note below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see note below.	1		2	3500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											1	2
H4523	015	0	1	01	01	H4523_015_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below	2	2	4	6	Varies by procedure, see note below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see note below.	1		2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											1	2
H4523	020	0	1	01	01	H4523_020_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below	2	2	4	6	Varies by procedure, see note below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see note below.	1		2	3500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	25.00	25.00			0.00	0.00											1	2
H4523	021	0	1	01	01	H4523_021_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below	2	2	4	6	Varies by procedure, see note below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see note below.	1		2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											1	2
H4523	024	0	1	01	01	H4523_024_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	See below.	2	2	6	6	Varies by procedure, see below.	1		2	3500.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4523	801	0	1	01	01	H4523_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4523	802	0	1	01	01	H4523_802_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4527	001	0	1	02	01	H4527_001_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H4527	002	0	1	02	01	H4527_002_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H4527	003	0	1	02	01	H4527_003_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H4527	004	0	1	02	01	H4527_004_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H4527	005	0	1	02	01	H4527_005_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H4527	006	0	1	02	01	H4527_006_0	3	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H4527	013	0	1	02	01	H4527_013_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H4527	015	0	1	02	01	H4527_015_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H4527	024	0	1	02	01	H4527_024_0	4	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H4527	037	0	1	02	01	H4527_037_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4527	039	0	1	02	01	H4527_039_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H4527	040	0	1	02	01	H4527_040_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H4527	041	0	1	02	01	H4527_041_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H4527	042	0	1	02	01	H4527_042_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H4527	045	0	1	02	01	H4527_045_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H4527	048	0	1	02	01	H4527_048_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H4527	051	0	1	02	01	H4527_051_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H4527	801	0	1	01	01	H4527_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4527	802	0	1	01	01	H4527_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4527	803	0	1	01	01	H4527_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4537	001	0	1	04	01	H4537_001_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4537	002	0	1	04	01	H4537_002_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1500.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	45.00	45.00															1	2
H4537	003	0	1	04	01	H4537_003_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4537	004	0	1	04	01	H4537_004_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4544	001	0	1	04	01	H4544_001_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4544	002	0	1	04	01	H4544_002_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4604	003	0	1	02	01	H4604_003_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4604	005	0	1	02	01	H4604_005_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4604	011	0	1	02	01	H4604_011_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4604	012	0	1	02	01	H4604_012_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4604	013	0	1	02	01	H4604_013_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4604	014	0	1	02	01	H4604_014_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4604	015	0	1	02	01	H4604_015_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4604	016	0	1	02	01	H4604_016_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4604	017	0	1	02	01	H4604_017_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4604	018	0	1	02	01	H4604_018_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4604	019	0	1	02	01	H4604_019_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4604	020	0	1	02	01	H4604_020_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4604	022	0	1	02	01	H4604_022_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H4604	801	0	1	01	01	H4604_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4604	803	0	1	01	01	H4604_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4604	805	0	1	01	01	H4604_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4604	809	0	1	01	01	H4604_809_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4604	810	0	1	01	01	H4604_810_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4604	811	0	1	01	01	H4604_811_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4605	001	0	1	04	01	H4605_001_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	20.00	20.00			0.00	0.00											2	2
H4605	002	0	1	04	01	H4605_002_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1	2	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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											2	2
H4605	004	0	1	04	01	H4605_004_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											2	2
H4605	801	0	1	04	01	H4605_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4605	802	0	1	04	01	H4605_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4605	803	0	1	04	01	H4605_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4605	804	0	1	04	01	H4605_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4620	001	0	1	04	01	H4620_001_0	5	1	1111	2	2	2	6	Periodic, extensive oral and re-evaluation problem focused-two every calendar yearLimited oral-3 every calendar yearComprehensive oral and periodontal evaluation-1 every 3 years.	2	2	2	3		2	2	2	3		2	2	1	3		1	2	5000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H4620	801	0	1	04	01	H4620_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4620	802	0	1	04	01	H4620_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4620	803	0	1	04	01	H4620_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4620	804	0	1	04	01	H4620_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H4623	001	0	1	02	01	H4623_001_0	12	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4623	002	0	1	02	01	H4623_002_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling up to unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative svcs up to 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adjstmnt, rebase, reline, and repair, and tissue conditioning 1/yr; bridge-crown 2/5 yrs; bridges-pontic, complete, and partial dentures 1/5 yrs; occlusal adjustment 1/3 yrs; oral surgery 2/yr	1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4624	001	0	1	01	01	H4624_001_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		2500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4624	003	0	1	01	01	H4624_003_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		2000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4624	006	0	1	01	01	H4624_006_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		2500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4624	010	0	1	01	01	H4624_010_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		2500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4624	011	0	1	01	01	H4624_011_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		2000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4624	012	0	1	01	01	H4624_012_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		2500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4624	016	0	1	01	01	H4624_016_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4624	019	0	1	01	01	H4624_019_0	11	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		1500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4624	022	0	1	01	01	H4624_022_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		2500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4624	023	0	1	01	01	H4624_023_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4624	024	0	1	01	01	H4624_024_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		3500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	2	1	3		1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4624	025	0	1	01	01	H4624_025_0	12	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		2500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4624	026	0	1	01	01	H4624_026_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		2000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4624	027	0	1	01	01	H4624_027_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4624	028	0	1	01	01	H4624_028_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	2	1	3		1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4624	801	0	1	01	01	H4624_801_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4624	802	0	1	01	01	H4624_802_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4624	803	0	1	01	01	H4624_803_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4624	804	0	1	01	01	H4624_804_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4626	001	0	1	20	08	H4626_001_0	1	2																																																																																																																																																						
H4626	002	0	1	20	08	H4626_002_0	1	2																																																																																																																																																						
H4661	001	0	1	02	01	H4661_001_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4661	002	0	1	02	01	H4661_002_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4661	003	0	1	02	01	H4661_003_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4676	001	0	1	01	01	H4676_001_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	2	3		2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		1		1				2					1	01000000	20	20															2		2																		1	2
H4676	002	0	1	01	01	H4676_002_0	7	1	1110	2	2	2	3		2	2	2	6	2 prophylaxis treatments per calendar year 1 periodontal scaling per quadrant per 24 months 2 periodontal maintenance per calendar year.						2	2	1	6	1 Complete series of oral x-rays every 36 months1 Bitewing x-rays per calendar year	1		3000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Diagnostics services: 2 Diagnostic oral exams per calendar year 1 Complete series of oral x-rays every 36 months1 Bitewing x-rays per calendar year	2	2	1	6	Restorative services described below in notes.	2	2	1	6	Endodontic services:1 endodontic therapy per tooth per lifetime1 retreatment of root canal per tooth per lifetime1 apicoectomy per tooth per lifetime	2	2	1	6	Services described below	2	2	1	6	Extractions are included as Medically Necessary.	2	2	1	6	Services described below	1		1				2					1	01000000	20	20															2		2																		1	2
H4699	001	0	1	04	01	H4699_001_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1500.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4699	003	0	1	04	01	H4699_003_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months.	1	2	2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4699	005	0	1	04	01	H4699_005_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4704	001	0	1	04	01	H4704_001_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4711	001	0	1	02	01	H4711_001_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4711	002	0	1	02	01	H4711_002_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4711	005	0	1	02	01	H4711_005_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4711	006	0	1	02	01	H4711_006_0	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4711	007	0	1	02	01	H4711_007_0	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4711	008	0	1	02	01	H4711_008_0	7	1	1111	2	1				2	1				2	1				2	1				1		1400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4711	009	0	1	02	01	H4711_009_0	7	1	1111	2	1				2	1				2	1				2	1				1		1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4711	010	0	1	02	01	H4711_010_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4711	011	0	1	01	01	H4711_011_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	6	see note below	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	see note below	2	2	1	6	Covered diagnostic services covered once per calendar year with the exception of carries risk assessments which are covered once every 3 calendar years.	2	2	1	1		2	2	1	6	All covered services allowed once per tooth per lifetime.	2	2	1	6	see note below	2	2	1	6	Extractions covered once per tooth per lifetime.	2	2	1	6	see note below	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4711	012	0	1	01	01	H4711_012_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4711	013	0	1	01	01	H4711_013_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	6	see note below	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	see note below	2	2	1	6	Covered diagnostic services covered once per calendar year with the exception of carries risk assessments which are covered once every 3 calendar years.	2	2	1	1		2	2	1	6	All covered services allowed once per tooth per lifetime.	2	2	1	6	see note below	2	2	1	6	Extractions covered once per tooth per lifetime.	2	2	1	6	see note below	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4711	801	0	1	01	01	H4711_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4711	802	0	1	01	01	H4711_802_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4714	001	0	1	20	08	H4714_001_0	1																																																																																																																																																							
H4714	002	0	1	20	08	H4714_002_0	1																																																																																																																																																							
H4733	001	0	1	01	01	H4733_001_0	6	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H4739	001	0	1	01	01	H4739_001_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	4	6	1 every 5 years per member per year.	2					2				2		2												2		2		2												2	2	1	1101111	2	1									2	1				2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Prior authorization required. Pre and post-op radiographs required. Prior authorization required.	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. 1 per 24 mo. Per quadrant. Debridement once per year. Subject to the $3000 combined limit every year.	2	1				2	2	1	6	Periodicity varies by procedure, see full note below.	1		2	3000.00	3		2					2																		2		2																		1	2
H4754	004	0	1	04	01	H4754_004_0	6	1	1111	4	1				4	1				4	1				4	1				1	2	500.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															1	2
H4754	006	0	1	04	01	H4754_006_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															1	2
H4754	008	0	1	04	01	H4754_008_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															1	2
H4754	011	0	1	04	01	H4754_011_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															1	2
H4754	012	0	1	04	01	H4754_012_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H4754	017	0	1	04	01	H4754_017_0	5	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	35.00	35.00															1	2
H4754	801	0	1	04	01	H4754_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4754	802	0	1	04	01	H4754_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4801	002	0	1	04	01	H4801_002_0	7	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	2000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	50.00	50.00															2	2
H4801	007	0	1	04	01	H4801_007_0	7	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H4801	011	0	1	04	01	H4801_011_0	7	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1	2	2	2000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	50.00	50.00															2	2
H4801	013	0	1	04	01	H4801_013_0	6	2		3					3										3																																														2		3										3					3					3					3					3											2					1	01000000	0	0															2		2																		2	2
H4801	014	0	1	04	01	H4801_014_0	6	2		3					3										3																																														2		3										3					3					3					3					3											2					1	01000000	0	0															2		2																		2	2
H4801	015	0	1	04	01	H4801_015_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H4801	016	0	1	04	01	H4801_016_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1	2	2	5000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H4801	018	0	1	04	01	H4801_018_0	7	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1	2	2	1000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H4801	019	0	1	04	01	H4801_019_0	5	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	2000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H4801	020	0	1	04	01	H4801_020_0	5	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H4801	021	0	1	04	01	H4801_021_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1	2	2	5000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H4801	022	0	1	04	01	H4801_022_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1	2	2	1000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H4808	001	0	1	04	01	H4808_001_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	3000.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H4808	002	0	1	04	01	H4808_002_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	4000.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H4808	003	0	1	04	01	H4808_003_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H4835	001	0	1	02	01	H4835_001_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4835	002	0	1	02	01	H4835_002_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4835	003	0	1	02	01	H4835_003_0	7	1	1111	2	1				2	1				2	1				2	1				1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4835	004	0	1	02	01	H4835_004_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4835	005	0	1	02	01	H4835_005_0	7	1	1111	2	1				2	1				2	1				2	1				1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4835	006	0	1	02	01	H4835_006_0	7	1	1111	2	1				2	1				2	1				2	1				1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4835	801	0	1	01	01	H4835_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4835	802	0	1	01	01	H4835_802_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4847	001	0	1	01	01	H4847_001_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4847	004	0	1	01	01	H4847_004_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4847	005	0	1	01	01	H4847_005_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	25.00	25.00															1	2
H4847	006	0	1	02	01	H4847_006_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	40.00	40.00															1	2
H4863	001	0	1	01	01	H4863_001_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Bitewing Xrays are covered once per CY. Full mouth or Panoramic Xrays are covered once per 5 year period.	1		3500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	2	1	6	Fillings and crown repairs are covered. Crowns and onlays are covered once per tooth per 5 year period.	2	1				2	2	1	6	Periodontal maintenance 2 per calendar year counts toward the annual cleaning frequency. Surgical Periodontal services once per 36 months. Root planing and scaling once per quarant per 24 months.	2	2	1	6	Simple Extractions -20% coinsuranceOther Oral Surgery-50% coinsuranceExtractions are covered once per tooth per lifetime.	2	2	1	6	Dentures, Bridges and Implants are covered once per 5 year period.	1		1				2					1	10001111							20	50	50	50	0	50	20	50	20	50	2		1	01000000	30.00	30.00															2	2
H4863	003	0	1	01	01	H4863_003_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Bitewing Xrays are covered once per CY. Full mouth or Panoramic Xrays are covered once per 5 year period.	1		3500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	2	1	6	Fillings and crown repairs are covered. Crowns and onlays are covered once per tooth per 5 year period.	2	1				2	2	1	6	Periodontal maintenance 2 per calendar year counts toward the annual cleaning frequency.  Surgical Periodontal services once per 36 months.  Root planing and scaling once per quarant per 24 months.	2	2	1	6	Simple Extractions -20% coinsuranceOther Oral Surgery-50% coinsuranceExtractions are covered once per tooth per lifetime.	2	2	1	6	Dentures, Bridges and Implants are covered once per 5 year period.	1		1				2					1	10001111							20	50	50	50	0	50	20	50	20	50	2		1	01000000	30.00	30.00															2	2
H4863	005	0	1	01	01	H4863_005_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Bitewing Xrays are covered once per CY. Full mouth or Panoramic Xrays are covered once per 5 year period.	1		3500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	2	1	6	Fillings and crown repairs are covered. Crowns and onlays are covered once per tooth per 5 year period.	2	1				2	2	1	6	Periodontal maintenance 2 per calendar year counts toward the annual cleaning frequency.  Surgical Periodontal services once per 36 months.  Root planing and scaling once per quarant per 24 months.	2	2	1	6	Simple Extractions -20% coinsuranceOther Oral Surgery-50% coinsuranceExtractions are covered once per tooth per lifetime.	2	2	1	6	Dentures, Bridges and Implants are covered once per 5 year period.	1		1				2					1	10001111							20	50	50	50	0	50	20	50	20	50	2		1	01000000	30.00	30.00															2	2
H4868	003	0	1	01	01	H4868_003_0	14	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4868	004	0	1	01	01	H4868_004_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS once per tooth	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4868	014	0	1	01	01	H4868_014_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4868	016	0	1	01	01	H4868_016_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	2000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4868	019	0	1	01	01	H4868_019_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1000.00	3		2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4869	001	0	1	02	01	H4869_001_0	11	1	1111	2	1				2	1				2	1				2	1				1		625.00	5		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H4869	002	0	1	02	01	H4869_002_0	9	1	1111	2	1				2	1				2	1				2	1				1		1000.00	5		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H4869	003	0	1	02	01	H4869_003_0	10	1	1111	2	1				2	1				2	1				2	1				1		625.00	5		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H4869	004	0	1	02	01	H4869_004_0	10	1	1111	2	1				2	1				2	1				2	1				1		1000.00	5		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H4869	005	0	1	02	01	H4869_005_0	12	1	1111	2	1				2	1				2	1				2	1				1		525.00	5		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H4869	009	0	1	02	01	H4869_009_0	11	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4869	010	0	1	02	01	H4869_010_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4875	016	1	1	04	01	H4875_016_1	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	20.00	225.00															1	2
H4875	016	2	1	04	01	H4875_016_2	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	20.00	225.00															1	2
H4875	016	3	1	04	01	H4875_016_3	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	20.00	225.00															1	2
H4875	016	4	1	04	01	H4875_016_4	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	20.00	225.00															1	2
H4875	016	5	1	04	01	H4875_016_5	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	20.00	225.00															1	2
H4875	017	1	1	04	01	H4875_017_1	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	15.00	200.00															1	2
H4875	017	2	1	04	01	H4875_017_2	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	15.00	200.00															1	2
H4875	017	3	1	04	01	H4875_017_3	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	15.00	200.00															1	2
H4875	017	4	1	04	01	H4875_017_4	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	15.00	200.00															1	2
H4875	017	5	1	04	01	H4875_017_5	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	15.00	200.00															1	2
H4875	018	1	1	04	01	H4875_018_1	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	15.00	250.00															1	2
H4875	018	2	1	04	01	H4875_018_2	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	15.00	250.00															1	2
H4875	018	3	1	04	01	H4875_018_3	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	15.00	250.00															1	2
H4875	018	4	1	04	01	H4875_018_4	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	15.00	250.00															1	2
H4875	018	5	1	04	01	H4875_018_5	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	15.00	250.00															1	2
H4875	020	1	1	04	01	H4875_020_1	6	1	1110	2	2	2	3		2	2	2	6	The mandatory preventive dental benefit includes two cleanings (regular or periodontal) every year.	3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	0.00	325.00															1	2
H4875	020	2	1	04	01	H4875_020_2	6	1	1110	2	2	2	3		2	2	2	6	The mandatory preventive dental benefit includes two cleanings (regular or periodontal) every year.	3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	0.00	325.00															1	2
H4875	020	3	1	04	01	H4875_020_3	6	1	1110	2	2	2	3		2	2	2	6	The mandatory preventive dental benefit includes two cleanings (regular or periodontal) every year.	3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	0.00	325.00															1	2
H4875	021	1	1	04	01	H4875_021_1	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	0.00	325.00															1	2
H4875	021	2	1	04	01	H4875_021_2	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1000010											3					3					2	2	2	3		3					4	2	1	3		2						2					2																		2		1	01000000	0.00	325.00															1	2
H4875	022	1	1	04	01	H4875_022_1	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1001011											4	2	1	6	Crown repairs are once every 12 months and fillings are once in any two year period, same tooth and same surface.	3					2	2	2	3		4	2	1	6	Coverage for simple extractions once per tooth per lifetime.	4	2	1	6	Brush biopsy once a year and unlimited coverage for anesthesia in conjunction with qualifying dental services only.	1	2	2	2500.00	3		2					2																		2		1	01000000	0.00	300.00															1	2
H4875	022	2	1	04	01	H4875_022_2	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1001011											4	2	1	6	Crown repairs are once every 12 months and fillings are once in any two year period, same tooth and same surface.	3					2	2	2	3		4	2	1	6	Coverage for simple extractions once per tooth per lifetime.	4	2	1	6	Brush biopsy once a year and unlimited coverage for anesthesia in conjunction with qualifying dental services only.	1	2	2	2500.00	3		2					2																		2		1	01000000	0.00	300.00															1	2
H4875	022	5	1	04	01	H4875_022_5	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1001011											4	2	1	6	Crown repairs are once every 12 months and fillings are once in any two year period, same tooth and same surface.	3					2	2	2	3		4	2	1	6	Coverage for simple extractions once per tooth per lifetime.	4	2	1	6	Brush biopsy once a year and unlimited coverage for anesthesia in conjunction with qualifying dental services only.	1	2	2	2500.00	3		2					2																		2		1	01000000	0.00	300.00															1	2
H4875	023	0	1	04	01	H4875_023_0	6	1	1110	2	2	2	3		2	2	2	3		3					2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2					2				2		2												2		2		2												2	2	1	1001011											4	2	1	6	Crown repairs are once every 12 months and fillings are once in any two year period, same tooth and same surface.	3					2	2	2	3		4	2	1	6	Coverage for simple extractions once per tooth per lifetime.	4	2	1	6	Brush biopsy once a year and unlimited coverage for anesthesia in conjunction with qualifying dental services only.	1	2	2	3000.00	3		2					2																		2		1	01000000	0.00	275.00															1	2
H4875	803	0	1	04	01	H4875_803_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4875	804	0	1	04	01	H4875_804_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4875	805	0	1	04	01	H4875_805_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4875	806	0	1	04	01	H4875_806_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4875	807	0	1	04	01	H4875_807_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4882	003	0	1	04	01	H4882_003_0	8	1	1111	4	2	1	3		4	2	1	3		4	2	1	3		4	2	1	2		1	2	1000.00	3		2				2		2												2		2		2												2	2	1	0000010	3					3					3					3					4	2	1	3		3					3					1		1				2					2																		2		2																		2	2
H4882	004	0	1	04	01	H4882_004_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1000.00	3		2				2		2												2		2		2												2	2	1	0000010																					2	2	2	3												1		1				2					2																		2		1	01000000	35.00	35.00															2	2
H4882	005	0	1	04	01	H4882_005_0	6	1	1111	2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	2		1	2	500.00	3		2				2		2												2		2		2												2	2	1	0000010																					2	2	1	3												1		1				2					2																		2		1	01000000	35.00	35.00															2	2
H4882	009	1	1	04	01	H4882_009_1	8	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	0001010	3					3					4	1				3					4	2	3	3		3					3					1		1				2					1	00001010							50	50			0	50					2		2																		2	2
H4882	009	2	1	04	01	H4882_009_2	9	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	0001010	3					3					4	1				3					4	2	3	3		3					3					1		1				2					1	00001010							50	50			0	50					2		2																		2	2
H4882	010	1	1	04	01	H4882_010_1	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	2	2	3		2	1				2	1				1		1				2					1	10001111							50	75	50	50	0	50	50	50	50	50	2		2																		2	2
H4882	010	2	1	04	01	H4882_010_2	7	1	1111	4	2	2	3		4	2	2	3		4	2	2	3		4	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	0000010	3					3					3					3					4	2	2	3		3					3					1		1				2					2																		2		2																		2	2
H4882	011	1	1	04	01	H4882_011_1	8	1	1111	4	2	2	3		4	2	2	3		4	2	2	3		4	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	0000010	3					3					3					3					4	2	2	3		3					3					1		1				2					2																		2		2																		2	2
H4882	011	2	1	04	01	H4882_011_2	8	1	1111	4	2	2	3		4	2	2	3		4	2	2	3		4	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	0000010	3					3					3					3					4	2	2	3		3					3					1		1				2					2																		2		2																		2	2
H4882	012	0	1	04	01	H4882_012_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1000.00	3		2				2		2												2		2		2												2	2	1	0000010																					2	2	2	3												1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H4882	801	0	1	04	01	H4882_801_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4882	803	0	1	04	01	H4882_803_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4882	804	0	1	04	01	H4882_804_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4882	805	0	1	04	01	H4882_805_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4882	806	0	1	04	01	H4882_806_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4909	014	0	1	04	01	H4909_014_0	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4909	015	0	1	04	01	H4909_015_0	6	1	1111	4	2	2	3		4	2	2	3		4	2	1	3		4	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H4909	016	0	1	04	01	H4909_016_0	7	1	1111	4	1				4	1				4	1				4	1				1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4909	018	0	1	04	01	H4909_018_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4909	020	0	1	04	01	H4909_020_0	5	1	1111	4	1				4	1				4	1				4	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4909	021	0	1	04	01	H4909_021_0	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4909	023	0	1	04	01	H4909_023_0	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4909	026	0	1	04	01	H4909_026_0	7	1	1111	4	1				4	1				4	1				4	1				1	2	1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4909	804	0	1	04	01	H4909_804_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4909	805	0	1	04	01	H4909_805_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4909	810	0	2	04	01	H4909_810_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4909	811	0	1	04	01	H4909_811_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4909	812	0	1	04	01	H4909_812_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4909	814	0	2	04	01	H4909_814_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4909	815	0	2	04	01	H4909_815_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4909	817	0	1	04	01	H4909_817_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4909	818	0	1	04	01	H4909_818_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4919	001	0	1	20	08	H4919_001_0	1	2																																																																																																																																																						
H4919	002	0	1	20	08	H4919_002_0	1	2																																																																																																																																																						
H4931	007	0	1	01	01	H4931_007_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	6	every 12 months	1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H4931	015	0	1	01	01	H4931_015_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	6	every 12 months	1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H4937	001	0	1	04	01	H4937_001_0	6	1	1111	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	4	2	1	4		4	2	2	4		4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				2		2												2		2		2												2	2	1	0010000						4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3					3					3					3					3					2						2					2																		2		1	01000000	5.00	20.00															2	2
H4937	002	0	1	04	01	H4937_002_0	6	1	1111	4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	4	2	1	4		4	2	2	4		4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2					2				2		2												2		2		2												2	2	1	0010000						4	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3					3					3					3					3					2						2					2																		2		1	01000000	10.00	25.00															2	2
H4937	801	0	1	04	01	H4937_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4937	802	0	1	04	01	H4937_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4937	803	0	1	04	01	H4937_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4937	804	0	1	04	01	H4937_804_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4937	805	0	1	04	01	H4937_805_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H4943	001	0	1	01	01	H4943_001_0	16	1	1110	2	2	1	4		2	2	1	4							2	2	1	1		1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	4		2	2	1	1		2	2	1	6	Dentures one every 5 years. Crowns 1 per year.	2	2	1	6	Root canal one per tooth per lifetime.	2	2	1	1		2	1				2	2	1	6	Dentures through Prosthodontist one every 5 years.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		2																		2	2
H4943	002	0	1	01	01	H4943_002_0	13	1	1110	2	2	1	4		2	2	1	4							2	2	1	1		1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	4		2	2	1	1		2	2	1	6	Dentures one every 5 years.	2	2	1	6	Root canal one per tooth per lifetime.	2	2	1	1		2	1				2	2	1	6	Dentures through Prosthodontist one every 5 years.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		2																		2	2
H4961	001	0	1	04	01	H4961_001_0	13	2																																																															2		3					3					3					3					3					3					3											2					2																		2		2																		1	2
H4961	003	0	1	04	01	H4961_003_0	13	2																																																															2		3					3					3					3					3					3					3											2					2																		2		2																		1	2
H4961	006	0	1	04	01	H4961_006_0	12	2																																																															2		3					3					3					3					3					3					3											2					2																		2		2																		1	2
H4961	007	0	1	04	01	H4961_007_0	12	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		2																		1	2
H4961	008	0	1	04	01	H4961_008_0	11	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		2																		1	2
H4961	801	0	1	04	01	H4961_801_0	2	2																																																															2																																											2					2																		2		2																		1	2
H4961	802	0	1	04	01	H4961_802_0	3	2																																																															2																																											2					2																		2		2																		1	2
H4961	803	0	1	04	01	H4961_803_0	2	2																																																															2																																											2					2																		2		2																		1	2
H4961	804	0	1	04	01	H4961_804_0	2	2																																																															2																																											2					2																		2		2																		1	2
H4982	001	0	1	01	01	H4982_001_0	7	1	1111	2	1				2	1				2	1				2	1				1		2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4982	002	0	1	01	01	H4982_002_0	7	1	1111	2	1				2	1				2	1				2	1				1		2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4982	003	0	1	01	01	H4982_003_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4982	004	0	1	01	01	H4982_004_0	7	1	1111	2	1				2	1				2	1				2	1				1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4982	005	0	1	01	01	H4982_005_0	7	1	1111	2	1				2	1				2	1				2	1				1		1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4982	006	0	1	01	01	H4982_006_0	7	1	1111	2	1				2	1				2	1				2	1				1		700.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4982	007	0	1	01	01	H4982_007_0	7	1	1111	2	1				2	1				2	1				2	1				1		1100.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4982	008	0	1	01	01	H4982_008_0	7	1	0100	2	1																			2					2				2		2												2		1	0100	2				0.00	0.00							2	2	1	1001000											2	2	1	6	1 every 5 calendar years, per tooth.																2	2	1	6	1 partial denture repair every 2 calendar years, per arch.  1 denture rebase procedure every 2 calendar years, per arch.  Pontics and abutment crowns - 1 every 5 years per tooth.	2						2					1	01000000	20	20															2		1	10001000							0.00	0.00							0.00	0.00	1	2
H4982	009	0	1	01	01	H4982_009_0	7	1	0100	2	1																			2					2				2		2												2		1	0100	2				0.00	0.00							2	2	1	1001000											2	2	1	6	1 every 5 calendar years, per tooth.																2	2	1	6	1 partial denture repair every 2 calendar years, per arch.  1 denture rebase procedure every 2 calendar years, per arch.  Pontics and abutment crowns - 1 every 5 years per tooth.	2						2					1	01000000	20	20															2		1	10001000							0.00	0.00							0.00	0.00	1	2
H4982	010	0	1	01	01	H4982_010_0	7	1	1111	2	1				2	1				2	1				2	1				1		1300.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4982	011	0	1	01	01	H4982_011_0	7	1	1111	2	1				2	1				2	1				2	1				1		850.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4982	012	0	1	01	01	H4982_012_0	7	1	1111	2	1				2	1				2	1				2	1				1		825.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4982	013	0	1	01	01	H4982_013_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4982	016	0	1	01	01	H4982_016_0	7	1	0100	2	1																			2					2				2		2												2		1	0100	2				0.00	0.00							2	2	1	1001000											2	2	1	6	1 every 5 calendar years, per tooth.																2	2	1	6	1 partial denture repair every 2 calendar years, per arch.  1 denture rebase procedure every 2 calendar years, per arch.  Pontics and abutment crowns - 1 every 5 years per tooth.	2						2					1	01000000	20	20															2		1	10001000							0.00	0.00							0.00	0.00	1	2
H4982	017	0	1	02	01	H4982_017_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4982	018	0	1	02	01	H4982_018_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H4982	801	0	1	01	01	H4982_801_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4982	802	0	1	01	01	H4982_802_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H4999	001	0	1	20	08	H4999_001_0	1																																																																																																																																																							
H4999	002	0	1	20	08	H4999_002_0	1																																																																																																																																																							
H5007	001	0	1	20	08	H5007_001_0	1																																																																																																																																																							
H5007	002	0	1	20	08	H5007_002_0	1																																																																																																																																																							
H5008	002	0	1	02	01	H5008_002_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5008	010	0	1	02	01	H5008_010_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5008	011	0	1	02	01	H5008_011_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5008	015	0	1	02	01	H5008_015_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5008	016	0	1	02	01	H5008_016_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5009	001	0	1	04	01	H5009_001_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											2	2
H5009	002	0	1	04	01	H5009_002_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											2	2
H5009	008	0	1	04	01	H5009_008_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1	2	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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											2	2
H5009	010	0	1	04	01	H5009_010_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											2	2
H5009	011	1	1	04	01	H5009_011_1	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											2	2
H5009	011	2	1	04	01	H5009_011_2	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											2	2
H5009	011	3	1	04	01	H5009_011_3	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											2	2
H5009	801	0	1	04	01	H5009_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5009	802	0	1	04	01	H5009_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5009	803	0	1	04	01	H5009_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5009	804	0	1	04	01	H5009_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5010	001	0	1	04	01	H5010_001_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											2	2
H5010	008	1	1	04	01	H5010_008_1	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											2	2
H5010	008	2	1	04	01	H5010_008_2	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	45.00	45.00			0.00	0.00											2	2
H5010	009	1	1	04	01	H5010_009_1	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1	2	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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											2	2
H5010	009	2	1	04	01	H5010_009_2	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1	2	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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service.	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											2	2
H5015	001	0	1	01	01	H5015_001_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H5037	001	0	1	20	08	H5037_001_0	1																																																																																																																																																							
H5037	002	0	1	20	08	H5037_002_0	1																																																																																																																																																							
H5042	009	0	1	04	01	H5042_009_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	850.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															2	2
H5042	011	0	1	04	01	H5042_011_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H5042	012	0	1	04	01	H5042_012_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H5042	801	0	1	04	01	H5042_801_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5042	802	0	1	04	01	H5042_802_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5042	803	0	1	04	01	H5042_803_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5042	804	0	1	04	01	H5042_804_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5050	001	0	1	01	01	H5050_001_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	30.00	30.00															1	1
H5050	004	0	1	01	01	H5050_004_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	1
H5050	009	0	1	01	01	H5050_009_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	30.00	30.00															1	1
H5050	013	0	1	01	01	H5050_013_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	30.00	30.00															1	1
H5050	017	0	1	01	01	H5050_017_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	30.00	30.00															1	1
H5050	019	0	1	01	01	H5050_019_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	25.00	25.00															1	1
H5050	021	0	1	01	01	H5050_021_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	25.00	25.00															1	1
H5050	022	0	1	01	01	H5050_022_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	35.00	35.00															1	1
H5050	023	0	1	01	01	H5050_023_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	50.00	50.00															1	1
H5050	801	0	1	01	01	H5050_801_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5050	802	0	1	01	01	H5050_802_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5080	001	0	1	20	08	H5080_001_0	1	2																																																																																																																																																						
H5080	002	0	1	20	08	H5080_002_0	1	2																																																																																																																																																						
H5085	003	0	1	20	08	H5085_003_0	1																																																																																																																																																							
H5085	004	0	1	20	08	H5085_004_0	1																																																																																																																																																							
H5087	005	0	1	01	01	H5087_005_0	16	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every 6 to 24 months.	2	2	1	3		2	2	1	2		2	2	1	6	Once per tooth	2	2	1	6	Every 6 to 36 months	2	2	1	6	Once per tooth	2	2	1	6	PROSTHODONTICS every 12 to 60 months or per procedure. OTHER ORAL MAXILLOFACIAL SURGERY every 60 months or per lifetime. OTHER SERVICES every 24 to 36 months or per lifetime.	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5087	016	0	1	01	01	H5087_016_0	16	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every 6 to 24 months.	2	2	1	3		2	2	1	2		2	2	1	6	Once per tooth	2	2	1	6	Every 6 to 36 months	2	2	1	6	Once per tooth	2	2	1	6	PROSTHODONTICS every 12 to 60 months or per procedure. OTHER ORAL MAXILLOFACIAL SURGERY every 60 months or per lifetime. OTHER SERVICES every 24 to 36 months or per lifetime.	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5087	024	0	1	01	01	H5087_024_0	16	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every 6 to 24 months.	2	2	1	3		2	2	1	2		2	2	1	6	Once per tooth	2	2	1	6	Every 6 to 36 months	2	2	1	6	Once per tooth	2	2	1	6	PROSTHODONTICS every 12 to 60 months or per procedure. OTHER ORAL MAXILLOFACIAL SURGERY every 60 months or per lifetime. OTHER SERVICES every 24 to 36 months or per lifetime.	2						2					2																		2		1	11111111	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5087	032	0	1	01	01	H5087_032_0	17	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every 6 to 24 months.	2	2	1	3		2	2	1	2		2	2	1	6	Once per tooth	2	2	1	6	Every 6 to 36 months	2	2	1	6	Once per tooth	2	2	1	6	PROSTHODONTICS every 12 to 60 months or per procedure. OTHER ORAL MAXILLOFACIAL SURGERY every 60 months or per lifetime. OTHER SERVICES every 24 to 36 months or per lifetime.	2						2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5087	033	0	1	01	01	H5087_033_0	18	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every 6 to 24 months.	2	2	1	3		2	2	1	2		2	2	1	6	Once per tooth	2	2	1	6	Every 6 to 36 months	2	2	1	6	Once per tooth	2	2	1	6	PROSTHODONTICS every 12 to 60 months or per procedure. OTHER ORAL MAXILLOFACIAL SURGERY every 60 months or per lifetime. OTHER SERVICES every 24 to 36 months or per lifetime.	2						2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5106	013	0	1	04	01	H5106_013_0	8	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five calendar years.	2					2				2		2												2		1		1	1110	15.00	15.00									2	2	2																																											2					2																		2		1	01000000	35.00	35.00															1	2
H5106	029	1	1	04	01	H5106_029_1	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five calendar years.	1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			10	10	10	10	10	10	10	10	10	10	10	10	10	10	2		1	01000000	20.00	20.00															1	2
H5106	029	2	1	04	01	H5106_029_2	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five calendar years.	1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			10	10	10	10	10	10	10	10	10	10	10	10	10	10	2		1	01000000	20.00	20.00															1	2
H5106	030	1	1	04	01	H5106_030_1	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five calendar years.	1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	25.00	25.00															1	2
H5106	030	2	1	04	01	H5106_030_2	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five calendar years.	1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	25.00	25.00															1	2
H5106	031	1	1	04	01	H5106_031_1	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five calendar years.	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	45.00	45.00															1	2
H5106	031	2	1	04	01	H5106_031_2	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five calendar years.	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	45.00	45.00															1	2
H5106	032	1	1	04	01	H5106_032_1	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five calendar years.	1	2	3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		2																		1	2
H5106	032	2	1	04	01	H5106_032_2	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five calendar years.	1	2	3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					2																		2		2																		1	2
H5106	033	1	1	04	01	H5106_033_1	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five calendar years.	1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	10.00	10.00															1	2
H5106	033	2	1	04	01	H5106_033_2	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five calendar years.	1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	-Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. -Periodontal cleaning limited to 2 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	10.00	10.00															1	2
H5106	806	0	1	04	01	H5106_806_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5106	807	0	1	04	01	H5106_807_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5106	808	0	1	04	01	H5106_808_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5106	810	0	1	04	01	H5106_810_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5117	801	0	1	01	01	H5117_801_0	12	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5124	001	0	1	20	08	H5124_001_0	1																																																																																																																																																							
H5124	002	0	1	20	08	H5124_002_0	1																																																																																																																																																							
H5140	001	0	1	04	01	H5140_001_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	Office visit copay applies per visitBitewing X-rays Two per calendar yearPeriapical X-rays Four films per calendar yearFull Mouth or Panoramic X-rays One per five-year period	2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	1111111	2	2	1	6	Crowns/Inlays/Onlays/Prosthodontics/Implants - Seven-year replacement limitPeriodontics Non Surgical - One per two year period	2	2	1	6	Two oral exams per year, two bitewing x-rays per year, four periapical x-rays per year, one fluoride treatment per year	2	2	1	6	Office visit copay applies, per visitDental visits are covered services until MaxBenefit Limit is met .50% coinsurance for covered services up to Max Plan Benefit.	2	2	1	6	Office visit copay applies, per visitDental visits are covered services until Maximum Benefit Limit is met .50% coinsurance for covered services up to Maximum Plan Benefit.	2	2	1	6	Office visit copay applies, per visitDental visits are covered services until Maximum Benefit Limit is met .50% coinsurance for covered services up to Maximum Plan Benefit.	2	1				2	2	1	6	Office visit copay applies, per visitDental visits are covered services until Maximum Benefit Limit is met .50% coinsurance for covered services up to Maximum Plan Benefit.	1	2	2	3000.00	3		2					1	11111111	20	20	50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	10111111			10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	2	2
H5140	002	0	1	04	01	H5140_002_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	Office visit copay applies, per visitBitewing X-rays Two per calendar yearPeriapical X-rays Four films per calendar yearFull Mouth or Panoramic X-rays One per five-year period	2					2				2		2												2		1		1	1111	10.00	10.00									2	2	1	1111111	2	2	1	6	Crowns/Inlays/Onlays/Prosthodontics/Implants - Seven-year replacement limitPeriodontics Non Surgical - One per two year period	2	2	1	6	Two oral exams per year, two bitewing x-rays per year, four periapical x-rays per year, one fluoride treatment per year	2	2	1	6	Office visit copay applies, per visitDental visits are covered services until MaxBenefit Limit is met .50% coinsurance for covered services up to Max Plan Benefit.	2	2	1	6	Office visit copay applies, per visitDental visits are covered services until Maximum Benefit Limit is met .50% coinsurance for covered services up to Maximum Plan Benefit.	2	2	1	6	Office visit copay applies, per visitDental visits are covered services until Maximum Benefit Limit is met .50% coinsurance for covered services up to Maximum Plan Benefit.	2	1				2	2	1	6	Office visit copay applies, per visitDental visits are covered services until Maximum Benefit Limit is met .50% coinsurance for covered services up to Maximum Plan Benefit.	1	2	2	3000.00	3		2					1	11111111	20	20	50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	10111111			10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	2	2
H5141	001	0	1	04	01	H5141_001_0	11	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Resin fillings-1 per tooth per 24 months Inlays/Onlays-1 per tooth per 60 monthsCrowns-1 per tooth per 60 monthsRe-cement-1 per tooth per 24 monthsProtective restoration-1 per tooth per lifetime	2	2	1	6	Pulpal debridement-1 per tooth per lifetime Treatment of root canals-1 per tooth per lifetime Apicoectomy/periadicular services-1 per tooth per lifetime Retrograde filling--1 per tooth per lifetime	2	2	1	6	osseous surgery-1 per quadrant per 36 monthsDebridement- full mouth per 36 monthsFull mouth scaling if gingival inflammation-2 per calendar yearPeriodontal Maintenance-4 per calendar year	2	2	1	6	Extractions, coronectomy-1 per tooth per lifetime	2	2	1	6	Removable complete & partial dentures-1 every 60 monthsDenture adjustments-2 per 12 monthsDenture rebase or relines-1 per 36 monthsFixed denture repair-1 per 24 months	1		1				2					2																		2		1	11001111	10.00	10.00					20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H5141	004	0	1	04	01	H5141_004_0	9	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Resin fillings-1 per tooth per 24 months Inlays/Onlays-1 per tooth per 60 monthsCrowns-1 per tooth per 60 monthsRe-cement-1 per tooth per 24 monthsProtective restoration-1 per tooth per lifetime	2	2	1	6	Pulpal debridement-1 per tooth per lifetime Treatment of root canals-1 per tooth per lifetime Apicoectomy/periadicular services-1 per tooth per lifetime Retrograde filling--1 per tooth per lifetime	2	2	1	6	osseous surgery-1 per quadrant per 36 monthsDebridement- full mouth per 36 monthsFull mouth scaling if gingival inflammation-2 per calendar yearPeriodontal Maintenance-4 per calendar year	2	2	1	6	Extractions, coronectomy-1 per tooth per lifetime	2	2	1	6	Removable complete & partial dentures-1 every 60 monthsDenture adjustments-2 per 12 monthsDenture rebase or relines-1 per 36 monthsFixed denture repair-1 per 24 months	1		1				2					2																		2		1	11001111	10.00	10.00					20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H5141	007	0	1	04	01	H5141_007_0	10	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Resin fillings-1 per tooth per 24 months Inlays/Onlays-1 per tooth per 60 monthsCrowns-1 per tooth per 60 monthsRe-cement-1 per tooth per 24 monthsProtective restoration-1 per tooth per lifetime	2	2	1	6	Pulpal debridement-1 per tooth per lifetime Treatment of root canals-1 per tooth per lifetime Apicoectomy/periadicular services-1 per tooth per lifetime Retrograde filling--1 per tooth per lifetime	2	2	1	6	osseous surgery-1 per quadrant per 36 monthsDebridement- full mouth per 36 monthsFull mouth scaling if gingival inflammation-2 per calendar yearPeriodontal Maintenance-4 per calendar year	2	2	1	6	Extractions, coronectomy-1 per tooth per lifetime	2	2	1	6	Removable complete & partial dentures-1 every 60 monthsDenture adjustments-2 per 12 monthsDenture rebase or relines-1 per 36 monthsFixed denture repair-1 per 24 months	1		1				2					2																		2		1	11001111	5.00	5.00					20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H5141	025	0	1	04	01	H5141_025_0	9	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Resin fillings-1 per tooth per 24 months Inlays/Onlays-1 per tooth per 60 monthsCrowns-1 per tooth per 60 monthsRe-cement-1 per tooth per 24 monthsProtective restoration-1 per tooth per lifetime	2	2	1	6	Pulpal debridement-1 per tooth per lifetime Treatment of root canals-1 per tooth per lifetime Apicoectomy/periadicular services-1 per tooth per lifetime Retrograde filling--1 per tooth per lifetime	2	2	1	6	osseous surgery-1 per quadrant per 36 monthsDebridement- full mouth per 36 monthsFull mouth scaling if gingival inflammation-2 per calendar yearPeriodontal Maintenance-4 per calendar year	2	2	1	6	Extractions, coronectomy-1 per tooth per lifetime	2	2	1	6	Removable complete & partial dentures-1 every 60 monthsDenture adjustments-2 per 12 monthsDenture rebase or relines-1 per 36 monthsFixed denture repair-1 per 24 months	1		1				2					2																		2		1	11001111	20.00	20.00					20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H5141	026	0	1	04	01	H5141_026_0	9	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Resin fillings-1 per tooth per 24 months Inlays/Onlays-1 per tooth per 60 monthsCrowns-1 per tooth per 60 monthsRe-cement-1 per tooth per 24 monthsProtective restoration-1 per tooth per lifetime	2	2	1	6	Pulpal debridement-1 per tooth per lifetime Treatment of root canals-1 per tooth per lifetime Apicoectomy/periadicular services-1 per tooth per lifetime Retrograde filling--1 per tooth per lifetime	2	2	1	6	osseous surgery-1 per quadrant per 36 monthsDebridement- full mouth per 36 monthsFull mouth scaling if gingival inflammation-2 per calendar yearPeriodontal Maintenance-4 per calendar year	2	2	1	6	Extractions, coronectomy-1 per tooth per lifetime	2	2	1	6	Removable complete & partial dentures-1 every 60 monthsDenture adjustments-2 per 12 monthsDenture rebase or relines-1 per 36 monthsFixed denture repair-1 per 24 months	1		1				2					2																		2		1	11001111	15.00	15.00					20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H5141	032	0	1	04	01	H5141_032_0	10	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Resin fillings-1 per tooth per 24 months Inlays/Onlays-1 per tooth per 60 monthsCrowns-1 per tooth per 60 monthsRe-cement-1 per tooth per 24 monthsProtective restoration-1 per tooth per lifetime	2	2	1	6	Pulpal debridement-1 per tooth per lifetime Treatment of root canals-1 per tooth per lifetime Apicoectomy/periadicular services-1 per tooth per lifetime Retrograde filling--1 per tooth per lifetime	2	2	1	6	osseous surgery-1 per quadrant per 36 monthsDebridement- full mouth per 36 monthsFull mouth scaling if gingival inflammation-2 per calendar yearPeriodontal Maintenance-4 per calendar year	2	2	1	6	Extractions, coronectomy-1 per tooth per lifetime	2	2	1	6	Removable complete & partial dentures-1 every 60 monthsDenture adjustments-2 per 12 monthsDenture rebase or relines-1 per 36 monthsFixed denture repair-1 per 24 months	1		1				2					2																		2		1	11001111	20.00	20.00					20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H5141	036	0	1	04	01	H5141_036_0	9	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Resin fillings-1 per tooth per 24 months Inlays/Onlays-1 per tooth per 60 monthsCrowns-1 per tooth per 60 monthsRe-cement-1 per tooth per 24 monthsProtective restoration-1 per tooth per lifetime	2	2	1	6	Pulpal debridement-1 per tooth per lifetime Treatment of root canals-1 per tooth per lifetime Apicoectomy/periadicular services-1 per tooth per lifetime Retrograde filling--1 per tooth per lifetime	2	2	1	6	osseous surgery-1 per quadrant per 36 monthsDebridement- full mouth per 36 monthsFull mouth scaling if gingival inflammation-2 per calendar yearPeriodontal Maintenance-4 per calendar year	2	2	1	6	Extractions, coronectomy-1 per tooth per lifetime	2	2	1	6	Removable complete & partial dentures-1 every 60 monthsDenture adjustments-2 per 12 monthsDenture rebase or relines-1 per 36 monthsFixed denture repair-1 per 24 months	1		1				2					2																		2		1	11001111	15.00	15.00					20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H5141	038	0	1	04	01	H5141_038_0	10	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Resin fillings-1 per tooth per 24 months Inlays/Onlays-1 per tooth per 60 monthsCrowns-1 per tooth per 60 monthsRe-cement-1 per tooth per 24 monthsProtective restoration-1 per tooth per lifetime	2	2	1	6	Pulpal debridement-1 per tooth per lifetime Treatment of root canals-1 per tooth per lifetime Apicoectomy/periadicular services-1 per tooth per lifetime Retrograde filling--1 per tooth per lifetime	2	2	1	6	osseous surgery-1 per quadrant per 36 monthsDebridement- full mouth per 36 monthsFull mouth scaling if gingival inflammation-2 per calendar yearPeriodontal Maintenance-4 per calendar year	2	2	1	6	Extractions, coronectomy-1 per tooth per lifetime	2	2	1	6	Removable complete & partial dentures-1 every 60 monthsDenture adjustments-2 per 12 monthsDenture rebase or relines-1 per 36 monthsFixed denture repair-1 per 24 months	1		1				2					2																		2		1	11001111	15.00	15.00					20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H5141	042	0	1	04	01	H5141_042_0	8	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Resin fillings-1 per tooth per 24 months Inlays/Onlays-1 per tooth per 60 monthsCrowns-1 per tooth per 60 monthsRe-cement-1 per tooth per 24 monthsProtective restoration-1 per tooth per lifetime	2	2	1	6	Pulpal debridement-1 per tooth per lifetime Treatment of root canals-1 per tooth per lifetime Apicoectomy/periadicular services-1 per tooth per lifetime Retrograde filling--1 per tooth per lifetime	2	2	1	6	osseous surgery-1 per quadrant per 36 monthsDebridement- full mouth per 36 monthsFull mouth scaling if gingival inflammation-2 per calendar yearPeriodontal Maintenance-4 per calendar year	2	2	1	6	Extractions, coronectomy-1 per tooth per lifetime	2	2	1	6	Removable complete & partial dentures-1 every 60 monthsDenture adjustments-2 per 12 monthsDenture rebase or relines-1 per 36 monthsFixed denture repair-1 per 24 months	1		1				2					2																		2		1	11001111	10.00	10.00					20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H5141	045	0	1	04	01	H5141_045_0	9	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Resin fillings-1 per tooth per 24 months Inlays/Onlays-1 per tooth per 60 monthsCrowns-1 per tooth per 60 monthsRe-cement-1 per tooth per 24 monthsProtective restoration-1 per tooth per lifetime	2	2	1	6	Pulpal debridement-1 per tooth per lifetime Treatment of root canals-1 per tooth per lifetime Apicoectomy/periadicular services-1 per tooth per lifetime Retrograde filling--1 per tooth per lifetime	2	2	1	6	osseous surgery-1 per quadrant per 36 monthsDebridement- full mouth per 36 monthsFull mouth scaling if gingival inflammation-2 per calendar yearPeriodontal Maintenance-4 per calendar year	2	2	1	6	Extractions, coronectomy-1 per tooth per lifetime	2	2	1	6	Removable complete & partial dentures-1 every 60 monthsDenture adjustments-2 per 12 monthsDenture rebase or relines-1 per 36 monthsFixed denture repair-1 per 24 months	1		1				2					2																		2		1	11001111	5.00	5.00					20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H5141	054	0	1	04	01	H5141_054_0	9	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		2					2				2		2												2		2		2												2	2	2																																											2					2																		2		1	01000000	35.00	35.00															2	2
H5141	055	0	1	04	01	H5141_055_0	9	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		2					2				2		2												2		2		2												2	2	2																																											2					2																		2		1	01000000	5.00	5.00															2	2
H5141	056	0	1	04	01	H5141_056_0	8	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Resin fillings-1 per tooth per 24 months Inlays/Onlays-1 per tooth per 60 monthsCrowns-1 per tooth per 60 monthsRe-cement-1 per tooth per 24 monthsProtective restoration-1 per tooth per lifetime	2	2	1	6	Pulpal debridement-1 per tooth per lifetime Treatment of root canals-1 per tooth per lifetime Apicoectomy/periadicular services-1 per tooth per lifetime Retrograde filling--1 per tooth per lifetime	2	2	1	6	osseous surgery-1 per quadrant per 36 monthsDebridement- full mouth per 36 monthsFull mouth scaling if gingival inflammation-2 per calendar yearPeriodontal Maintenance-4 per calendar year	2	2	1	6	Extractions, coronectomy-1 per tooth per lifetime	2	2	1	6	Removable complete & partial dentures-1 every 60 monthsDenture adjustments-2 per 12 monthsDenture rebase or relines-1 per 36 monthsFixed denture repair-1 per 24 months	1		1				2					2																		2		1	11001111	35.00	35.00					20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H5141	057	0	1	04	01	H5141_057_0	8	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Resin fillings-1 per tooth per 24 months Inlays/Onlays-1 per tooth per 60 monthsCrowns-1 per tooth per 60 monthsRe-cement-1 per tooth per 24 monthsProtective restoration-1 per tooth per lifetime	2	2	1	6	Pulpal debridement-1 per tooth per lifetime Treatment of root canals-1 per tooth per lifetime Apicoectomy/periadicular services-1 per tooth per lifetime Retrograde filling--1 per tooth per lifetime	2	2	1	6	osseous surgery-1 per quadrant per 36 monthsDebridement- full mouth per 36 monthsFull mouth scaling if gingival inflammation-2 per calendar yearPeriodontal Maintenance-4 per calendar year	2	2	1	6	Extractions, coronectomy-1 per tooth per lifetime	2	2	1	6	Removable complete & partial dentures-1 every 60 monthsDenture adjustments-2 per 12 monthsDenture rebase or relines-1 per 36 monthsFixed denture repair-1 per 24 months	1		1				2					2																		2		1	11001111	35.00	35.00					20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H5141	058	0	1	04	01	H5141_058_0	9	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Resin fillings-1 per tooth per 24 months Inlays/Onlays-1 per tooth per 60 monthsCrowns-1 per tooth per 60 monthsRe-cement-1 per tooth per 24 monthsProtective restoration-1 per tooth per lifetime	2	2	1	6	Pulpal debridement-1 per tooth per lifetime Treatment of root canals-1 per tooth per lifetime Apicoectomy/periadicular services-1 per tooth per lifetime Retrograde filling--1 per tooth per lifetime	2	2	1	6	osseous surgery-1 per quadrant per 36 monthsDebridement- full mouth per 36 monthsFull mouth scaling if gingival inflammation-2 per calendar yearPeriodontal Maintenance-4 per calendar year	2	2	1	6	Extractions, coronectomy-1 per tooth per lifetime	2	2	1	6	Removable complete & partial dentures-1 every 60 monthsDenture adjustments-2 per 12 monthsDenture rebase or relines-1 per 36 monthsFixed denture repair-1 per 24 months	1		1				2					2																		2		1	11001111	20.00	20.00					20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H5141	059	0	1	04	01	H5141_059_0	9	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Resin fillings-1 per tooth per 24 months Inlays/Onlays-1 per tooth per 60 monthsCrowns-1 per tooth per 60 monthsRe-cement-1 per tooth per 24 monthsProtective restoration-1 per tooth per lifetime	2	2	1	6	Pulpal debridement-1 per tooth per lifetime Treatment of root canals-1 per tooth per lifetime Apicoectomy/periadicular services-1 per tooth per lifetime Retrograde filling--1 per tooth per lifetime	2	2	1	6	osseous surgery-1 per quadrant per 36 monthsDebridement- full mouth per 36 monthsFull mouth scaling if gingival inflammation-2 per calendar yearPeriodontal Maintenance-4 per calendar year	2	2	1	6	Extractions, coronectomy-1 per tooth per lifetime	2	2	1	6	Removable complete & partial dentures-1 every 60 monthsDenture adjustments-2 per 12 monthsDenture rebase or relines-1 per 36 monthsFixed denture repair-1 per 24 months	1		1				2					2																		2		1	11001111	10.00	10.00					20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H5141	801	0	1	04	01	H5141_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5163	001	0	1	01	01	H5163_001_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	3		2	2	2	3		2	2	1	3		2	2	2	3		2	2	3	3		2	2	1	3		2						2					2																		2		1	10001111							22.00	530.00	22.00	535.00	0.00	435.00	70.00	175.00	0.00	1615.00	2	2
H5163	002	0	1	01	01	H5163_002_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	3		2	2	2	3		2	2	1	3		2	2	2	3		2	2	3	3		2	2	1	3		2						2					2																		2		1	10001111							22.00	530.00	22.00	535.00	0.00	435.00	70.00	175.00	0.00	1615.00	2	2
H5167	001	0	1	20	08	H5167_001_0	1																																																																																																																																																							
H5167	002	0	1	20	08	H5167_002_0	1																																																																																																																																																							
H5178	002	0	1	01	01	H5178_002_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative services include amalgam and/or composite filling up to unlimited per year, bridge and crown recementation up to 1/ 5 years, crown and other restorative services 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1/yr. Bridges-crown 2/5 yrs. Bridges-pontic, complete/partial dentures 1/5 yrs. Occlusal adjustment 1/3 yrs. Oral surgery 2/year	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5190	801	0	1	01	01	H5190_801_0	12	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5199	008	0	1	04	01	H5199_008_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1	2	2	1000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	30.00	30.00															1	2
H5199	010	0	1	04	01	H5199_010_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5199	012	0	1	04	01	H5199_012_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5199	014	0	1	04	01	H5199_014_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1500.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5199	016	0	1	04	01	H5199_016_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5209	002	0	1	01	01	H5209_002_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5209	004	0	1	01	01	H5209_004_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		2500.00	3		2				1	1110	2				20	20	20	20			20	20	2		2		2												2	2	1	1011001						2	2	2	3		2	2	1	6	Includes simple restorative (resin, amalgam) at 1 restoration per tooth per year											2	1				2	1				1		1				2					1	11011001	20	20			20	20	20	20					20	20	20	20	2		2																		1	2
H5211	001	0	1	02	01	H5211_001_0	3	1	1110	4	2	1	3		4	2	1	3		3					4	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				2		2												2		2		2												2	2	2							3					3					3					3					3					3											2					2																		1	100.00	2																		2	2
H5211	002	0	1	02	01	H5211_002_0	5	1	1110	4	2	1	3		4	2	1	3		3					4	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				2		2												2		2		2												2	2	2							3					3					3					3					3					3											2					2																		1	100.00	2																		2	2
H5211	003	0	1	02	01	H5211_003_0	3	1	1110	4	2	1	3		4	2	1	3		3					4	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				2		2												2		2		2												2	2	2							3					3					3					3					3					3											2					2																		1	100.00	2																		2	2
H5211	004	0	1	02	01	H5211_004_0	4	1	1110	4	2	1	3		4	2	1	3		3					4	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				2		2												2		2		2												2	2	2							3					3					3					3					3					3											2					2																		1	100.00	2																		2	2
H5211	010	0	1	01	01	H5211_010_0	5	1	1110	4	2	1	3		4	2	1	3		3					4	2	1	3		2					2				2		2												2		2		2												2	2	2							3					3					3					3					3					3											2					2																		1	100.00	2																		2	2
H5211	012	0	1	02	01	H5211_012_0	4	1	1110	4	2	1	3		4	2	1	3		3					4	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				2		2												2		2		2												2	2	2							3					3					3					3					3					3											2					2																		1	100.00	2																		2	2
H5211	013	0	1	02	01	H5211_013_0	4	1	1110	4	2	1	3		4	2	1	3		3					4	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				2		2												2		2		2												2	2	2							3					3					3					3					3					3											2					2																		1	100.00	2																		2	2
H5212	001	0	1	20	08	H5212_001_0	1																																																																																																																																																							
H5212	002	0	1	20	08	H5212_002_0	1																																																																																																																																																							
H5213	001	0	1	20	08	H5213_001_0	1																																																																																																																																																							
H5213	002	0	1	20	08	H5213_002_0	1																																																																																																																																																							
H5215	001	0	1	04	01	H5215_001_0	7	1	0110	4	2	1	3		4	2	1	3		3					3					1	2	100.00	3		2				2		2												2		1		1	0110	30.00	30.00									2	2	2												3					3					3					3					3											2					2																		2		1	01000000	25.00	25.00															2	2
H5215	002	0	1	04	01	H5215_002_0	5	1	0110	4	2	1	3		4	2	1	3		3					3					1	2	100.00	3		2				2		2												2		1		1	0110	30.00	30.00									2	2	2												3					3					3					3					3											2					2																		2		1	01000000	25.00	25.00															2	2
H5215	005	0	1	04	01	H5215_005_0	5	1	0110	4	2	1	3		4	2	1	3		3					3					1	2	100.00	3		2				2		2												2		1		1	0110	30.00	30.00									2	2	2												3					3					3					3					3											2					2																		2		2																		2	2
H5215	006	0	1	04	01	H5215_006_0	7	1	0110	4	2	1	3		4	2	1	3		3					3					1	2	100.00	3		2				2		2												2		1		1	0110	30.00	30.00									2	2	2												3					3					3					3					3											2					2																		2		2																		2	2
H5215	007	0	1	04	01	H5215_007_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H5215	008	0	1	04	01	H5215_008_0	5	1	1111	4	1				4	1				4	1				4	1				1	2	550.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	45.00	45.00															2	2
H5215	009	0	1	04	01	H5215_009_0	5	1	1111	4	1				4	1				4	1				4	1				1	2	1525.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	35.00	35.00															2	2
H5215	010	0	1	04	01	H5215_010_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															2	2
H5215	011	0	1	04	01	H5215_011_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	45.00	45.00															2	2
H5215	012	0	1	04	01	H5215_012_0	8	1	1111	4	1				4	1				4	1				4	1				1	2	775.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	30.00	30.00															2	2
H5215	013	0	1	04	01	H5215_013_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	5000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H5215	014	0	1	04	01	H5215_014_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	5000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H5215	806	0	1	04	01	H5215_806_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5215	807	0	1	04	01	H5215_807_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5215	808	0	1	04	01	H5215_808_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5216	001	0	1	04	01	H5216_001_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	006	0	1	04	01	H5216_006_0	6	1	1111	2	2	3	6	Oral Exams include emergency diagnostic exam up to 1 per year, and periodic oral exam up to 2 per year.	2	2	6	6	Prophylaxis include periodontal maintenance up to 4 per year, and prophylaxis (cleaning) up to 2 per year.	2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	011	0	1	04	01	H5216_011_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	013	0	1	04	01	H5216_013_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	6	6	Fillings $25 2 per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	2	2	3		2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	40.00	40.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5216	014	0	1	04	01	H5216_014_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	500.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	017	0	1	04	01	H5216_017_0	10	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	019	0	1	04	01	H5216_019_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	1	3		3					3					3					3					1		1				2					2																		2		1	01011000	45.00	45.00			0.00	0.00	25.00	25.00									1	2
H5216	023	0	1	04	01	H5216_023_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	45.00	45.00			0.00	0.00	25.00	25.00									1	2
H5216	024	0	1	04	01	H5216_024_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H5216	027	0	1	04	01	H5216_027_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		2		2												2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01000000	45.00	45.00															1	2
H5216	032	0	1	04	01	H5216_032_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	034	0	1	04	01	H5216_034_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H5216	037	0	1	04	01	H5216_037_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	40.00	40.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
H5216	039	0	1	04	01	H5216_039_0	5	1	1111	4	1				4	1				4	1				4	1				1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	042	0	1	04	01	H5216_042_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjust/rebase/reline/repair,tissue cond 1/yr,bridges-crown 2/5 yrs,bridges-pontic, complete+prtl dentures 1/5 yrs, occlusal adj 1/3 yrs, oral surgery 2/yr, restoration implant 1/tooth/lifetime	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	043	1	1	04	01	H5216_043_1	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	043	5	1	04	01	H5216_043_5	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative svc include amalgam and/or composite filling/unlimited/yr. Crown/ Core buildup and Prefab post and core up to 1 / tooth / lifetime, crown recementation 1/5 years.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	10	6	Prosthodontics, Oral/Maxillo Surgery, adjust to dentures, rebase, reline, repair and tissue Condit 1/yr. Complete dentures / partial dentures 1/5 yrs.  Occlusal adjust 1/3yr.  Oral surgery 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	043	6	1	04	01	H5216_043_6	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	044	0	1	04	01	H5216_044_0	5	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	047	0	1	04	01	H5216_047_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H5216	048	0	1	04	01	H5216_048_0	9	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays - Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	6	6	include amalgam/ composite filling up to 2/year, bridge and crown recementation 1/5 years, crown/other restorative services-core buildup and prefabricated post and core up to 1 per tooth per lifetime.	4	2	2	6	Endodontics - Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	1	1		4	2	2	3		4	2	6	6	include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	30.00	30.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5216	053	0	1	04	01	H5216_053_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	1000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and bridge up to 1 every 5 years, crown and other restorative services up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, oral surgery up to 2 per year, occlusal adjustments up to 1 every 3 years.	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	057	0	1	04	01	H5216_057_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	bitewing/introral x-rays - 1 set(s) per year, panoramic film or diagnostic x-rays - 1 every 5 years	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	40.00	40.00			0.00	0.00											1	2
H5216	058	0	1	04	01	H5216_058_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H5216	059	0	1	04	01	H5216_059_0	3	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	6	6	Fillings $25 2 per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	2	2	3		4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	40.00	40.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5216	062	0	1	04	01	H5216_062_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	063	0	1	04	01	H5216_063_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	25.00	25.00			0.00	0.00											1	2
H5216	064	0	1	04	01	H5216_064_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	35.00	35.00			0.00	0.00	25.00	25.00									1	2
H5216	068	0	1	04	01	H5216_068_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010						2	2	1	1		2	1									2	2	2	1												1		1				2					2																		2		1	01011010	30.00	30.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
H5216	070	0	1	04	01	H5216_070_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	3		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	1	0011000						2	2	1	1		2	2	2	3																						1		1				2					2																		2		1	01011000	45.00	45.00			0.00	0.00	25.00	25.00									1	2
H5216	072	0	1	04	01	H5216_072_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000						2	2	1	1																											2						2					2																		2		1	01010000	40.00	40.00			0.00	0.00											1	2
H5216	073	0	1	04	01	H5216_073_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	bitewing and intraoral x-rays- 1 set(s) per year,panoramic film or diagnostic x-rays- 1 every 5 years	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
H5216	074	0	1	04	01	H5216_074_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111011	2	2	2	3		2	2	1	1		2	2	3	6	Fillings to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.						2	2	2	1		2	1				2	2	8	6	Denture adjustments, rebase, reline, repair, tissue conditioning up to 1 per year, complete dentures and partial dentures up to 1 every 5 years, occlusal adjustment up to 1 every 3 years	1		1				2					2																		2		1	11111011	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	077	0	1	04	01	H5216_077_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	amalgam/composite filling unlimited/ year, bridge/crown recementation 1/ 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime.	2	2	2	6	1 per tooth per lifetime	2	2	2	1		2	1				2	2	6	6	bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	078	1	1	04	01	H5216_078_1	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
H5216	078	2	1	04	01	H5216_078_2	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge recementation and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Partial/complete dentures 1 set(s)/5 years, adjustment, reline, repair, rebase, tissue conditioning 1/year, occlusal adjustments 1/3 years, oral surgery 2/year, bridges 1/5 years.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	081	0	1	04	01	H5216_081_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	14	6	Denture adj, rebase, reline, repair and tissue cond. 1/year, bridge-crown 2/5 years, bridge-pontic, complete+part denture 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year, implant 1/tooth/life	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	083	0	1	04	01	H5216_083_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	088	0	1	04	01	H5216_088_0	7	1	1111	4	2	3	6	Oral Exams include emergency diagnostic exam up to 1 per year, and periodic oral exam up to 2 per year.	4	2	6	6	Prophylaxis include periodontal maintenance up to 4 per year, and prophylaxis (cleaning) up to 2 per year.	4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	20.00	20.00			0.00	0.00											1	2
H5216	089	0	1	04	01	H5216_089_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1	2	2	1000.00	3		2					2																		2		1	01011000	40.00	40.00			0.00	0.00	25.00	25.00									1	2
H5216	092	0	1	04	01	H5216_092_0	6	1	1111	4	2	3	6	Oral Exams services include emergency diagnostic exam up to 1 per year, periodic oral exam up to 2 per year.	4	2	6	6	Prophylaxis (cleaning) services include periodontal maintenance up to 4 per year, prophylaxis (cleaning) up to 2 per year.	4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
H5216	097	0	1	04	01	H5216_097_0	9	1	1111	4	2	3	6	Oral Exams - Oral Exams services include emergency diagnostic exam up to 1 per year, periodic oral exam up to 2 per year.	4	2	6	6	Prophylaxis (cleaning) - Prophylaxis (cleaning) services include periodontal maintenance up to 4 per year, prophylaxis (cleaning) up to 2 per year.	4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	1000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	45.00	45.00			0.00	0.00	25.00	25.00									1	2
H5216	099	0	1	04	01	H5216_099_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative services include amalgam and/or composite filling up to unlimited per year, bridge recementation and crown recementation up to 1 every 5 years, crown and other restorative services - core	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years,	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	100	0	1	04	01	H5216_100_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	35.00	35.00			0.00	0.00	25.00	25.00									1	2
H5216	105	0	1	04	01	H5216_105_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	30.00	30.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
H5216	106	0	1	04	01	H5216_106_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	107	0	1	04	01	H5216_107_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	40.00	40.00			0.00	0.00	25.00	25.00									1	2
H5216	112	0	1	04	01	H5216_112_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative Services- Fillings up to unlimited per year, recementation of crown and bridge up to 1 every 5 years, crown and other restorative services 1 tooth per lifetime,	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services- bridges-crown up to 2 every 5 yrs, oral surgery up to 2 per yr, occlusal adjustments up to 1 every 3 yrs, bridges-pontic 1 every 5 yrs	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	114	0	1	04	01	H5216_114_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative services-amalgam and/or composite filling up to unlimited per year, bridge and crown recementation to 1 every 5 years, crown and other restorative services up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Adjs to dentures, denture rebase, reline, repair and tissue conditioning 1/yr, bridges-crown 2/5 yrs, bridges-pontic, complete and partial dentures 1/5 yrs, occlusal adj up to 1/3 yrs, oral surgery up	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	116	0	1	04	01	H5216_116_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	25.00	25.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
H5216	117	0	1	04	01	H5216_117_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/yea	1		1				2					1	01000000	18	18															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	120	0	1	04	01	H5216_120_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1	2	2	2000.00	3		2					2																		2		1	01011000	30.00	30.00			0.00	0.00	25.00	25.00									1	2
H5216	124	0	1	04	01	H5216_124_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	30.00	30.00			0.00	0.00	25.00	25.00									1	2
H5216	128	0	1	04	01	H5216_128_0	4	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Srvc include amalgam and/or composite filling unlimited/year, crown + other restorative services - core buildup, prefab post and core up to 1/ tooth/ lifetime, crown recementation up to 1/ 5 yrs	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	denture adjust, rebase, reline, repair, tissue conditioning up to 1/year, complete dentures, partial dentures up to 1/5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	131	0	1	04	01	H5216_131_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	132	0	1	04	01	H5216_132_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	133	0	1	04	01	H5216_133_0	9	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative includes unlimited amalgam and/or composite fillings, bridge and crown recementation 1 every 5 years, and crown and other restorative services 1 tooth per lifetime.	2	2	2	6	Endodontics to include root canal and root canal retreatment at 1 tooth per lifetime.	2	2	2	6	Periodontics to include scaling and root planing (deep cleaning) at 1 per quadrant every 3 years and scaling for moderate inflammation at 1 every 3 years.	2	1				2	2	13	6	Denture adj, rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj., 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	136	0	1	04	01	H5216_136_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	40.00	40.00			0.00	0.00	25.00	25.00									1	2
H5216	137	0	1	04	01	H5216_137_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	2	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
H5216	138	0	1	04	01	H5216_138_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
H5216	140	0	1	04	01	H5216_140_0	11	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	141	0	1	04	01	H5216_141_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H5216	142	1	1	04	01	H5216_142_1	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H5216	142	2	1	04	01	H5216_142_2	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	bitewing x-rays 1 set(s) per yearintraoral x-rays 1 set(s) per yearpanoramic film or diagnostic x-rays 1 every 5 years	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
H5216	144	0	1	04	01	H5216_144_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H5216	152	0	1	04	01	H5216_152_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	35.00	35.00			0.00	0.00	25.00	25.00									1	2
H5216	154	0	1	04	01	H5216_154_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H5216	157	0	1	04	01	H5216_157_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	160	0	1	04	01	H5216_160_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	161	0	1	04	01	H5216_161_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	164	0	1	04	01	H5216_164_0	8	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Dent. adjustment, rebase, reline, repair, and tissue conditioning 1/yr, bridges-crown 2/5 yrs, bridges-pontic, complete dent., and partial dent. 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2/yr	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	168	0	1	04	01	H5216_168_0	6	1	1111	4	2	3	6	Oral Exams services include emergency diagnostic exam up to 1 per year; periodic oral exam up to 2 per year.	4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	35.00	35.00			0.00	0.00											1	2
H5216	169	0	1	04	01	H5216_169_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	bitewing/intraoral x-rays 1 set(s) per year, panoramic film or diagnostic x-rays 1 every 5 years	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	30.00	30.00			0.00	0.00											1	2
H5216	170	0	1	04	01	H5216_170_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	20.00	20.00			0.00	0.00	25.00	25.00									1	2
H5216	171	0	1	04	01	H5216_171_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010						2	2	1	1		2	1									2	2	2	1												1		1				2					1	01000000	20	20															2		1	00011010					0.00	0.00	0.00	0.00			0.00	0.00					1	2
H5216	172	0	1	04	01	H5216_172_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
H5216	173	0	1	04	01	H5216_173_0	5	1	1111	2	2	3	6	Oral Exams services include emergency diagnostic exam up to 1 per year, periodic oral exam up to 2 per year.	2	2	6	6	Prophylaxis (cleaning) services include periodontal maintenance up to 4 per year, prophylaxis (cleaning) up to 2 per year.	2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	174	0	1	04	01	H5216_174_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Fillings $25 unlimited per year, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime, crown recementation $25 1 every 5 years.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Denture adjustments, rebase, reline, repair, tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	40.00	40.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5216	175	0	1	04	01	H5216_175_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Amalgam and/or composite filling unlimited per yr, crown/other restorative services - core buildup/ prefabricated post/core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	4	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	176	0	1	04	01	H5216_176_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Complete and partial dentures 1 every 5 years, oral surgery 2 per year, denture adjustment, reline, repair, rebase, and tissue conditioning 1 per year, occlusal adjustments 1 every 3 years	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	177	0	1	04	01	H5216_177_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	1500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	$25 Amalgam and/or composite filling/unlimited / yr, $25 bridge recementation + crown recementation 1 /5 yr.  50% core buildup and prefabricated post, core 1/ tooth/ lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	30.00	30.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5216	179	0	1	04	01	H5216_179_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	180	0	1	04	01	H5216_180_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges up to 1 every 5 years, oral surgery up to 2 per year, occlusal adjustments up to 1 every 3 years.	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	182	0	1	04	01	H5216_182_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	Partial/complete dentures 1 set(s)/5 years. denture adjustment, reline, repair, and rebase, and tissue conditioning 1/year. Occlusal adjustments 1/3 years. Oral surgery 2/year. Bridges 1/5 years.	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	185	0	1	04	01	H5216_185_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	1000.00	3		2				2		2												2		1	0101	2				0.00	0.00			0.00	0.00			2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	186	0	1	04	01	H5216_186_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	188	0	1	04	01	H5216_188_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling unlimited per yr, bridge/crown recementation 1 every 5 yrs, crown/other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj, rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	190	0	1	04	01	H5216_190_0	4	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative services include fillings up to unlimited/year, recementation of crown and bridge up to 1 /5 years, crown up to 1 per tooth /lifetime, other restorative service up to 1 per tooth /lifetime	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Prosthodontics, Other Oral/Maxillofacial Surgery, -bridges up to 2 every 5 years, oral surgery up to 2 per year, occlusal adjustments up to 1 every 3 years, bridges-pontic up to 1 every 5 years	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	192	0	1	04	01	H5216_192_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					1	2	2	0.00	1		2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
H5216	193	0	1	04	01	H5216_193_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative service-amalgam and/or composite filling up to unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services up to 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	denture adjust, rebase, reline, repair, tissue condit 1/year; bridges-crown 2/ 5 year; bridges-pontic, complete dentures, partial dentures 1/ 5 years, occlusal adjust 1/3 years, oral surgery 2/ year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	194	0	1	04	01	H5216_194_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	65.00	65.00			0.00	0.00	25.00	25.00									1	2
H5216	195	0	1	04	01	H5216_195_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	3		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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include amalgam and/or composite filling up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth lifetime	2	2	2	3		2	2	2	1		2	1				2	2	10	6	Prosths, Oral/Maxillo Surgery, bridges-crown up to 2 every 5 years, bridges-pontic up to 1every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year	1	2	2	1000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	196	1	1	04	01	H5216_196_1	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	196	2	1	04	01	H5216_196_2	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
H5216	197	0	1	04	01	H5216_197_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-ray up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	198	0	1	04	01	H5216_198_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	200	0	1	04	01	H5216_200_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	201	0	1	04	01	H5216_201_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	203	1	1	04	01	H5216_203_1	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Bitewing x-rays and intraoral x-rays up to 1 set(s) per year. Panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Amalgam and/or composite filling unlimited/yr; bridge recementation and crown recementation 1/5 yrs; crown and other restorative services - core buildup, prefabricated post and core 1/tooth/lifetime	4	2	2	6	Root canal and root canal retreatment up to 1 per tooth per lifetime	4	2	2	1		4	1				4	2	13	6	Denture adjustment, rebase, reline, and repair and tissue conditioning 1/yr; bridges-crown 2/5 yrs; bridges-pontic, complete, and part. dentures 1/5 yrs; occlusal adjustment 1/3 yrs; oral surgery 2/yr	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	203	2	1	04	01	H5216_203_2	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	205	0	1	04	01	H5216_205_0	11	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	206	0	1	04	01	H5216_206_0	8	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Include amalgam and/or composite filling unlimited per year, crown +other restorative services - core buildup + prefabricated post and core  to 1/ tooth/ lifetime, crown recementation up to 1/5 years	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	10	6	Include adjust. dentures/rebase/denture reline/ repair/tissue conditioning 1/ year, complete+  partial dentures  1/5 years, occlusal adjustment  1/3 years, oral surgery 2/year.	1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	207	0	1	04	01	H5216_207_0	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	211	0	1	04	01	H5216_211_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	2	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	45.00	45.00			0.00	0.00	25.00	25.00									1	2
H5216	213	0	1	04	01	H5216_213_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Amalgam and/or composite filling unlimited/year.Bridge Recementation, crown recementation 1/5 years.Crown/other restorative services-core buildup and prefabricated post and core 1/tooth per lifetime.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	215	0	1	04	01	H5216_215_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	adj to dentures,rebase, reline, repair and tissue conditioning up to 1 per year, complete and partial dentures up to 1 every 5 years, occlusal adj up to 1 every 3 years oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	216	0	1	04	01	H5216_216_0	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	217	0	1	04	01	H5216_217_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	218	0	1	04	01	H5216_218_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	219	0	1	04	01	H5216_219_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Pro, Or/Max Sur, Oth. include part den and com den up to 1 set(s)/5 years, den adj, den rel., den re., tiss cond up to 1/year, occ adj up to 1/3 years, or surg up to 2/year, bridges up to 1/5 years.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	220	0	1	04	01	H5216_220_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative amalgam and/or composite filling 0% unlimited per yr, bridge recementation/crown recementation $25 1/5 yrs, crown - core buildup/prefabricated post and core 50% 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Adj to dentures/rebase/reline/repair/tissue conditioning 1/yr, complete dentures/partial dentures, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs, occlusal adjustment 1 /3 yrs, oral surgery 2/ yr.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	221	0	1	04	01	H5216_221_0	4	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	223	0	1	04	01	H5216_223_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Filling up to unlimited per year, bridge+crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj, rebase, reline, repair, tissue cond. 1/year, bridges-crown 2/5 years, bridges-pontic, complete/part dentures 1/5 years, occlusal adj. 1/3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	224	0	1	04	01	H5216_224_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	225	0	1	04	01	H5216_225_0	4	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling unlimited per yr, bridge/crown recementation 1 every 5 yrs, crown/other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj, rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	226	0	1	04	01	H5216_226_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Amalgam and/or composite filling unlimited per yr, bridge/crown recementation 1 every 5 yrs, crown/other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	227	0	1	04	01	H5216_227_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	228	0	1	04	01	H5216_228_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Srvc include amalgam/composite filling unlimited/year, bridge/crown recementation up to 1/5 years, crown + other restorative services - core buildup and prefab post and core up to 1/tooth/lifetime	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	denture adjust/rebase/reline/repair, tissue condit 1/year, bridges-crown 2/ 5 years, bridges-pontic, complete and partial dentures 1/ 5 years, occlusal adj 1/ 3 years, oral surgery up to 2 per year.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	229	0	1	04	01	H5216_229_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	amalgam and/or composite filling up to unlimited per year, crown and other restorative services up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	adj to dentures, denture rebase, denture reline, denture repair and tissue conditioning up to 1/yr, complete and partial dentures up to 1/5 yrs, occlusal adj up to 1/3 yrs, oral surgery up to 2/yr	1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	231	0	1	04	01	H5216_231_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	232	1	1	04	01	H5216_232_1	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	30.00	30.00			0.00	0.00	25.00	25.00									1	2
H5216	232	2	1	04	01	H5216_232_2	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	30.00	30.00			0.00	0.00	25.00	25.00									1	2
H5216	233	1	1	04	01	H5216_233_1	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	40.00	40.00			0.00	0.00	25.00	25.00									1	2
H5216	233	2	1	04	01	H5216_233_2	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	40.00	40.00			0.00	0.00	25.00	25.00									1	2
H5216	234	0	1	04	01	H5216_234_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	1500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					1	00010000					0	0											2		1	01001010	45.00	45.00					25.00	25.00			25.00	25.00					1	2
H5216	235	0	1	04	01	H5216_235_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative srv include amalgam and/or composite filling up to unlimited per year, bridge/crown recementation up to 1/5 yrs, crown/core buildup and prefabricated post and core up to 1/tooth/lifetime.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges-crown up to 2/5 yrs, bridges-pontic up to 1/5 yrs, occlusal adjustment up to 1/3 yrs, oral surgery up to 2 per yr.	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	236	0	1	04	01	H5216_236_0	10	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	242	0	1	04	01	H5216_242_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	243	0	1	04	01	H5216_243_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	244	0	1	04	01	H5216_244_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays up to 1 set(s)per year, intraoral x-rays up to 1 per year and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	40.00	40.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5216	246	0	1	04	01	H5216_246_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2000.00	3		2				1		1	1111	0	0									2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Fillings $25 unlimited per year, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime, crown recementation $25 1 every 5 years.	4	2	2	3		4	2	2	1		4	1				4	2	10	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	40.00	40.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5216	247	0	1	04	01	H5216_247_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	root canal and root canal retreatment up to 1 per tooth per lifetime	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	249	0	1	04	01	H5216_249_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	40.00	40.00			0.00	0.00											1	2
H5216	250	0	1	04	01	H5216_250_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Amalgam and/or composite filling unlimited per yr, bridge/crown recementation 1 every 5 yrs, crown/other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	251	0	1	04	01	H5216_251_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	10	6	Complete and partial dentures 1 every 5 years, oral surgery 2 per year, denture adjustment, reline, repair, rebase, and tissue conditioning 1 per year, occlusal adjustments 1 every 3 years	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	252	0	1	04	01	H5216_252_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	include partial complete dentures up to 1 every 5 ys, oral surgery 2 per yr, denture adj, denture reline, repair, rebase, tissue conditioning up to 1 per yr, occlusal adj up to 1 every 3 years.	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	253	0	1	04	01	H5216_253_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	include partial and complete dentures up to 1 every 5 yrs, oral surgery 2 per yr, denture adj, denture reline, repair, rebase, tissue conditioning up to 1 per yr, occlusal adj up to 1 every 3 yrs.	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	254	0	1	04	01	H5216_254_0	10	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	1	1		2	1				2	2	10	6	Complete and partial dentures 1 every 5 years, oral surgery 2 per year, denture adjustment, reline, repair, rebase, and tissue conditioning 1 per year, occlusal adjustments 1 every 3 years	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	255	0	1	04	01	H5216_255_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	256	0	1	04	01	H5216_256_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	Adjustments to dentures, denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete/partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	257	0	1	04	01	H5216_257_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics - Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	8	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	258	0	1	04	01	H5216_258_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	260	0	1	04	01	H5216_260_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	261	0	1	04	01	H5216_261_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	srvc incl amalgam and/or composite filling unlimited/year, bridge recementation/crown recementation 1/5 yrs, crown + other restorative services - core buildup, prefab post and core 1/tooth/lifetime	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	partial dentures, complete dentures 1/ 5 years, denture adjust, reline, repair, rebase, tissue condit 1/ year, occlusal adjust 1/ 3 years, oral surgery 2/ year, bridges 1/ 5 years.	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	263	0	1	04	01	H5216_263_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	264	0	1	04	01	H5216_264_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	4	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges up to 1 every 5 years, oral surgery up to 2 per year, occlusal adjustments up to 1 every 3 years.	1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	265	0	1	04	01	H5216_265_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	266	0	1	04	01	H5216_266_0	5	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	267	0	1	04	01	H5216_267_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	14	6	Denture adj, rebase, reline, repair and tissue cond. 1/year, bridge-crown 2/5 years, bridge-pontic, complete+part denture 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year, implant 1/tooth/life	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	268	0	1	04	01	H5216_268_0	7	1	1111	2	2	3	6	Oral Exams services include emergency diagnostic exam up to 1 per year, periodic oral exam up to 2 per year.	2	2	6	6	Prophylaxis include periodontal maintenance up to 4 per year, and prophylaxis (cleaning) up to 2 per year.	2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	269	0	1	04	01	H5216_269_0	12	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	271	0	1	04	01	H5216_271_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	273	0	1	04	01	H5216_273_0	6	1	1111	4	2	3	6	Oral Exams services include emergency diagnostic exam up to 1 per year, periodic oral exam up to 2 per year.	4	2	6	6	Prophylaxis (cleaning) services include periodontal maintenance up to 4 per year, prophylaxis (cleaning) up to 2 per year.	4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	274	0	1	04	01	H5216_274_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	275	0	1	04	01	H5216_275_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	277	0	1	04	01	H5216_277_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	10	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	278	1	1	04	01	H5216_278_1	4	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	278	3	1	04	01	H5216_278_3	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	279	0	1	04	01	H5216_279_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	280	1	1	04	01	H5216_280_1	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	280	2	1	04	01	H5216_280_2	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	281	0	1	04	01	H5216_281_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling unlimited/year.Bridge recementation, crown recementation 1/5 years.Crown/other restorative services-core buildup and prefabricated post and core 1/tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Prosths, Oral/Maxillo Surgery, bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	283	0	1	04	01	H5216_283_0	5	1	1111	2	2	3	6	Oral Exams services include emergency diagnostic exam up to 1 per year, periodic oral exam up to 2 per year.	2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	amalgam and/or composite filling up to unlimited per yr, crown/other restorative services - core buildup, prefabricated post and core up to 1 per tooth per lifetime crown recementation up to 1 per yr.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	10	6	services include adjustments to dentures, rebase, reline, repair and tissue conditioning 1/yr. complete and partial dentures 1 every 5 yrs. occlusal adj. 1 every 3 yrs. oral surgery 2 per yr	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	284	0	1	04	01	H5216_284_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	285	0	1	04	01	H5216_285_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	286	0	1	04	01	H5216_286_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					2	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	50.00	50.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
H5216	287	0	1	04	01	H5216_287_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	14	6	Denture adj, rebase, reline, repair and tissue cond. 1/year, bridge-crown 2/5 years, bridge-pontic, complete+part denture 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year, implant 1/tooth/life	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	288	0	1	04	01	H5216_288_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	289	0	1	04	01	H5216_289_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	40.00	40.00			0.00	0.00											1	2
H5216	290	0	1	04	01	H5216_290_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	291	0	1	04	01	H5216_291_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	292	0	1	04	01	H5216_292_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	293	0	1	04	01	H5216_293_0	9	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Prosthodontics, Other Services include dentures up to 1 set(s) every 5 years, , occlusal adjustments up to 1 every 3 years, oral surgery up to 2 per year, bridges up to 1 every 5 years.	1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	294	0	1	04	01	H5216_294_0	4	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges up to 1 every 5 years, oral surgery up to 2 per year, occlusal adjustments up to 1 every 3 years.	1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	296	0	1	04	01	H5216_296_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Svcs incl partial & complete dentures 1/5 yrs; oral surgery 2/yr; denture adj/reline/repair/rebase, tissue condit. 1/yr; occlusal adj 1/3 yrs	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	298	0	1	04	01	H5216_298_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to 2 per year, crowns up to 2 per year, recementation of crown and recementation of dentures up to 1 every 5 years.	2	2	2	3		2	2	2	1		2	1				2	2	10	6	adjustments to dentures, denture repair, tissue conditioning up to 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1	2	2	2000.00	3		2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	300	0	1	04	01	H5216_300_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	1750.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	301	1	1	04	01	H5216_301_1	3	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	301	2	1	04	01	H5216_301_2	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	301	3	1	04	01	H5216_301_3	3	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	301	4	1	04	01	H5216_301_4	4	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	302	0	1	04	01	H5216_302_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling unlimited/yr; bridge recementation and crown recementation 1/5 yrs; crown and other restorative services - core buildup, prefabricated post and core 1/tooth/lifetime	2	2	2	6	Root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	14	6	Dent. adjstmnt/rebase/reline/repair, tissue cndtioning 1/yr; brdges-crown 2/5yrs; brdges-pontic, comp., part. dent. 1/5yrs; occlusal adjstmnt 1/3yrs; oral surgery2/yr; restoration implant 1/tooth/life	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	304	0	1	04	01	H5216_304_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	305	0	1	04	01	H5216_305_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	45.00	45.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5216	306	0	1	04	01	H5216_306_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative svc include amalgam and/or composite filling/unlimited per year, bridge/crown recementation up to 1/5 yrs, crown/core buildup and prefabricated post and core up to 1/tooth/lifetime	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	307	0	1	04	01	H5216_307_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays, intraoral s-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	45.00	45.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5216	308	0	1	04	01	H5216_308_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H5216	309	0	1	04	01	H5216_309_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	310	0	1	04	01	H5216_310_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	311	0	1	04	01	H5216_311_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010						2	2	1	1		2	1									2	2	2	1												1		1				2					2																		2		1	01011010	35.00	35.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
H5216	312	0	1	04	01	H5216_312_0	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	313	0	1	04	01	H5216_313_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	30.00	30.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5216	314	0	1	04	01	H5216_314_0	10	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	amalgam and/or composite filling unlimited per year, bridge/crown recementation up to 1/5 yrs, crown and other restorative services- core buildup & prefabricated post & core up to 1/tooth/lifetime	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	dent adj.,rebase,reline,repair, tissue conditioning up to 1/yr, bridges-crown up to 2/5 yrs, bridges-pontic/complete/partial dentures up to 1/5yrs, occlusal adj. up to 1/3 yrs, oral surgery up to 2/yr	1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	315	0	1	04	01	H5216_315_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	316	1	1	04	01	H5216_316_1	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Srvc incl amalgam and/or composite filling unlimited/yr, bridge/crown recementation 1/ 5 yrs, crown and other restorative services - core buildup and prefabricated post and core 1/ tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	5	1		2	1				2	2	13	6	Srvc incl adj to dentures, denture rebase/reline/repair, tissue conditioning 1/ yr, bridges-crown 2/ 5 yrs, bridges-pontic, complete/prtl dentures 1/ 5 yrs, occlusal adj 1/ 3 yrs, oral surgery 2/ yr	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	316	3	1	04	01	H5216_316_3	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	amalgam/composite filling unlimited per year, bridge and crown recementation 1 per 5 years, crown and other restorative services - core buildup and prefabricated post and 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	adj dentures, denture rebase/reline/repair and tissue conditioning 1/yr, bridges-crown 2/5 yrs, bridges-pontic, complete dentures and prtl dentures 1/5 yrs, occlusal adj 1/3 yrs, oral surgery 2/yr	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	317	0	1	04	01	H5216_317_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	amalgam and/or composite filling/unlimited/ yr. bridge/crown recementation 1/5 yrs, crown /core buildup and prefabricated post and core 1/ tooth/lifetime	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	318	1	1	04	01	H5216_318_1	10	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	318	2	1	04	01	H5216_318_2	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Services include amalgam and/or composite filling up to unlimited per year, bridge and crown recementation  up to 1 every 5 years, crown and other restorative services - up to 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Services include adjustments to dentures up to 1 per year. Denture rebase, reline, repair and tissue conditioning up to 1 per year. Bridges-crown up to 2 every 5 years. Bridges-pontic, complete and pa	1	2	2	2500.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	318	3	1	04	01	H5216_318_3	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	2	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	319	0	1	04	01	H5216_319_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
H5216	320	0	1	04	01	H5216_320_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	45.00	45.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5216	322	0	1	04	01	H5216_322_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Amalgam and/or composite filling unlimited per yr, bridge/crown recementation 1 every 5 yrs, crown/other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	324	0	1	04	01	H5216_324_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Amalgam and/or composite filling $25 up to unlimited per year, bridge/crown recementation  $25 up to 1 every 5 years, crown and other restorative services 50% up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	30.00	30.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5216	325	0	1	04	01	H5216_325_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	326	0	1	04	01	H5216_326_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	327	0	1	04	01	H5216_327_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	328	0	1	04	01	H5216_328_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and bridge up to 1 every 5 years, crown and other restorative services up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	4	6	Prosthodontics, Other Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, oral surgery up to 2 per year, occlusal adjustments up to 1 every 3 years.	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	329	0	1	04	01	H5216_329_0	10	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	330	0	1	04	01	H5216_330_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	331	0	1	04	01	H5216_331_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	1		1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	332	0	1	04	01	H5216_332_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	333	0	1	04	01	H5216_333_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	334	0	1	04	01	H5216_334_0	6	1	1111	2	2	3	6	Oral Exams - Oral Exams services include emergency diagnostic exam up to 1 per year, periodic oral exam up to 2 per year.	2	2	6	6	Prophylaxis (cleaning) - Prophylaxis (cleaning) services include periodontal maintenance up to 4 per year, prophylaxis (cleaning) up to 2 per year.	2	2	2	3		2	2	3	6	Dental X-Rays - Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	5	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	335	0	1	04	01	H5216_335_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling unlimited/year.Bridge Recementation, crown recementation 1/5 years.Crown/other restorative services-core buildup and prefabricated post and core 1/tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1/year.Bridges-crown 2/5 years.Bridges-pontic, complete/part. dentures 1/5 years.Occlusal adjustment 1/3 years.Oral surgery 2/year.	1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	337	1	1	04	01	H5216_337_1	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Srvc incl amalgam/composite filling unlimited/yr, bridge/crown recementation 1/ 5 yrs, crown and other restorative services - core buildup and prefabricated post and core 1/ tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	5	1		4	1				4	2	13	6	Srvc incl adj to dentures, denture rebase/reline/repair, tissue conditioning 1/ yr, bridges-crown 2/ 5 yrs, bridges-pontic, complete/prtl dentures 1/ 5 yrs, occlusal adj 1/ 3 yrs, oral surgery 2/ year	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	337	2	1	04	01	H5216_337_2	8	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	337	3	1	04	01	H5216_337_3	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	338	0	1	04	01	H5216_338_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Amalgam and/or composite filling unlimited/yr; bridge recementation and crown recementation 1/5 yrs; crown and other restorative services - core buildup, prefabricated post and core 1/tooth/lifetime	4	2	2	6	Root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	13	6	Denture adjustment, rebase, reline, and repair and tissue conditioning 1/yr; bridges-crown 2/5 yrs; bridges-pontic, complete, and part. dentures 1/5 yrs; occlusal adjustment 1/3 yrs; oral surgery 2/yr	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	339	0	1	04	01	H5216_339_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	4	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges up to 1 every 5 years, oral surgery up to 2 per year, occlusal adjustments up to 1 every 3 years.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	340	0	1	04	01	H5216_340_0	5	1	1111	2	2	3	6	Oral Exams services include emergency diagnostic exam up to 1 per year, periodic oral exam up to 2 per year.	2	2	6	6	Prophylaxis (cleaning) services include periodontal maintenance up to 4 per year, prophylaxis (cleaning) up to 2 per year.	2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	341	0	1	04	01	H5216_341_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	343	0	1	04	01	H5216_343_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	345	0	1	04	01	H5216_345_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	40.00	40.00			0.00	0.00											1	2
H5216	346	0	1	04	01	H5216_346_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
H5216	347	0	1	04	01	H5216_347_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Amalgam and/or composite filling unlimited/yr; bridge recementation and crown recementation 1/5 yrs; crown and other restorative services - core buildup, prefabricated post and core 1/tooth/lifetime	4	2	2	6	Root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adjustment, rebase, reline, and repair and tissue conditioning 1/yr; bridges-crown 2/5 yrs; bridges-pontic, complete, and part. dentures 1/5 yrs; occlusal adjustment 1/3 yrs; oral surgery 2/yr	1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	348	0	1	04	01	H5216_348_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	40.00	40.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
H5216	349	0	1	04	01	H5216_349_0	5	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	350	0	1	04	01	H5216_350_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3										3					3					1		1				2					2																		2		1	01011000	45.00	45.00			0.00	0.00	25.00	25.00									1	2
H5216	351	0	1	04	01	H5216_351_0	8	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Pros, Or/Max Surg, Oth Serv include part dent and com den up to 1/5 years, or sur up to 2/year, den adj, den rel, den rep, den reb, tis cond up to 1/year, occlusal adjustments up to 1/3 years.	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	352	0	1	04	01	H5216_352_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	353	0	1	04	01	H5216_353_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	4	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	354	0	1	04	01	H5216_354_0	3	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	355	0	1	04	01	H5216_355_0	3	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	356	0	1	04	01	H5216_356_0	5	1	1111	2	2	3	6	Oral Exams services include emergency diagnostic exam up to 1 per year, periodic oral exam up to 2 per year.	2	2	6	6	Prophylaxis (cleaning) services include periodontal maintenance up to 4 per year, prophylaxis (cleaning) up to 2 per year.	2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	357	0	1	04	01	H5216_357_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling unlimited/year.Bridge Recementation, crown recementation 1/5 years.Crown/other restorative services-core buildup and prefabricated post and core 1/tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	5	1		2	1				2	2	13	6	Denture adjust, rebase, reline, repair, tissue condit 1/year; bridges-crown 2/ 5 year; bridges-pontic, complete dentures, partial dentures 1/ 5 years, occlusal adjust 1/3 years, oral surgery 2/ year.	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	358	0	1	04	01	H5216_358_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Srvc incl amalgam/composite filling unlimited/ yr, bridge/crown recementation 1/ 5 yrs, crown and other restorative services - core buildup and prefabricated post and core 1/ tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	359	0	1	04	01	H5216_359_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	45.00	45.00			0.00	0.00	25.00	25.00									1	2
H5216	360	0	1	04	01	H5216_360_0	8	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Pro, Or/Max Surg, Oth Serv include part den and com den up to 1/5 years, or surg up to 2/year, den adj, den rel, den rep, den reb, tiss cond up to 1 per year, occlusal adjustments up to 1/3 years.	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	361	0	1	04	01	H5216_361_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	362	0	1	04	01	H5216_362_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	363	0	1	04	01	H5216_363_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	364	0	1	04	01	H5216_364_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	365	0	1	04	01	H5216_365_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	366	0	1	04	01	H5216_366_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	367	0	1	04	01	H5216_367_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	368	0	1	04	01	H5216_368_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	2	1	0011000	3					4	2	1	1		4	2	4	6	Bridge recrem 1 every 5 yearscrown 1 per tooth per lifetimecrown recem 1 every 5 yearscore build up  1 per tooth per lifetime	3					3					3					3					1		1				2					2																		2		1	01011000	40.00	40.00			0.00	0.00	25.00	25.00									1	2
H5216	369	0	1	04	01	H5216_369_0	10	1	1111	2	1				2	1				2	1				2	1				1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	370	0	1	04	01	H5216_370_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	371	0	1	04	01	H5216_371_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	amalgam and/or composite filling unlimited/yr, bridge/crown recementation up to 1/5 yrs, crown, other restorative services- core buildup & prefabricated post & core up to 1/tooth/lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	14	6	Denture adj/rebase/reline/repair, tissue conditioning 1/yr, bridges-crown 2/5yrs, bridges-pontic, comp/part dent 1/5 yrs, occlusal adj. 1/3 yrs, oral surgery 2/yr, restoration implant 1/tooth/lifetime	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	372	0	1	04	01	H5216_372_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Srvc incl amalgam/composite filling unlimited/yr, bridge and crown recementation 1/ 5 yrs, crown and other restorative services - core buildup and prefabricated post and core up to 1/ tooth/ lifetime.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	srvc incl adj to dentures, denture rebase/reline/repair, tissue conditioning 1/ yr, bridges-crown 2/ 5 yrs, bridges-pontic, complete/prtl dentures 1/ 5 yrs, occlusal adj 1/ 3 yrs, oral surgery 2/ yr	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	373	0	1	04	01	H5216_373_0	8	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	5	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	14	6	Denture adj, rebase, reline, repair and tissue cond. 1/year, bridge-crown 2/5 years, bridge-pontic, complete+part denture 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year, implant 1/tooth/life	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	375	0	1	04	01	H5216_375_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative services-amalgam and/or composite filling up to unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services-bridges-crown 2 every 5 years, bridges-pontic 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery up to 2 per year	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	376	0	1	04	01	H5216_376_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	14	6	Denture adj, rebase, reline, repair and tissue cond. 1/year, bridge-crown 2/5 years, bridge-pontic, complete+part denture 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year, implant 1/tooth/life	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	377	0	1	04	01	H5216_377_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	378	0	1	04	01	H5216_378_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	0.00	0.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
H5216	379	0	1	04	01	H5216_379_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	380	0	1	04	01	H5216_380_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	45.00	45.00			0.00	0.00	25.00	25.00									1	2
H5216	381	0	1	04	01	H5216_381_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	382	0	1	04	01	H5216_382_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	1000.00	3		2				2		2												2		1	0111	2				0.00	0.00	0.00	0.00	0.00	0.00			2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings unlimited per year, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime, crown recementation 1 every 5 years	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adj., rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	383	0	1	04	01	H5216_383_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	30.00	30.00			0.00	0.00											1	2
H5216	384	0	1	04	01	H5216_384_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative services-amalgam and/or composite filling up to unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	385	0	1	04	01	H5216_385_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services: amalgam and/or composite filling up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	386	1	1	04	01	H5216_386_1	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	386	2	1	04	01	H5216_386_2	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	387	1	1	04	01	H5216_387_1	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	387	2	1	04	01	H5216_387_2	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	388	0	1	04	01	H5216_388_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative service-amalgam and/or composite filling up to unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services up to 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Adjs to dentures, denture rebase, reline, repair and tissue conditioning 1/yr, bridges-crown 2/5 yrs, bridges-pontic, complete and partial dentures 1/5 yrs, occlusal adjs.1/3 yrs, oral surgery 2/yr	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	389	0	1	04	01	H5216_389_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	25.00	25.00			0.00	0.00	25.00	25.00									1	2
H5216	390	0	1	04	01	H5216_390_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	denture adjust, rebase, reline, repair, tissue condit 1/year; bridges-crown 2/ 5 year; bridges-pontic, complete dentures, partial dentures 1/ 5 years, occlusal adjust 1/3 years, oral surgery 2/ year.	1	2	2	2500.00	3		2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	391	0	1	04	01	H5216_391_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays, intraoral s-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	5	6	Restorative includes fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	45.00	45.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5216	392	0	1	04	01	H5216_392_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11011111	35.00	35.00			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	393	0	1	04	01	H5216_393_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010						2	2	1	1		2	1									2	2	2	1												1		1				2					2																		2		1	01011010	45.00	45.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
H5216	394	0	1	04	01	H5216_394_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	395	0	1	04	01	H5216_395_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	45.00	45.00			0.00	0.00	25.00	25.00									1	2
H5216	396	0	1	04	01	H5216_396_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays, intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	45.00	45.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5216	397	0	1	04	01	H5216_397_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Include amalgam, composite filling unlimited per year, crown and other restorative services, core buildup, prefabricated post and core up to 1 per tooth per lifetime, crown recementation 1 every 5 yrs	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	10	6	Services include adjustments to dentures, rebase, reline, repair, and tissue conditioning 1/yr. complete and partial dentures 1 every 5 yrs. occlusal adj. 1 every 3 yrs. oral surgery 2/ yr.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	398	0	1	04	01	H5216_398_0	5	1	1111	2	2	3	6	Oral Exams services include emergency diagnostic exam up to 1 per year, periodic oral exam up to 2 per year.	2	2	6	6	Prophylaxis (cleaning) services include periodontal maintenance up to 4 per year, prophylaxis (cleaning) up to 2 per year.	2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	399	0	1	04	01	H5216_399_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	partial dentures, complete dentures 1 every 5 years, surgery up to 2 per year, denture adj, denture reline, repair, rebase, tissue conditioning up to 1 per year, occlusal adj 1 every 3 years.	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	400	0	1	04	01	H5216_400_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	401	0	1	04	01	H5216_401_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5216	805	0	1	04	01	H5216_805_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5216	806	0	1	04	01	H5216_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5216	808	0	2	04	01	H5216_808_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5216	809	0	2	04	01	H5216_809_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5216	811	0	1	04	01	H5216_811_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5216	812	0	1	04	01	H5216_812_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5216	813	0	1	04	01	H5216_813_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5216	814	0	1	04	01	H5216_814_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5216	817	0	1	04	01	H5216_817_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5216	818	0	1	04	01	H5216_818_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5216	821	0	1	04	01	H5216_821_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5216	824	0	1	04	01	H5216_824_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5232	001	0	1	04	01	H5232_001_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	7500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	2	6	N/A	2	2	1	6	Amalgam and Resin based composites are limited to one procedure per tooth every 3 years	2	2	1	6	Select endodontics procedures will only be eligible for retreatment every 4 years per the details in the evidence of coverage.	2	2	1	6	Periodontics Scaling and root planning procedures requires submission of supporting documentation and subject to utilization review. Must contain 4 teeth with 4+MM pockets, covered every 3 years. Peri	2	1				2	1				1		1				2					1	11111111	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2
H5232	002	0	1	04	01	H5232_002_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	2	6	Diagnostic evaluations – This Plan covers problem-focused exams which are limited to two evaluations per calendar year. Diagnostic Services includes Intraoral - complete series of radiographic images	2	2	1	6	Amalgam and Resin based composites are limited to one procedure per tooth every 3 years.	2	2	1	6	Select endodontics procedures will only be eligible for retreatment every 4 years per the details in the evidence of coverage.	2	2	1	6	Periodontics Scaling and root planning procedures requires submission of supporting documentation and subject to utilization review. Must contain 4 teeth with 4+MM pockets, covered every 3 years.	2	1				2	1				1		1				2					1	11111111	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2
H5244	001	0	1	01	01	H5244_001_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010	3					4	2	2	3		3					3					4	1				3					3					2						2					2																		2		1	01000000	20.00	20.00															1	2
H5244	002	0	1	01	01	H5244_002_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010	3					4	2	2	3		3					3					4	1				3					3					2						2					2																		2		1	01000000	20.00	20.00															1	2
H5244	003	0	1	01	01	H5244_003_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010	3					4	2	2	3		3					3					4	1				3					3					2						2					2																		2		1	01000000	20.00	20.00															1	2
H5244	004	0	1	01	01	H5244_004_0	10	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010						2	2	2	3												2	1														2						2					1	01000000	20	20															2		2																		1	2
H5253	004	0	1	02	01	H5253_004_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	007	0	1	02	01	H5253_007_0	4	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5253	011	0	1	02	01	H5253_011_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	021	0	1	02	01	H5253_021_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	024	0	1	02	01	H5253_024_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5253	030	0	1	02	01	H5253_030_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	033	0	1	02	01	H5253_033_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	034	0	1	02	01	H5253_034_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	035	0	1	02	01	H5253_035_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	036	0	1	02	01	H5253_036_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	037	0	1	02	01	H5253_037_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	038	0	1	02	01	H5253_038_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	039	0	1	02	01	H5253_039_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	040	0	1	02	01	H5253_040_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	041	0	1	02	01	H5253_041_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5253	042	0	1	02	01	H5253_042_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5253	043	0	1	02	01	H5253_043_0	4	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5253	047	0	1	02	01	H5253_047_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	048	0	1	02	01	H5253_048_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	051	0	1	02	01	H5253_051_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	059	0	1	02	01	H5253_059_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5253	060	0	1	02	01	H5253_060_0	4	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5253	062	0	1	02	01	H5253_062_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	064	0	1	02	01	H5253_064_0	4	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5253	072	0	1	02	01	H5253_072_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	073	0	1	02	01	H5253_073_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	079	0	1	02	01	H5253_079_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	080	0	1	02	01	H5253_080_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	081	0	1	02	01	H5253_081_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	082	0	1	02	01	H5253_082_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	083	0	1	02	01	H5253_083_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	084	0	1	02	01	H5253_084_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	087	0	1	02	01	H5253_087_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	088	0	1	02	01	H5253_088_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	089	0	1	02	01	H5253_089_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	097	0	1	02	01	H5253_097_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	099	0	1	02	01	H5253_099_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	100	0	1	02	01	H5253_100_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	102	0	1	02	01	H5253_102_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	103	0	1	02	01	H5253_103_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	104	0	1	02	01	H5253_104_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	105	0	1	02	01	H5253_105_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H5253	107	1	1	02	01	H5253_107_1	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	107	2	1	02	01	H5253_107_2	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	108	1	1	02	01	H5253_108_1	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	108	2	1	02	01	H5253_108_2	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	108	3	1	02	01	H5253_108_3	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	109	1	1	02	01	H5253_109_1	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	109	2	1	02	01	H5253_109_2	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	109	4	1	02	01	H5253_109_4	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	110	0	1	02	01	H5253_110_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H5253	111	1	1	02	01	H5253_111_1	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	111	2	1	02	01	H5253_111_2	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	112	1	1	02	01	H5253_112_1	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	112	2	1	02	01	H5253_112_2	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	113	0	1	02	01	H5253_113_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	116	0	1	02	01	H5253_116_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	117	0	1	02	01	H5253_117_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	119	0	1	02	01	H5253_119_0	5	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H5253	120	0	1	02	01	H5253_120_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	121	0	1	02	01	H5253_121_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H5253	122	0	1	02	01	H5253_122_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	124	1	1	02	01	H5253_124_1	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	124	2	1	02	01	H5253_124_2	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	125	1	1	02	01	H5253_125_1	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	125	2	1	02	01	H5253_125_2	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	126	1	1	02	01	H5253_126_1	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	126	2	1	02	01	H5253_126_2	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	127	0	1	02	01	H5253_127_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H5253	128	0	1	02	01	H5253_128_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	130	0	1	02	01	H5253_130_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	131	0	1	02	01	H5253_131_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	132	0	1	02	01	H5253_132_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	133	0	1	02	01	H5253_133_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	134	0	1	02	01	H5253_134_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	135	0	1	02	01	H5253_135_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H5253	136	0	1	02	01	H5253_136_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	141	0	1	02	01	H5253_141_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	142	0	1	02	01	H5253_142_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	143	0	1	02	01	H5253_143_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	144	1	1	02	01	H5253_144_1	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	144	2	1	02	01	H5253_144_2	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5253	801	0	1	01	01	H5253_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	802	0	1	01	01	H5253_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	805	0	1	01	01	H5253_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	810	0	1	01	01	H5253_810_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	811	0	1	01	01	H5253_811_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	812	0	1	01	01	H5253_812_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	813	0	1	01	01	H5253_813_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	814	0	1	01	01	H5253_814_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	815	0	1	01	01	H5253_815_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	816	0	2	01	01	H5253_816_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	817	0	2	01	01	H5253_817_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	818	0	1	01	01	H5253_818_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	819	0	1	01	01	H5253_819_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	820	0	1	01	01	H5253_820_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	821	0	1	01	01	H5253_821_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	822	0	1	01	01	H5253_822_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	823	0	1	01	01	H5253_823_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	824	0	1	01	01	H5253_824_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	825	0	1	01	01	H5253_825_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5253	826	0	2	01	01	H5253_826_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5256	001	0	1	18	06	H5256_001_0	3	2																																																															2																																											2					2																		2		2																		2	2
H5256	002	0	1	18	06	H5256_002_0	3	2																																																															2																																											2					2																		2		2																		2	2
H5256	004	0	1	18	06	H5256_004_0	3	2																																																															2																																											2					2																		2		2																		2	2
H5256	005	0	1	18	06	H5256_005_0	3	2																																																															2																																											2					2																		2		2																		2	2
H5262	001	0	1	01	01	H5262_001_0	5	1	1111	4	1				4	1				4	1				4	1				1		1550.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	30.00	30.00															2	2
H5262	003	0	1	01	01	H5262_003_0	4	1	1111	4	1				4	1				4	1				4	1				1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H5262	004	0	1	01	01	H5262_004_0	3	1	1111	4	1				4	1				4	1				4	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H5262	005	0	1	01	01	H5262_005_0	3	1	1111	4	1				4	1				4	1				4	1				1		1200.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	30.00	30.00															2	2
H5262	007	0	1	01	01	H5262_007_0	4	1	1111	4	1				4	1				4	1				4	1				1		750.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	25.00	25.00															2	2
H5262	008	0	1	01	01	H5262_008_0	4	1	1111	4	1				4	1				4	1				4	1				1		600.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	35.00	35.00															2	2
H5262	009	0	1	01	01	H5262_009_0	3	1	1111	4	1				4	1				4	1				4	1				1		350.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	35.00	35.00															2	2
H5262	010	0	1	01	01	H5262_010_0	3	1	1111	4	1				4	1				4	1				4	1				1		550.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	25.00	25.00															2	2
H5262	011	0	1	01	01	H5262_011_0	4	1	1111	4	1				4	1				4	1				4	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	35.00	35.00															2	2
H5262	012	0	1	01	01	H5262_012_0	4	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	50.00	50.00															2	2
H5262	013	0	1	01	01	H5262_013_0	3	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	35.00	35.00															2	2
H5262	018	0	1	01	01	H5262_018_0	4	1	1111	4	1				4	1				4	1				4	1				1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	35.00	35.00															2	2
H5262	019	0	1	01	01	H5262_019_0	4	1	1111	4	1				4	1				4	1				4	1				1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	45.00	45.00															2	2
H5262	020	0	1	01	01	H5262_020_0	3	1	1111	4	1				4	1				4	1				4	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	35.00	35.00															2	2
H5262	021	0	1	01	01	H5262_021_0	4	1	1111	4	1				4	1				4	1				4	1				1		850.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	50.00	50.00															2	2
H5262	023	0	1	01	01	H5262_023_0	4	1	1111	4	1				4	1				4	1				4	1				1		550.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	50.00	50.00															2	2
H5262	024	0	1	01	01	H5262_024_0	4	1	1111	4	1				4	1				4	1				4	1				1		3750.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	25.00	25.00															2	2
H5262	025	0	1	01	01	H5262_025_0	3	1	1111	4	1				4	1				4	1				4	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	25.00	25.00															2	2
H5262	026	0	1	01	01	H5262_026_0	4	1	1111	4	1				4	1				4	1				4	1				1		1550.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	25.00	25.00															2	2
H5262	027	0	1	01	01	H5262_027_0	3	1	1111	4	1				4	1				4	1				4	1				1		1200.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	25.00	25.00															2	2
H5262	029	0	1	01	01	H5262_029_0	4	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H5262	030	0	1	01	01	H5262_030_0	4	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H5262	031	0	1	01	01	H5262_031_0	4	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H5262	801	0	1	01	01	H5262_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5262	802	0	1	01	01	H5262_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5264	002	0	1	18	06	H5264_002_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	once per 36 month period	2	2	1	6	Diagnostic x-ray: Once per calendar yearPeriodontal maintenance: Twice per year	2	1				2	1				2	2	1	6	Surgical periodontal services: Once per 36 monthsRoot planing and scaling: once per quadrant every 24 months.	2	1				2	2	1	6	Services are limited to once in a five-year period per tooth.	1		1				2					1	10111111			50	50	0	50	50	50	50	50	50	50	50	50	50	50	2		2																		2	2
H5264	005	0	1	18	06	H5264_005_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	once per 36 month period	2	2	1	6	Diagnostic x-ray: Once per calendar yearPeriodontal maintenance: Twice per year	2	1				2	1				2	2	1	6	Surgical periodontal services: Once per 36 monthsRoot planing and scaling: once per quadrant every 24 months.	2	1				2	2	1	6	Services are limited to once in a five-year period per tooth.	1		1				2					1	10111111			50	50	0	50	50	50	50	50	50	50	50	50	50	50	2		2																		2	2
H5273	001	0	1	01	01	H5273_001_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	4		2	2	2	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	3		2	2	1	6	Intraoral complete series of radiographic images are covered once every five years.	2	2	1	6	Protective restorations covered once per tooth. Major restorations covered once per tooth every 84 months. Minor restorations covered once per surface per tooth every 24 months.	2	2	1	6	Root canals are covered once per tooth per lifetime.	2	2	1	6	Depending on type of service, periodicity may range from once every 6 months to once per lifetime.	2	2	1	6	Simple extraction covered once per tooth.	2	2	1	6	Depending on type of service, periodicity ranges from as needed to once every 84 months. Implants are covered once every 5 years.	1		1				2					1	10111111			20	20	20	20	20	50	50	50	50	50	50	50	50	50	2		1	01000000	45.00	45.00															2	2
H5273	801	0	1	01	01	H5273_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5273	802	0	1	01	01	H5273_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5273	803	0	1	01	01	H5273_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5273	804	0	1	01	01	H5273_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5280	001	0	1	48	05	H5280_001_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		2																		1	2
H5294	010	0	1	01	01	H5294_010_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 months.Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5294	011	0	1	01	01	H5294_011_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	NON-ROUTINE SERVICES every date of service to 60 months.	2	2	1	3		2	2	1	6	every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5294	012	0	1	01	01	H5294_012_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1500.00	3		2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5294	013	0	1	01	01	H5294_013_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5294	014	0	1	01	01	H5294_014_0	15	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5294	015	0	1	01	01	H5294_015_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5294	016	0	1	01	01	H5294_016_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	30.00	30.00															1	2
H5294	017	0	1	01	01	H5294_017_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1500.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	30.00	30.00															1	2
H5294	018	0	1	01	01	H5294_018_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5294	019	0	1	01	01	H5294_019_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H5294	020	0	1	01	01	H5294_020_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5296	003	0	1	02	01	H5296_003_0	13	1	1111	2	1				2	1				2	1				2	1				1		1000.00	4		2				2		2												2		2		2												1	1	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H5296	004	0	1	02	01	H5296_004_0	13	1	1111	2	1				2	1				2	1				2	1				1		1500.00	4		2				2		2												2		2		2												1	1	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H5296	005	0	1	02	01	H5296_005_0	13	1	1111	2	1				2	1				2	1				2	1				1		1000.00	4		2				2		2												2		2		2												1	1	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H5296	006	0	1	01	01	H5296_006_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												1	1	2		3					3					3					3					3					3					3											2					2																		2		2																		2	2
H5296	007	0	1	01	01	H5296_007_0	13	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1		3000.00	3		2				2		2												2		2		2												1	1	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H5296	008	0	1	01	01	H5296_008_0	13	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												1	1	2		3					3					3					3					3					3					3											2					2																		2		2																		2	2
H5296	801	0	1	01	01	H5296_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5296	802	0	1	01	01	H5296_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5296	803	0	1	01	01	H5296_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5296	804	0	1	01	01	H5296_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5299	001	0	1	01	01	H5299_001_0	11	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H5299	002	0	1	01	01	H5299_002_0	10	1	1111	2	1				2	1				2	1				2	1				1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H5299	003	0	1	01	01	H5299_003_0	11	1	1111	2	1				2	1				2	1				2	1				1		1750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H5299	004	0	1	01	01	H5299_004_0	11	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H5299	006	0	1	01	01	H5299_006_0	13	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	7500.00	3		2					2																		2		2																		1	2
H5299	009	0	1	01	01	H5299_009_0	12	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	6000.00	3		2					2																		2		1	01000000	15.00	15.00															1	2
H5299	012	0	1	01	01	H5299_012_0	10	1	1111	2	1				2	1				2	1				2	1				1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H5302	012	0	1	01	01	H5302_012_0	6	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5302	013	0	1	01	01	H5302_013_0	6	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5302	014	0	1	01	01	H5302_014_0	6	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5302	019	0	1	01	01	H5302_019_0	7	1	1111	2	1				2	1				2	1				2	1				1		2350.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5302	020	0	1	01	01	H5302_020_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5302	809	0	1	01	01	H5302_809_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5302	810	0	1	01	01	H5302_810_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5309	001	0	1	04	01	H5309_001_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5309	002	0	1	04	01	H5309_002_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5309	003	0	1	04	01	H5309_003_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5309	004	0	1	04	01	H5309_004_0	1	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5322	001	0	1	02	01	H5322_001_0	4	2																																																															2																																											2					1	01000000	0	20															2		2																		1	2
H5322	003	0	1	02	01	H5322_003_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	0	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5322	025	0	1	02	01	H5322_025_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5322	026	0	1	02	01	H5322_026_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5322	028	0	1	02	01	H5322_028_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5322	029	0	1	02	01	H5322_029_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5322	030	0	1	02	01	H5322_030_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5322	031	0	1	02	01	H5322_031_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5322	033	0	1	02	01	H5322_033_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5322	034	0	1	02	01	H5322_034_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5322	038	0	1	02	01	H5322_038_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	1
H5322	039	0	1	02	01	H5322_039_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5322	040	0	1	02	01	H5322_040_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5322	041	0	1	02	01	H5322_041_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5322	042	0	1	02	01	H5322_042_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5322	043	0	1	02	01	H5322_043_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5322	044	0	1	02	01	H5322_044_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5322	801	0	1	01	01	H5322_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5322	802	0	1	01	01	H5322_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5322	803	0	1	01	01	H5322_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5322	804	0	2	01	01	H5322_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5325	001	0	1	01	01	H5325_001_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5325	002	0	1	01	01	H5325_002_0	6	1	1111	2	1				2	1				2	1				2	1				1		4500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5325	003	0	1	01	01	H5325_003_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5325	004	0	1	01	01	H5325_004_0	6	1	1111	2	1				2	1				2	1				2	1				1		4500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5325	005	0	1	01	01	H5325_005_0	6	1	1111	2	1				2	1				2	1				2	1				1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5325	006	0	1	01	01	H5325_006_0	6	1	1111	2	1				2	1				2	1				2	1				1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5325	007	0	1	01	01	H5325_007_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5325	009	0	1	01	01	H5325_009_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5325	010	0	1	01	01	H5325_010_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5325	011	0	1	01	01	H5325_011_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5361	001	0	1	04	01	H5361_001_0	4	1	1111	2	2	1	6	Subject to limitations described in note	2	2	1	4		2	2	1	3		2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1001111											2	1				2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime. 1 root canal retreatment and repair per tooth per lifetime.	2	2	1	6	#16b5, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	2	1				2	2	1	6	Subject to limitations described in note	1	2	2	1500.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	20.00	20.00															2	2
H5361	002	0	1	04	01	H5361_002_0	4	1	1111	2	2	1	6	Subject to limitations described in note.	2	2	1	4		2	2	1	3		2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1001111											2	2	1	6	#16b3, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years	2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime. 1 root canal retreatment and repair per tooth per lifetime.	2	2	1	6	#16b5, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	2	1				2	2	1	6	Subject to limitations described in note	1	2	2	2000.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	5.00	5.00															2	2
H5361	003	0	1	04	01	H5361_003_0	4	1	1111	2	2	1	6	Subject to limitations described in note.	2	2	1	4		2	2	1	3		2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1001111											2	2	1	6	#16b3, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years	2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime. 1 root canal retreatment and repair per tooth per lifetime.	2	2	1	6	#16b5, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	2	1				2	2	1	6	Subject to limitations described in note.	1	2	2	1000.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	40.00	40.00															2	2
H5361	004	0	1	04	01	H5361_004_0	4	1	1111	2	2	1	6	Subject to limitations described in note.	2	2	1	4		2	2	1	3		2	2	1	6	#16a4, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1001111											2	2	1	6	#16b3, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years	2	2	1	6	#16b4, Endodontics: Includes root canals 1 per tooth per lifetime. 1 root canal retreatment and repair per tooth per lifetime.	2	2	1	6	#16b5, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	2	1				2	2	1	6	Subject to limitations described in note.	1	2	2	1000.00	3		2					1	10001111							20	20	20	20	20	20	20	20	40	40	2		1	01000000	50.00	50.00															2	2
H5373	001	0	1	02	01	H5373_001_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		7500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	2	6	N/A	2	2	1	6	Amalgam and Resin based composites are limited to one procedure per tooth every 3 years. 30% coinsurance applies to all other services except crown services which are not covered.	2	2	1	6	Select endodontics procedures will only be eligible for retreatment every 4 years per the details in the evidence of coverage.	2	2	1	6	Periodontics Scaling and root planning procedures requires submission of supporting documentation and subject to utilization review. Must contain 4 teeth with 4+MM pockets, covered every 3 years.	2	2	1	6	Extractions	2	1				1		1				2					1	11111111	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		1	2
H5374	001	0	1	01	01	H5374_001_0	9	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H5377	002	0	1	02	01	H5377_002_0	11	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5386	003	0	1	01	01	H5386_003_0	5	2		3					3										3																																														2							3					3					3					3					3					3											2					2																		2		1	01000000	35.00	35.00															1	1
H5386	004	0	1	01	01	H5386_004_0	5	1	1110	4	1				4	2	1	4							4	2	1	4		2					2				2		2												2		1	0010	2						15.00	15.00					2	2	1	1011111						4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	11011111	30.00	30.00			0.00	5.00	20.00	425.00	0.00	475.00	0.00	450.00	35.00	150.00	20.00	495.00	1	1
H5386	005	0	1	01	01	H5386_005_0	5	1	1110	4	1				4	2	1	4							4	2	1	4		2					2				2		2												2		1	0010	2						15.00	15.00					2	2	1	1011111						4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	11011111	35.00	35.00			0.00	5.00	20.00	425.00	0.00	475.00	0.00	450.00	35.00	150.00	20.00	495.00	1	1
H5386	801	0	1	01	01	H5386_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5386	802	0	1	01	01	H5386_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5386	803	0	1	01	01	H5386_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5398	002	0	1	01	01	H5398_002_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 months.Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					1	10111111			30	30	30	30	30	30	30	30	30	30	30	30	30	30	2		1	01000000	30.00	30.00															1	2
H5398	004	0	1	01	01	H5398_004_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H5403	001	0	1	20	08	H5403_001_0	1																																																																																																																																																							
H5403	002	0	1	20	08	H5403_002_0	1																																																																																																																																																							
H5405	001	0	1	20	08	H5405_001_0	1																																																																																																																																																							
H5405	002	0	1	20	08	H5405_002_0	1																																																																																																																																																							
H5406	001	0	1	20	08	H5406_001_0	1																																																																																																																																																							
H5406	002	0	1	20	08	H5406_002_0	1																																																																																																																																																							
H5410	004	0	1	01	01	H5410_004_0	5	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H5410	013	0	1	01	01	H5410_013_0	9	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H5410	018	0	1	01	01	H5410_018_0	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H5410	024	0	1	01	01	H5410_024_0	7	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H5410	025	0	1	01	01	H5410_025_0	8	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H5410	026	0	1	01	01	H5410_026_0	7	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H5410	027	0	1	01	01	H5410_027_0	7	1	1111	2	1				2	1				2	1				2	1				1		1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H5410	028	0	1	01	01	H5410_028_0	7	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H5410	029	0	1	01	01	H5410_029_0	7	1	1111	2	1				2	1				2	1				2	1				1		1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H5410	030	0	1	01	01	H5410_030_0	7	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H5410	031	0	1	01	01	H5410_031_0	8	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H5410	032	0	1	01	01	H5410_032_0	8	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H5410	037	0	1	01	01	H5410_037_0	7	1	1111	2	1				2	1				2	1				2	1				1		1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H5410	039	0	1	01	01	H5410_039_0	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H5410	040	0	1	01	01	H5410_040_0	7	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H5410	041	0	1	01	01	H5410_041_0	8	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H5410	042	0	1	01	01	H5410_042_0	8	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H5410	043	0	1	01	01	H5410_043_0	7	1	1111	2	1				2	1				2	1				2	1				1		2100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H5410	044	0	1	01	01	H5410_044_0	7	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H5410	045	0	1	01	01	H5410_045_0	8	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H5410	046	0	1	01	01	H5410_046_0	8	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H5410	047	0	1	01	01	H5410_047_0	8	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H5410	048	0	1	01	01	H5410_048_0	7	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H5410	049	0	1	01	01	H5410_049_0	9	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H5410	050	0	1	01	01	H5410_050_0	7	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H5410	051	0	1	01	01	H5410_051_0	7	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H5410	052	0	1	01	01	H5410_052_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H5410	053	0	1	01	01	H5410_053_0	7	1	1111	2	1				2	1				2	1				2	1				1		2600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	5.00	5.00															1	2
H5410	054	0	1	01	01	H5410_054_0	7	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H5410	055	0	1	01	01	H5410_055_0	8	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H5410	056	0	1	01	01	H5410_056_0	8	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H5410	057	0	1	01	01	H5410_057_0	5	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H5410	058	0	1	01	01	H5410_058_0	5	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H5410	808	0	1	01	01	H5410_808_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5420	001	0	1	01	01	H5420_001_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1011001						2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.											2	2	1	3		2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2						2					2																		2		1	11011001	0.00	0.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	2
H5420	003	0	1	01	01	H5420_003_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1011001						2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.											2	2	1	3		2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2						2					2																		2		1	11011001	0.00	0.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	2
H5420	006	0	1	01	01	H5420_006_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1011001						2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.											2	2	1	3		2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2						2					2																		2		1	11011001	0.00	0.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	2
H5420	014	0	1	01	01	H5420_014_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1011001						2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.											2	2	1	3		2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2						2					2																		2		1	11011001	0.00	0.00			0.00	0.00	0.00	0.00					0.00	0.00	0.00	0.00	1	2
H5422	007	0	1	01	01	H5422_007_0	5	1	1111	2	1				2	1				2	1				2	1				1		4500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5422	011	0	1	01	01	H5422_011_0	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5422	013	0	1	01	01	H5422_013_0	6	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5422	014	0	1	01	01	H5422_014_0	5	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5422	015	0	1	01	01	H5422_015_0	5	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5422	016	0	1	01	01	H5422_016_0	5	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5422	018	0	1	01	01	H5422_018_0	5	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5422	019	0	1	01	01	H5422_019_0	5	1	1111	2	1				2	1				2	1				2	1				1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5422	803	0	1	01	01	H5422_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5422	804	0	1	01	01	H5422_804_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5422	806	0	2	01	01	H5422_806_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5422	807	0	2	01	01	H5422_807_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5422	809	0	1	01	01	H5422_809_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5422	811	0	2	01	01	H5422_811_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5425	001	0	1	01	01	H5425_001_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010	3					4	2	2	3		3					3					4	1				3					3					2						2					2																		2		1	01000000	10.00	10.00															1	2
H5425	004	0	1	01	01	H5425_004_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010	3					4	2	2	3		3					3					4	1				3					3					2						2					2																		2		1	01000000	10.00	10.00															1	2
H5425	005	0	1	01	01	H5425_005_0	8	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	10.00	10.00															1	2
H5425	006	0	1	01	01	H5425_006_0	10	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	007	0	1	01	01	H5425_007_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	008	0	1	01	01	H5425_008_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	009	0	1	01	01	H5425_009_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	019	0	1	01	01	H5425_019_0	8	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		2																		1	2
H5425	020	0	1	01	01	H5425_020_0	6	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		2																		1	2
H5425	028	0	1	01	01	H5425_028_0	9	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	033	0	1	01	01	H5425_033_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	034	0	1	01	01	H5425_034_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	055	0	1	01	01	H5425_055_0	8	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	30.00	30.00															1	2
H5425	065	0	1	01	01	H5425_065_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	066	0	1	01	01	H5425_066_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	067	0	1	01	01	H5425_067_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	068	0	1	01	01	H5425_068_0	6	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	069	0	1	01	01	H5425_069_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		1	1110	2				10.00	10.00	5.00	5.00			15.00	15.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	10111111			0.00	65.00	0.00	15.00	25.00	500.00	25.00	525.00	0.00	375.00	0.00	145.00	30.00	650.00	1	2
H5425	070	0	1	01	01	H5425_070_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		1	1110	2				10.00	10.00	5.00	5.00			15.00	15.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	10111111			0.00	65.00	0.00	15.00	25.00	500.00	25.00	525.00	0.00	375.00	0.00	145.00	30.00	650.00	1	2
H5425	073	0	1	01	01	H5425_073_0	6	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	5.00	5.00															1	2
H5425	075	0	1	01	01	H5425_075_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010	3					4	2	2	3		3					3					4	1				3					3					2						2					2																		2		2																		1	2
H5425	076	0	1	01	01	H5425_076_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010	3					4	2	2	3		3					3					4	1				3					3					2						2					2																		2		2																		1	2
H5425	077	0	1	01	01	H5425_077_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010	3					4	2	2	3		3					3					4	1				3					3					2						2					2																		2		2																		1	2
H5425	078	0	1	01	01	H5425_078_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010	3					4	2	2	3		3					3					4	1				3					3					2						2					2																		2		2																		1	2
H5425	082	0	1	01	01	H5425_082_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010	3					4	2	2	3		3					3					4	1				3					3					2						2					2																		2		2																		1	2
H5425	083	0	1	01	01	H5425_083_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		1	1110	2				10.00	10.00	5.00	5.00			15.00	15.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	10.00	10.00	0.00	65.00	0.00	15.00	25.00	500.00	25.00	525.00	0.00	375.00	0.00	145.00	30.00	650.00	1	2
H5425	084	0	1	01	01	H5425_084_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	5.00	5.00	0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	085	0	1	01	01	H5425_085_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	5.00	5.00	0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	086	0	1	01	01	H5425_086_0	9	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	087	0	1	01	01	H5425_087_0	9	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	091	0	1	01	01	H5425_091_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	092	0	1	01	01	H5425_092_0	6	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	096	0	1	01	01	H5425_096_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010	3					4	2	2	3		3					3					4	1				3					3					2						2					2																		2		2																		1	2
H5425	097	0	1	01	01	H5425_097_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010						2	2	2	3												2	1														2						2					1	01000000	20	20															2		2																		1	2
H5425	098	0	1	01	01	H5425_098_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010						2	2	2	3												2	1														2						2					1	01000000	20	20															2		2																		1	2
H5425	100	0	1	01	01	H5425_100_0	6	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	101	0	1	01	01	H5425_101_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010	3					4	2	2	3		3					3					4	1				3					3					2						2					2																		2		2																		1	2
H5425	102	0	1	01	01	H5425_102_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010	3					4	2	2	3		3					3					4	1				3					3					2						2					2																		2		2																		1	2
H5425	103	0	1	01	01	H5425_103_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010	3					4	2	2	3		3					3					4	1				3					3					2						2					2																		2		2																		1	2
H5425	104	0	1	01	01	H5425_104_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	105	0	1	01	01	H5425_105_0	8	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010	3					4	2	2	3		3					3					4	1				3					3					2						2					2																		2		2																		1	2
H5425	106	0	1	01	01	H5425_106_0	8	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		2																		1	2
H5425	107	0	1	01	01	H5425_107_0	8	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		2																		1	2
H5425	108	0	1	01	01	H5425_108_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	109	0	1	01	01	H5425_109_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	110	0	1	01	01	H5425_110_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	111	0	1	01	01	H5425_111_0	8	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		2																		1	2
H5425	112	0	1	01	01	H5425_112_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		1	1110	2				10.00	10.00	5.00	5.00			15.00	15.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	10111111			0.00	65.00	0.00	15.00	25.00	500.00	25.00	525.00	0.00	375.00	0.00	145.00	30.00	650.00	1	2
H5425	115	0	1	01	01	H5425_115_0	6	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	11111111	10.00	10.00	0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	116	0	1	01	01	H5425_116_0	6	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	11111111	10.00	10.00	0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H5425	803	0	1	01	01	H5425_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5425	804	0	1	01	01	H5425_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5425	806	0	1	01	01	H5425_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5425	807	0	1	01	01	H5425_807_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5427	052	0	1	01	01	H5427_052_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0100001	2	2	2	3																						2	2	1	3							2						2					2																		2		1	01100001	0.00	0.00	0.00	0.00									0.00	0.00			2	1
H5427	059	0	1	01	01	H5427_059_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0100001	2	2	2	3																						2	2	1	3							2						2					2																		2		1	01100001	0.00	0.00	0.00	0.00									0.00	0.00			2	1
H5427	060	0	1	01	01	H5427_060_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0100001	2	2	2	3																						2	2	1	3							2						2					2																		2		1	01100001	0.00	0.00	0.00	0.00									0.00	0.00			2	1
H5427	070	0	1	01	01	H5427_070_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1101011	2	2	2	3							2	2	2	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	2	3		2	2	2	6	Prosthodontics services include:Partial or full denture - 1 per 5 yearsDenture align - 1 per year	2						2					2																		2		1	11101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5427	072	0	1	01	01	H5427_072_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	077	0	1	01	01	H5427_077_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	078	0	1	01	01	H5427_078_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1101011	2	2	2	3							2	2	2	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	2	3		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2						2					2																		2		1	11101001	0.00	0.00	0.00	0.00			0.00	0.00					0.00	0.00	0.00	0.00	1	1
H5427	082	0	1	01	01	H5427_082_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	083	0	1	01	01	H5427_083_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101001	0.00	0.00	0.00	0.00			0.00	0.00					0.00	0.00			1	1
H5427	087	0	1	01	01	H5427_087_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1101011	2	2	2	3							2	2	2	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	2	3		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2						2					2																		2		1	11101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5427	088	0	1	01	01	H5427_088_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	089	0	1	01	01	H5427_089_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	091	0	1	01	01	H5427_091_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	092	0	1	01	01	H5427_092_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	093	0	1	01	01	H5427_093_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	094	0	1	01	01	H5427_094_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	096	0	1	01	01	H5427_096_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	098	0	1	01	01	H5427_098_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	099	0	1	01	01	H5427_099_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1101011	2	2	2	3							2	2	2	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	2	3		2	2	2	6	Prosthodontics services include:Partial or full denture - 1 per 5 yearsDenture align - 1 per year per year	2						2					2																		2		1	11101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5427	102	0	1	01	01	H5427_102_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	103	0	1	01	01	H5427_103_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	104	0	1	01	01	H5427_104_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1101011	2	2	2	3							2	2	2	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	2	3		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2						2					2																		2		1	11101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5427	105	0	1	01	01	H5427_105_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	106	0	1	01	01	H5427_106_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	107	0	1	01	01	H5427_107_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1101011	2	2	2	3							2	2	2	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	2	3		2	2	2	6	Prosthodontics services include: Partial or full denture - 1 per 5 yearsDenture align - 1 per year	2						2					2																		2		1	11101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5427	108	0	1	01	01	H5427_108_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	109	0	1	01	01	H5427_109_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1101011	2	2	2	3							2	2	2	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	2	3		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2						2					2																		2		1	11101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5427	110	0	1	01	01	H5427_110_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1101011	2	2	2	3							2	2	2	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	2	3		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2						2					2																		2		1	11101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5427	111	0	1	01	01	H5427_111_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1101011	2	2	2	3							2	2	2	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	2	3		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2						2					2																		2		1	11101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5427	112	0	1	02	01	H5427_112_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5427	113	0	1	02	01	H5427_113_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5430	805	0	1	01	01	H5430_805_0	12	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5431	001	0	1	01	01	H5431_001_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	X-rays include:• Up to 1 series of bitewing dental x-ray(s) 2 times per year• Up to 1 complete series of full-mouth x-rays (panoramic) every 3 years	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1001111											2	2	4	3		2	2	2	3		2	2	5	6	1 Scaling/root planing per each quadrant every year  1 Full mouth debridement every 24 consecutive months	2	2	4	3		2	1				1		1				2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5431	006	0	1	01	01	H5431_006_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	X-rays include:• Up to 1 series of bitewing dental x-ray(s) 2 times per year• Up to 1 complete series of full-mouth x-rays (panoramic) every 3 years	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1001111											2	2	4	3		2	2	2	3		2	2	5	6	1 Scaling/root planing per each quadrant every year (Periodontics) 1 Full mouth debridement every 24 consecutive months (Periodontics)	2	2	4	3		2	1				1		1				2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5431	012	0	1	01	01	H5431_012_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	X-rays include:• Up to 1 series of bitewing dental x-ray(s) 2 times per year• Up to 1 complete series of full-mouth x-rays (panoramic) every 3 years	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1001111											2	2	4	3		2	2	2	3		2	2	5	6	1 Scaling/root planing per each quadrant every year1 Full mouth debridement every 24 consecutive months	2	2	4	3		2	1				1		1				2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5431	013	0	1	01	01	H5431_013_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	X-rays include:• Up to 1 series of bitewing dental x-ray(s) 2 times per year• Up to 1 complete series of full-mouth x-rays (panoramic) every 3 years	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1001111											2	2	4	3		2	2	2	3		2	2	5	6	1 Scaling/root planing per each quadrant every year1 Full mouth debridement every 24 consecutive months	2	2	4	3		2	1				1		1				2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5431	016	0	1	01	01	H5431_016_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	X-rays include:• Up to 1 series of bitewing dental x-ray(s) 2 times per year• Up to 1 complete series of full-mouth x-rays (panoramic) every 3 years	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1001111											2	2	4	3		2	2	2	3		2	2	5	6	1 Scaling/root planing per each quadrant every year 1 Full mouth debridement every 24 consecutive months	2	2	4	3		2	1				1		1				2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5431	017	0	1	01	01	H5431_017_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	X-rays include:• Up to 1 series of bitewing dental x-ray(s) 2 times per year• Up to 1 complete series of full-mouth x-rays (panoramic) every 3 years	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	1	1001111											2	2	4	3		2	2	2	3		2	2	5	6	1 Scaling/root planing per each quadrant every year1 Full mouth debridement every 24 consecutive months	2	2	4	3		2	1				1		1				2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5431	018	0	1	01	01	H5431_018_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	X-rays include:• Up to 1 series of bitewing dental x-ray(s) 2 times per year• Up to 1 complete series of full-mouth x-rays (panoramic) every 3 years	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	1	1001111											2	2	4	3		2	2	2	3		2	2	5	6	1 Scaling/root planing per each quadrant every year1 Full mouth debridement every 24 consecutive months	2	2	4	3		2	1				1		1				2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5431	019	0	1	01	01	H5431_019_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	X-rays include:• Up to 1 series of bitewing dental x-ray(s) 2 times per year• Up to 1 complete series of full-mouth x-rays (panoramic) every 3 years	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1001111											2	2	4	3		2	2	2	3		2	2	5	6	1 Scaling/root planing per each quadrant every year1 Full mouth debridement every 24 consecutive months	2	2	4	3		2	1				1		1				2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5431	020	0	1	01	01	H5431_020_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	X-rays include:• Up to 1 series of bitewing dental x-ray(s) 2 times per year• Up to 1 complete series of full-mouth x-rays (panoramic) every 3 years	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	1	1001111											2	2	4	3		2	2	2	3		2	2	5	6	1 Scaling/root planing per each quadrant every year1 Full mouth debridement every 24 consecutive months	2	2	4	3		2	1				1		1				2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5431	021	0	1	01	01	H5431_021_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	X-rays include:• Up to 1 series of bitewing dental x-ray(s) 2 times per year• Up to 1 complete series of full-mouth x-rays (panoramic) every 3 years	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	1	1001111											2	2	4	3		2	2	2	3		2	2	5	6	1 Scaling/root planing per each quadrant every year1 Full mouth debridement every 24 consecutive months	2	2	4	3		2	1				1		1				2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5431	022	0	1	01	01	H5431_022_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	3	6	X-rays include:• Up to 1 series of bitewing dental x-ray(s) 2 times per year• Up to 1 complete series of full-mouth x-rays (panoramic) every 3 years	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	1	1001111											2	2	4	3		2	2	2	3		2	2	5	6	1 Scaling/root planing per each quadrant every year1 Full mouth debridement every 24 consecutive months	2	2	4	3		2	1				1		1				2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5433	001	0	1	01	01	H5433_001_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5434	002	0	1	04	01	H5434_002_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1000001																										2	2	2	3		2	2	2	3		2						2					2																		2		1	11000001	45.00	45.00											0.00	0.00	0.00	0.00	1	2
H5434	023	0	1	04	01	H5434_023_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	30.00	39.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5434	024	0	1	04	01	H5434_024_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	35.00	44.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5434	025	0	1	04	01	H5434_025_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	2		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	42.00	42.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5434	026	0	1	04	01	H5434_026_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	35.00	44.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5434	030	0	1	04	01	H5434_030_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	30.00	39.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5434	031	0	1	04	01	H5434_031_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	35.00	44.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5434	032	0	1	04	01	H5434_032_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	35.00	44.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5434	033	0	1	04	01	H5434_033_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	35.00	44.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5434	034	0	1	04	01	H5434_034_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	35.00	45.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5434	035	0	1	04	01	H5434_035_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	30.00	40.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5434	036	0	1	04	01	H5434_036_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	35.00	45.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5434	038	0	1	04	01	H5434_038_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1000001																										2	2	2	3		2	2	2	3		2						2					2																		2		1	11000001	45.00	45.00											0.00	0.00	0.00	0.00	1	2
H5434	039	0	1	04	01	H5434_039_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	4	3		2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	4	6	Crown: 1 per year in conjunction with a listed root canal procedure code. Core build-up, or Pin Retention: 1 per yearFillings: 2 per year	2	2	1	3		2	2	2	6	Scaling and root planning -1 per quadrant per 24 month period Full mouth debridement -1 per 36 month period	2	2	4	3		2	2	6	6	Partials/Dentures-1 set (1 upper, 1 lower) per 60 mnths-Complete or Immediate.  Adjustments: 1 each (1 upper, 1 lower)  per year. Repairs - 2 per year (5 max per  year).	2						2					2																		2		1	11001111	32.00	32.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5434	040	0	1	04	01	H5434_040_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1000001																										2	2	2	3		2	2	2	3		2						2					2																		2		1	11000001	45.00	45.00											0.00	0.00	0.00	0.00	1	2
H5434	041	0	1	04	01	H5434_041_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1000001																										2	2	2	3		2	2	2	3		2						2					2																		2		1	11000001	45.00	45.00											0.00	0.00	0.00	0.00	1	2
H5434	042	0	1	04	01	H5434_042_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1000001																										2	2	2	3		2	2	2	3		2						2					2																		2		1	11000001	45.00	45.00											0.00	0.00	0.00	0.00	1	2
H5434	044	0	1	04	01	H5434_044_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing X-rays (1 series set) 1 a year, or Full mouth (Intraoral complete series) or Panoramic radiographic image X-rays 1 every 3 years & count against the 1 a year limit for Bitewings.	2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1000001																										2	2	2	3		2	2	2	3		2						2					2																		2		1	11000001	45.00	45.00											0.00	0.00	0.00	0.00	1	2
H5434	801	0	1	04	01	H5434_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5434	802	0	1	04	01	H5434_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5435	001	0	1	09	04	H5435_001_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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			1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				
H5435	024	0	1	09	04	H5435_024_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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			1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				
H5439	010	0	1	04	01	H5439_010_0	15	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	25.00	25.00															1	2
H5439	011	0	1	04	01	H5439_011_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1	2	2	2000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	25.00	25.00															1	2
H5439	015	0	1	04	01	H5439_015_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H5439	017	0	1	04	01	H5439_017_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1	2	2	1500.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5439	019	0	1	04	01	H5439_019_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1	2	2	1000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	30.00	30.00															1	2
H5447	001	0	1	01	01	H5447_001_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		1800.00	3		2				2		2												2		2		2												2	2	1	1111011	2	1				2	1				2	1									2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															2	2
H5447	002	0	1	01	01	H5447_002_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		1900.00	3		2				2		2												2		2		2												2	2	1	1111011	2	1				2	1				2	1									2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H5454	001	0	1	01	01	H5454_001_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	1500.00	3		2					2																		2		1	01000000	30.00	30.00															2	2
H5454	002	0	1	01	01	H5454_002_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	1500.00	3		2					2																		2		1	01000000	30.00	30.00															2	2
H5454	005	0	1	01	01	H5454_005_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					2																		2		1	01000000	30.00	30.00															2	2
H5454	006	0	1	01	01	H5454_006_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					2																		2		1	01000000	30.00	30.00															2	2
H5471	064	0	1	01	01	H5471_064_0	13	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	065	0	1	01	01	H5471_065_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	066	0	1	01	01	H5471_066_0	10	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	068	0	1	01	01	H5471_068_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	069	0	1	01	01	H5471_069_0	8	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	070	0	1	01	01	H5471_070_0	10	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	071	0	1	01	01	H5471_071_0	10	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	072	0	1	01	01	H5471_072_0	9	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	073	0	1	01	01	H5471_073_0	8	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	074	0	1	01	01	H5471_074_0	8	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	075	0	1	01	01	H5471_075_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	076	0	1	01	01	H5471_076_0	9	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	077	0	1	01	01	H5471_077_0	8	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	078	0	1	01	01	H5471_078_0	8	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	080	0	1	01	01	H5471_080_0	8	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	082	0	1	01	01	H5471_082_0	9	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	083	0	1	01	01	H5471_083_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	084	0	1	01	01	H5471_084_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	085	0	1	01	01	H5471_085_0	8	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	103	0	1	01	01	H5471_103_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	104	0	1	01	01	H5471_104_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	105	0	1	01	01	H5471_105_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	106	0	1	01	01	H5471_106_0	9	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					2																		2		1	01000000	0.00	0.00															1	2
H5471	107	0	1	01	01	H5471_107_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	108	0	1	01	01	H5471_108_0	7	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					2																		2		1	01000000	0.00	0.00															1	2
H5471	110	0	1	01	01	H5471_110_0	8	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	111	0	1	01	01	H5471_111_0	9	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	112	0	1	01	01	H5471_112_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	113	0	1	01	01	H5471_113_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	114	0	1	01	01	H5471_114_0	9	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	115	0	1	01	01	H5471_115_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	116	0	1	01	01	H5471_116_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	117	0	1	01	01	H5471_117_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	118	0	1	01	01	H5471_118_0	10	1	1110	2	2	2	3		2	2	2	3							2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	119	0	1	01	01	H5471_119_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	120	0	1	01	01	H5471_120_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	121	0	1	01	01	H5471_121_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	122	0	1	01	01	H5471_122_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	123	0	1	01	01	H5471_123_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	124	0	1	01	01	H5471_124_0	8	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	125	0	1	01	01	H5471_125_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	3	3		2					2				2		2												2		1	1110	2				0.00	0.00	0.00	0.00			0.00	0.00	2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	1	6	1 Scaling/root planning per each quadrant every three years	2	2	6	3		2	2	6	6	Number of visits is determined by the services listed below in the notes section.	2						2					2																		2		1	11001111	0.00	0.00					0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5471	126	0	1	01	01	H5471_126_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5472	001	0	1	02	01	H5472_001_0	15	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1		2500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H5472	002	0	1	02	01	H5472_002_0	14	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1		2000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H5472	003	0	1	02	01	H5472_003_0	12	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3					3											2					2																		2		2																		2	2
H5472	004	0	1	02	01	H5472_004_0	16	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	1		1		4000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H5472	801	0	1	01	01	H5472_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5472	802	0	1	01	01	H5472_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5472	803	0	1	01	01	H5472_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5472	804	0	1	01	01	H5472_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5475	001	0	1	02	01	H5475_001_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	5000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5475	011	0	1	02	01	H5475_011_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months.	1		2	2000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5475	021	0	1	02	01	H5475_021_0	15	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5475	022	0	1	02	01	H5475_022_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months.	1		2	2000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5475	024	0	1	02	01	H5475_024_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	5000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5475	026	0	1	02	01	H5475_026_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5475	031	0	1	01	01	H5475_031_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					1	01000000	20	20															2		1	00110000			0.00	0.00	0.00	0.00											1	2
H5475	032	0	1	01	01	H5475_032_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					1	01000000	20	20															2		1	00110000			0.00	0.00	0.00	0.00											1	2
H5475	038	0	1	01	01	H5475_038_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5475	039	0	1	01	01	H5475_039_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5493	001	0	1	20	08	H5493_001_0	2																																																																																																																																																							
H5493	002	0	1	20	08	H5493_002_0	2																																																																																																																																																							
H5496	005	0	1	01	01	H5496_005_0	5	1	1111	2	2	1	6	Intraoral Exams – 1 every 12 months	2	2	1	4		2	2	1	4		2	2	1	6	Bitewings – 1 every six monthsPanoramic radiographic image – 1 every 12 monthsDiagnostic casts – 1 every 12 months	1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	2	1	6	Yearly amounts do not roll overEndodontic covered services – 1 tooth per lifetime	2	2	1	6	Yearly amounts do not roll overFull mouth periodontal scaling – 1 every six monthsOther covered periodontal – 1 every 24 months	2	1				2	1				1		2	1000.00	3		2					2																		2		2																		2	2
H5496	007	0	1	01	01	H5496_007_0	6	1	1111	2	2	1	6	Intraoral Exams – 1 every 12 months	2	2	1	4		2	2	1	4		2	2	1	6	Bitewings – 1 every six monthsPanoramic radiographic image – 1 every 12 monthsDiagnostic casts – 1 every 12 months	1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	2	1	6	Yearly amounts do not roll overEndodontic covered services – 1 tooth per lifetime	2	2	1	6	Yearly amounts do not roll overFull mouth periodontal scaling – 1 every six monthsOther covered periodontal – 1 every 24 months	2	1				2	1				1		2	1000.00	3		2					2																		2		2																		2	2
H5496	011	0	1	01	01	H5496_011_0	7	1	1111	2	2	1	6	Intraoral Exams – 1 every 12 months	2	2	1	4		2	2	1	4		2	2	1	6	Bitewings – 1 every six monthsPanoramic radiographic image – 1 every 12 monthsDiagnostic casts – 1 every 12 months	1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	2	1	6	Yearly amounts do not roll overEndodontic covered services – 1 tooth per lifetime	2	2	1	6	Yearly amounts do not roll overFull mouth periodontal scaling – 1 every six monthsOther covered periodontal – 1 every 24 months	2	1				2	1				1		2	1000.00	3		2					2																		2		2																		2	2
H5496	012	0	1	01	01	H5496_012_0	7	1	1111	2	2	1	6	Intraoral Exams – 1 every 12 months	2	2	1	4		2	2	1	4		2	2	1	6	Bitewings – 1 every six monthsPanoramic radiographic image – 1 every 12 monthsDiagnostic casts – 1 every 12 months	1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	2	1	6	Yearly amounts do not roll overEndodontic covered services – 1 tooth per lifetime	2	2	1	6	Yearly amounts do not roll overFull mouth periodontal scaling – 1 every six monthsOther covered periodontal – 1 every 24 months	2	1				2	1				1		2	1000.00	3		2					2																		2		2																		2	2
H5496	014	0	1	01	01	H5496_014_0	6	1	1111	2	2	1	6	Intraoral Exams – 1 every 12 months	2	2	1	4		2	2	1	4		2	2	1	6	Bitewings – 1 every six monthsPanoramic radiographic image – 1 every 12 monthsDiagnostic casts – 1 every 12 months	1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	2	1	6	Yearly amounts do not roll overEndodontic covered services – 1 tooth per lifetime	2	2	1	6	Yearly amounts do not roll overFull mouth periodontal scaling – 1 every six monthsOther covered periodontal – 1 every 24 months	2	1				2	1				1		2	1000.00	3		2					2																		2		2																		2	2
H5496	016	0	1	01	01	H5496_016_0	5	1	1111	2	2	1	6	Intraoral Exams – 1 every 12 months	2	2	1	4		2	2	1	4		2	2	1	6	Bitewings – 1 every six monthsPanoramic radiographic image – 1 every 12 monthsDiagnostic casts – 1 every 12 months	1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	2	1	6	Yearly amounts do not roll overEndodontic covered services – 1 tooth per lifetime	2	2	1	6	Yearly amounts do not roll overFull mouth periodontal scaling – 1 every six monthsOther covered periodontal – 1 every 24 months	2	1				2	1				1		2	1000.00	3		2					2																		2		2																		2	2
H5521	013	0	1	04	01	H5521_013_0	9	1	1110	2	2	4	3		2	2	2	3							2	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	2																																											2					2																		2		1	01000000	45.00	45.00															1	2
H5521	015	0	1	04	01	H5521_015_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	016	0	1	04	01	H5521_016_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	020	0	1	04	01	H5521_020_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	022	0	1	04	01	H5521_022_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	027	0	1	04	01	H5521_027_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	033	0	1	04	01	H5521_033_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	037	0	1	04	01	H5521_037_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	040	0	1	04	01	H5521_040_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															1	2
H5521	053	0	1	04	01	H5521_053_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	055	0	1	04	01	H5521_055_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	056	0	1	04	01	H5521_056_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	076	0	1	04	01	H5521_076_0	7	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	35.00	35.00															1	2
H5521	077	0	1	04	01	H5521_077_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	081	0	1	04	01	H5521_081_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	084	0	1	04	01	H5521_084_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2700.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	085	0	1	04	01	H5521_085_0	7	1	1110	2	2	4	3		2	2	2	3							2	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	1	0111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	1	6	Plan will cover 1 filling per tooth per year and recement once per tooth per year.	2	2	2	6	Plan will cover 1 root canal and the retreatment of 1 root canal per tooth per lifetime.	2	2	3	6	Plan will cover scaling and root planing once per quadrant every 2 years and periodontal maintenance 2 times per year.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.						1	2	2	2000.00	3		2					1	00101111			50	50			50	50	50	50	50	50	50	50			2		1	01010000	0.00	0.00			0.00	0.00											1	2
H5521	086	0	1	04	01	H5521_086_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	087	0	1	04	01	H5521_087_0	6	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Plan will cover 1 filling per tooth per year and recement once per tooth per year.	2	2	2	6	Plan will cover 1 root canal and the retreatment of 1 root canal per tooth per lifetime.	2	2	4	6	Plan will cover scaling and root planing once per quadrant every 2 years and periodontal maintenance 2 times per year.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see notes.	1	2	2	2000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	0.00	0.00			0.00	0.00											1	2
H5521	088	0	1	04	01	H5521_088_0	7	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	0.00	0.00			0.00	0.00											1	2
H5521	089	0	1	04	01	H5521_089_0	7	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Plan will cover 1 filling per tooth per year and recement once per tooth per year.	2	2	2	6	Plan will cover 1 root canal and the retreatment of 1 root canal per tooth per lifetime.	2	2	4	6	Plan will cover scaling and root planing once per quadrant every 2 years and periodontal maintenance 2 times per year.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see notes.	1	2	2	1000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	0.00	0.00			0.00	0.00											1	2
H5521	090	0	1	04	01	H5521_090_0	7	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1		1	1110	0.00	0.00									2	2	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Plan will cover 1 filling per tooth per year and recement once per tooth per year.	2	2	2	6	Plan will cover 1 root canal and the retreatment of 1 root canal per tooth per lifetime.	2	2	4	6	Plan will cover scaling and root planing once per quadrant every 2 years and periodontal maintenance 2 times per year.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see notes.	1	2	2	2000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	0.00	0.00			0.00	0.00											1	2
H5521	091	0	1	04	01	H5521_091_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	1150.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	095	0	1	04	01	H5521_095_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	099	0	1	04	01	H5521_099_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1450.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	100	0	1	04	01	H5521_100_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	101	0	1	04	01	H5521_101_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	110	0	1	04	01	H5521_110_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	116	0	1	04	01	H5521_116_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	117	0	1	04	01	H5521_117_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	118	0	1	04	01	H5521_118_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	119	0	1	04	01	H5521_119_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	120	0	1	04	01	H5521_120_0	7	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	35.00	35.00															1	2
H5521	121	0	1	04	01	H5521_121_0	7	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															1	2
H5521	122	0	1	04	01	H5521_122_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	123	0	1	04	01	H5521_123_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	35.00	35.00															1	2
H5521	124	0	1	04	01	H5521_124_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	35.00	35.00															1	2
H5521	125	0	1	04	01	H5521_125_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	127	0	1	04	01	H5521_127_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1050.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	128	0	1	04	01	H5521_128_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1050.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	134	0	1	04	01	H5521_134_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	139	0	1	04	01	H5521_139_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	140	0	1	04	01	H5521_140_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	1900.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	141	0	1	04	01	H5521_141_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	144	0	1	04	01	H5521_144_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	150	0	1	04	01	H5521_150_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	154	0	1	04	01	H5521_154_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	2300.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	156	0	1	04	01	H5521_156_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	157	0	1	04	01	H5521_157_0	10	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	159	0	1	04	01	H5521_159_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	160	0	1	04	01	H5521_160_0	10	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	168	0	1	04	01	H5521_168_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	169	0	1	04	01	H5521_169_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	170	0	1	04	01	H5521_170_0	9	1	1111	2	1				2	1				2	1				2	1				1	2	2900.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	171	0	1	04	01	H5521_171_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	178	0	1	04	01	H5521_178_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1300.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	184	0	1	04	01	H5521_184_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	190	0	1	04	01	H5521_190_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	194	0	1	04	01	H5521_194_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	195	0	1	04	01	H5521_195_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	197	0	1	04	01	H5521_197_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	207	0	1	04	01	H5521_207_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	211	0	1	04	01	H5521_211_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	900.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	214	0	1	04	01	H5521_214_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	215	0	1	04	01	H5521_215_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	216	0	1	04	01	H5521_216_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	217	0	1	04	01	H5521_217_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	218	0	1	04	01	H5521_218_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	219	0	1	04	01	H5521_219_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	220	0	1	04	01	H5521_220_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	222	0	1	04	01	H5521_222_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	223	0	1	04	01	H5521_223_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1300.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	224	0	1	04	01	H5521_224_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	226	0	1	04	01	H5521_226_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	227	0	1	04	01	H5521_227_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	229	0	1	04	01	H5521_229_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	230	0	1	04	01	H5521_230_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	231	0	1	04	01	H5521_231_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	232	0	1	04	01	H5521_232_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	233	0	1	04	01	H5521_233_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1300.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	234	0	1	04	01	H5521_234_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	235	0	1	04	01	H5521_235_0	3	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	236	0	1	04	01	H5521_236_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	241	0	1	04	01	H5521_241_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	243	0	1	04	01	H5521_243_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	2900.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	245	0	1	04	01	H5521_245_0	9	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	246	0	1	04	01	H5521_246_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	247	0	1	04	01	H5521_247_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	249	0	1	04	01	H5521_249_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	2100.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	250	0	1	04	01	H5521_250_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1650.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	251	0	1	04	01	H5521_251_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	254	0	1	04	01	H5521_254_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	259	0	1	04	01	H5521_259_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	260	0	1	04	01	H5521_260_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2100.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	261	0	1	04	01	H5521_261_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	262	0	1	04	01	H5521_262_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	263	0	1	04	01	H5521_263_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	266	0	1	04	01	H5521_266_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2100.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	268	0	1	04	01	H5521_268_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	269	0	1	04	01	H5521_269_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1900.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	270	0	1	04	01	H5521_270_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1900.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	271	0	1	04	01	H5521_271_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1650.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	272	0	1	04	01	H5521_272_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	273	0	1	04	01	H5521_273_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1450.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	275	0	1	04	01	H5521_275_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	277	0	1	04	01	H5521_277_0	9	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															1	2
H5521	278	0	1	04	01	H5521_278_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	30.00	30.00															1	2
H5521	279	0	1	04	01	H5521_279_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	280	0	1	04	01	H5521_280_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	2600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	283	0	1	04	01	H5521_283_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2150.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	284	0	1	04	01	H5521_284_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	285	0	1	04	01	H5521_285_0	9	1	1111	2	1				2	1				2	1				2	1				1	2	1450.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	286	0	1	04	01	H5521_286_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	288	0	1	04	01	H5521_288_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	289	0	1	04	01	H5521_289_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1300.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	290	0	1	04	01	H5521_290_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	292	0	1	04	01	H5521_292_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	293	0	1	04	01	H5521_293_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	294	0	1	04	01	H5521_294_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	296	0	1	04	01	H5521_296_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	299	0	1	04	01	H5521_299_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	301	0	1	04	01	H5521_301_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	302	0	1	04	01	H5521_302_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	303	0	1	04	01	H5521_303_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	305	0	1	04	01	H5521_305_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	306	0	1	04	01	H5521_306_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	308	0	1	04	01	H5521_308_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	310	0	1	04	01	H5521_310_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	311	0	1	04	01	H5521_311_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	312	0	1	04	01	H5521_312_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	313	0	1	04	01	H5521_313_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	45.00	45.00															1	2
H5521	314	0	1	04	01	H5521_314_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	318	0	1	04	01	H5521_318_0	7	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															1	2
H5521	319	0	1	04	01	H5521_319_0	9	1	1111	2	1				2	1				2	1				2	1				1	2	2900.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	320	0	1	04	01	H5521_320_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	321	0	1	04	01	H5521_321_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	322	0	1	04	01	H5521_322_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	323	0	1	04	01	H5521_323_0	3	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	324	0	1	04	01	H5521_324_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	326	0	1	04	01	H5521_326_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	328	0	1	04	01	H5521_328_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2150.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	329	0	1	04	01	H5521_329_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	330	0	1	04	01	H5521_330_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	331	0	1	04	01	H5521_331_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	332	0	1	04	01	H5521_332_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	333	0	1	04	01	H5521_333_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	340	0	1	04	01	H5521_340_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	341	0	1	04	01	H5521_341_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	45.00	45.00															1	2
H5521	344	0	1	04	01	H5521_344_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	345	0	1	04	01	H5521_345_0	7	1	1110	2	2	4	3		2	2	2	3							2	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	2																																											2					2																		2		1	01000000	50.00	50.00															1	2
H5521	347	0	1	04	01	H5521_347_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	348	0	1	04	01	H5521_348_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	349	0	1	04	01	H5521_349_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	350	0	1	04	01	H5521_350_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	351	0	1	04	01	H5521_351_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	352	0	1	04	01	H5521_352_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	353	0	1	04	01	H5521_353_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	355	0	1	04	01	H5521_355_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	360	0	1	04	01	H5521_360_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	363	0	1	04	01	H5521_363_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	364	0	1	04	01	H5521_364_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	365	0	1	04	01	H5521_365_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	366	0	1	04	01	H5521_366_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	369	0	1	04	01	H5521_369_0	3	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	370	0	1	04	01	H5521_370_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	371	0	1	04	01	H5521_371_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	372	0	1	04	01	H5521_372_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	373	0	1	04	01	H5521_373_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	374	0	1	04	01	H5521_374_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	375	0	1	04	01	H5521_375_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	376	0	1	04	01	H5521_376_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	377	0	1	04	01	H5521_377_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	378	0	1	04	01	H5521_378_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	379	0	1	04	01	H5521_379_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	380	0	1	04	01	H5521_380_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	381	0	1	04	01	H5521_381_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	382	0	1	04	01	H5521_382_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	383	0	1	04	01	H5521_383_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	384	0	1	04	01	H5521_384_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	386	0	1	04	01	H5521_386_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	387	0	1	04	01	H5521_387_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1300.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	388	0	1	04	01	H5521_388_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	389	0	1	04	01	H5521_389_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	1650.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	390	0	1	04	01	H5521_390_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	30.00	30.00															1	2
H5521	391	0	1	04	01	H5521_391_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	30.00	30.00															1	2
H5521	392	0	1	04	01	H5521_392_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	393	0	1	04	01	H5521_393_0	7	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2																																											2					2																		2		1	01000000	40.00	40.00															1	2
H5521	395	0	1	04	01	H5521_395_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	396	0	1	04	01	H5521_396_0	9	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	397	0	1	04	01	H5521_397_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	398	0	1	04	01	H5521_398_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	399	0	1	04	01	H5521_399_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	400	0	1	04	01	H5521_400_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	403	0	1	04	01	H5521_403_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	404	0	1	04	01	H5521_404_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2900.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	405	0	1	04	01	H5521_405_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2300.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	406	0	1	04	01	H5521_406_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2350.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	407	0	1	04	01	H5521_407_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	408	0	1	04	01	H5521_408_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	409	0	1	04	01	H5521_409_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	2550.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	410	0	1	04	01	H5521_410_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	411	0	1	04	01	H5521_411_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	412	0	1	04	01	H5521_412_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1150.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	413	0	1	04	01	H5521_413_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	414	0	1	04	01	H5521_414_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	419	0	1	04	01	H5521_419_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	420	0	1	04	01	H5521_420_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	421	0	1	04	01	H5521_421_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	422	0	1	04	01	H5521_422_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	1050.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	423	0	1	04	01	H5521_423_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	424	0	1	04	01	H5521_424_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	425	0	1	04	01	H5521_425_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	431	0	1	04	01	H5521_431_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	432	0	1	04	01	H5521_432_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1550.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	433	0	1	04	01	H5521_433_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	434	0	1	04	01	H5521_434_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	435	0	1	04	01	H5521_435_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	436	0	1	04	01	H5521_436_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1900.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	437	0	1	04	01	H5521_437_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2100.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	438	0	1	04	01	H5521_438_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2100.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	439	0	1	04	01	H5521_439_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	440	0	1	04	01	H5521_440_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	441	0	1	04	01	H5521_441_0	7	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Plan will cover 1 filling per tooth per year, recement once per tooth per year, crown repair once per tooth per year, and 1 crown per tooth every 5 years.	2	2	2	6	Plan will cover 1 root canal and the retreatment of 1 root canal per tooth per lifetime.	2	2	4	6	Plan will cover scaling and root planing once per quadrant every 2 years and periodontal maintenance 2 times per year.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	ADD NOTE	1	2	2	2000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											1	2
H5521	442	0	1	04	01	H5521_442_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	443	0	1	04	01	H5521_443_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	444	0	1	04	01	H5521_444_0	9	1	1111	2	1				2	1				2	1				2	1				1	2	1300.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	445	0	1	04	01	H5521_445_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	1400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	446	0	1	04	01	H5521_446_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	447	0	1	04	01	H5521_447_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	448	0	1	04	01	H5521_448_0	9	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	449	0	1	04	01	H5521_449_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	450	0	1	04	01	H5521_450_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	451	0	1	04	01	H5521_451_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	455	0	1	04	01	H5521_455_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	456	0	1	04	01	H5521_456_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	457	0	1	04	01	H5521_457_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	458	0	1	04	01	H5521_458_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	459	0	1	04	01	H5521_459_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	460	0	1	04	01	H5521_460_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	461	0	1	04	01	H5521_461_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	462	0	1	04	01	H5521_462_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	463	0	1	04	01	H5521_463_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	464	0	1	04	01	H5521_464_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	465	0	1	04	01	H5521_465_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	2550.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	467	0	1	04	01	H5521_467_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	468	0	1	04	01	H5521_468_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	469	0	1	04	01	H5521_469_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	470	0	1	04	01	H5521_470_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2650.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	471	0	1	04	01	H5521_471_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	472	0	1	04	01	H5521_472_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	473	0	1	04	01	H5521_473_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	474	0	1	04	01	H5521_474_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	475	0	1	04	01	H5521_475_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1150.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	476	0	1	04	01	H5521_476_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	477	0	1	04	01	H5521_477_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5521	801	0	1	04	01	H5521_801_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	802	0	1	04	01	H5521_802_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	805	0	2	04	01	H5521_805_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	806	0	2	04	01	H5521_806_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	809	0	1	04	01	H5521_809_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	810	0	1	04	01	H5521_810_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	812	0	1	04	01	H5521_812_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	814	0	2	04	01	H5521_814_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	815	0	2	04	01	H5521_815_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	816	0	2	04	01	H5521_816_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	817	0	1	04	01	H5521_817_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	818	0	2	04	01	H5521_818_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	819	0	1	04	01	H5521_819_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	820	0	1	04	01	H5521_820_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	821	0	1	04	01	H5521_821_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	822	0	1	04	01	H5521_822_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	823	0	2	04	01	H5521_823_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	824	0	2	04	01	H5521_824_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	825	0	1	04	01	H5521_825_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	826	0	2	04	01	H5521_826_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	827	0	2	04	01	H5521_827_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	828	0	2	04	01	H5521_828_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	829	0	1	04	01	H5521_829_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	830	0	2	04	01	H5521_830_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	831	0	1	04	01	H5521_831_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	832	0	1	04	01	H5521_832_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	833	0	1	04	01	H5521_833_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	834	0	1	04	01	H5521_834_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	835	0	2	04	01	H5521_835_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	836	0	1	04	01	H5521_836_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5521	837	0	1	04	01	H5521_837_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	001	0	1	04	01	H5522_001_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5522	002	0	1	04	01	H5522_002_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5522	004	0	1	04	01	H5522_004_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5522	005	0	1	04	01	H5522_005_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5522	013	0	1	04	01	H5522_013_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5522	014	0	1	04	01	H5522_014_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5522	017	0	1	04	01	H5522_017_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5522	022	0	1	04	01	H5522_022_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5522	023	0	1	04	01	H5522_023_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5522	024	0	1	04	01	H5522_024_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5522	025	0	1	04	01	H5522_025_0	6	1	1110	2	2	4	3		2	2	2	3							2	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	2																																											2					2																		2		1	01000000	50.00	50.00															1	2
H5522	026	0	1	04	01	H5522_026_0	6	1	1110	2	2	4	3		2	2	2	3							2	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	2																																											2					2																		2		1	01000000	30.00	30.00															1	2
H5522	027	0	1	04	01	H5522_027_0	6	1	1110	2	2	4	3		2	2	2	3							2	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	2																																											2					2																		2		1	01000000	30.00	30.00															1	2
H5522	028	0	1	04	01	H5522_028_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5522	029	0	1	04	01	H5522_029_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5522	802	0	1	04	01	H5522_802_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	803	0	1	04	01	H5522_803_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	808	0	2	04	01	H5522_808_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	809	0	2	04	01	H5522_809_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	810	0	1	04	01	H5522_810_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	811	0	1	04	01	H5522_811_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	813	0	2	04	01	H5522_813_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	814	0	2	04	01	H5522_814_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	815	0	1	04	01	H5522_815_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	816	0	1	04	01	H5522_816_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	817	0	2	04	01	H5522_817_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	818	0	2	04	01	H5522_818_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	819	0	1	04	01	H5522_819_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	820	0	1	04	01	H5522_820_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	821	0	1	04	01	H5522_821_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	822	0	2	04	01	H5522_822_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	823	0	1	04	01	H5522_823_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	824	0	2	04	01	H5522_824_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	825	0	2	04	01	H5522_825_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	826	0	2	04	01	H5522_826_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	827	0	2	04	01	H5522_827_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	828	0	1	04	01	H5522_828_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	829	0	2	04	01	H5522_829_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	830	0	1	04	01	H5522_830_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	831	0	1	04	01	H5522_831_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	832	0	1	04	01	H5522_832_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	833	0	1	04	01	H5522_833_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	834	0	2	04	01	H5522_834_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	835	0	1	04	01	H5522_835_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5522	836	0	1	04	01	H5522_836_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5525	004	0	1	04	01	H5525_004_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	50.00	50.00			0.00	0.00	25.00	25.00									1	2
H5525	005	0	1	04	01	H5525_005_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	40.00	40.00			0.00	0.00	25.00	25.00									1	2
H5525	006	0	1	04	01	H5525_006_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					2	2	1	1		4	2	2	3		3					3					3					3					1	2	2	1000.00	3		2					2																		2		1	01011000	40.00	40.00			0.00	0.00	25.00	25.00									1	2
H5525	008	0	1	04	01	H5525_008_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	45.00	45.00			0.00	0.00	25.00	25.00									1	2
H5525	017	0	1	04	01	H5525_017_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	024	0	1	04	01	H5525_024_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	3		2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	0010000	3					2	2	1	1		3					3										3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
H5525	026	0	1	04	01	H5525_026_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H5525	027	0	1	04	01	H5525_027_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1	2	2	1000.00	3		2					2																		2		1	01011000	40.00	40.00			0.00	0.00	25.00	25.00									1	2
H5525	030	0	1	04	01	H5525_030_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	30.00	30.00			0.00	0.00	25.00	25.00									1	2
H5525	031	0	1	04	01	H5525_031_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	034	0	1	04	01	H5525_034_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative services include fillings $25 up to unlmtd yr, recementation of crown $25 up to 1 every 5 yrs, recementation of denture $25 up to 1 every 5 yrs, crown 50% up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	4	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges up to 1 every 5 years, oral surgery up to 2 per year, occlusal adjustments up to 1 every 3 years.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	0.00	0.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5525	035	0	1	04	01	H5525_035_0	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	036	0	1	04	01	H5525_036_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	041	0	1	04	01	H5525_041_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete and partial dentures up to 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery up to 2 per year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	042	0	1	04	01	H5525_042_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	2	1		3					3					3					3					3					2						2					2																		2		1	01010000	55.00	55.00			0.00	0.00											1	2
H5525	044	0	1	04	01	H5525_044_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative services include amalgam and/or composite filling up to unlimited per year, bridge/crown recementation up to 1/5 yrs, crown and other restorative services  up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj, rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	045	0	1	04	01	H5525_045_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	14	6	Denture adj, rebase, reline, repair and tissue cond. 1/year, bridge-crown 2/5 years, bridge-pontic, complete+part denture 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year, implant 1/tooth/life	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	046	0	1	04	01	H5525_046_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	049	0	1	04	01	H5525_049_0	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	050	0	1	04	01	H5525_050_0	5	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	051	1	1	04	01	H5525_051_1	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	35.00	35.00			0.00	0.00											1	2
H5525	051	2	1	04	01	H5525_051_2	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	40.00	40.00			0.00	0.00	25.00	25.00									1	2
H5525	052	0	1	04	01	H5525_052_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1	2	2	1000.00	3		2					2																		2		1	01011010	50.00	50.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
H5525	053	0	1	04	01	H5525_053_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	054	0	1	04	01	H5525_054_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	055	0	1	04	01	H5525_055_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	$25 Amalgam and/or composite filling/unlimited / yr, $25 bridge recementation + crown recementation 1 /5 yr.  50% core buildup and prefabricated post, core 1/ tooth/ lifetime.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Prosths, Oral/Maxillo Surgery, bridges-crown up to 2 every 5 years, bridges-pontic up to 1every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	30.00	30.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5525	056	0	1	04	01	H5525_056_0	5	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	057	0	1	04	01	H5525_057_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative svc amalgam and/or composite filling/unlimited/ year, crown + other restorative services - core buildup + prefabricated post and core up to 1/tooth/lifetime, crown recementation 1/5 years.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Prosthodontics, Oral/Maxillo Surgery, adjust to dentures, rebase, reline, repair and tissue Condit 1/yr. Complete dentures / partial dentures 1/5 yrs.  Occlusal adjust 1/3yr.  Oral surgery 2 per year.	1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	058	0	1	04	01	H5525_058_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
H5525	059	0	1	04	01	H5525_059_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	060	0	1	04	01	H5525_060_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	061	0	1	04	01	H5525_061_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	35.00	35.00			0.00	0.00	25.00	25.00			25.00	25.00					1	2
H5525	062	0	1	04	01	H5525_062_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	45.00	45.00			0.00	0.00	25.00	25.00			25.00	25.00					1	2
H5525	063	0	1	04	01	H5525_063_0	5	1	1111	4	1				4	1				4	1				4	1				1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	064	0	1	04	01	H5525_064_0	3	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2000.00	3		2				1		1	1111	0	0									2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	2000.00	3		2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	40.00	40.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5525	065	0	1	04	01	H5525_065_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	067	0	1	04	01	H5525_067_0	5	1	1111	4	2	3	6	Oral Exams include emergency diagnostic exam up to 1 per year, and periodic oral exam up to 2 per year.	4	2	6	6	Prophylaxis include periodontal maintenance up to 4 per year, and prophylaxis (cleaning) up to 2 per year.	4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	10	6	ProsthodonticsDenture adjustments, rebase, reline, repair, tissue conditioning 1 per yr, complete dentures, partial dentures 1 every 5 yrs, occlusal adjustment 1 every 3 yrs, oral surgery 2 per yr	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	068	0	1	04	01	H5525_068_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	amalgam/ composite Fillings up to unlimited per year, crown and other restorative services - core buildup, prefabricated post, core up to 1 per tooth per lifetime, crown recementation 1 every 5 yrs	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	069	0	1	04	01	H5525_069_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	amalgam and/or composite filling up to unlimited per year, bridge recementation crown recementation up to 1 every 5 years, crown and other restorative services core up to 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	070	0	1	04	01	H5525_070_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	071	0	1	04	01	H5525_071_0	5	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	072	0	1	04	01	H5525_072_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	10	6	Include adjustments to dentures/ rebase/ reline/ repair + tissue conditioning 1/ year, complete and partial dentures up to 1 /5 years, occlusal adjustment up to 1 /3 years, oral surgery up to 2 / year	1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	073	0	1	04	01	H5525_073_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	partial dentures and complete dentures up to 1 every 5 years, oral surgery up to 2 per year, denture adjustment, reline, repair,rebase, tissue conditioning up to 1 per year, occlusal adjustments	1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	074	0	1	04	01	H5525_074_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Amalgam/composite fillings unlimited per year, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime, crown recementation 1 every 5 years.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Denture adj., rebase, reline, repair, and tissue conditioning 1 per year, complete and partial dentures 1 set(s) every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year.	2						2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	075	0	1	04	01	H5525_075_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Amalgam and/or composite filling unlimited/year, crown and other restorative services - core buildup and prefabricated post and core up to 1/tooth/lifetime, crown recementation 1 every 5 years.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, complete and partial dentures 1/5 years, occlusal adj 1/3 years, oral surgery 2/year.	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	076	0	1	04	01	H5525_076_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Amalgam/composite fillings unlimited per year, crown and other restorative services - core buildup and prefabricated post and core 1/tooth/lifetime. Crown recementation 1 every 5 years.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Denture adj., rebase, reline, repair, and tissue conditioning 1 per year, complete and partial dentures 1 set(s) every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year.	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	077	0	1	04	01	H5525_077_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Fillings unlimited per year, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime, crown recementation 1 every 5 years.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Denture adj., rebase, reline, repair, and tissue conditioning 1 per year, complete and partial dentures 1 set(s) every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	078	0	1	04	01	H5525_078_0	4	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Srvc incl amalgam/composite filling unlimited/year, bridge + crown recementation 1/ 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1/tooth/lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	14	6	Denture adjust/rebase/reline/repair,tissue cond 1/yr,bridges-crown 2/5 yrs,bridges-pontic, complete+prtl dentures 1/5 yrs, occlusal adj 1/3 yrs, oral surgery 2/yr, restoration implant 1/tooth/lifetime	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	079	0	1	04	01	H5525_079_0	3	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Srvc incl amalgam/composite filling unlimited/year, bridge and crown recementation 1/5 years, crown and other restorative services - core buildup and prefabricated post and core 1/tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	14	6	Denture adj/rebase/reline/repair,tissue cond 1/yr,bridges-crown 2/5 years,bridges-pontic,complete+prtl dentures 1/5 years,occlusal adj 1/3 years,oral surgery 2/yr,restoration implant 1/tooth/lifetime	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	080	0	1	04	01	H5525_080_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Srvc incl amalgam/composite filling unlimited/year, bridge and crown recementation 1/5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1/tooth/lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	14	6	Denture adjust/rebase/reline/repair, tissue cond 1/yr,bridges-crown 2/5 yrs, bridges-pontic, complete/prtl dentures 1/5 yrs, occlusal adj 1/3 yrs,oral surgery 2/yr,restoration implant 1/tooth/lifetime	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5525	809	0	1	04	01	H5525_809_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5525	810	0	1	04	01	H5525_810_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5525	812	0	2	04	01	H5525_812_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5525	813	0	2	04	01	H5525_813_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5525	816	0	1	04	01	H5525_816_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5525	817	0	1	04	01	H5525_817_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5525	818	0	1	04	01	H5525_818_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5525	819	0	1	04	01	H5525_819_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5525	826	0	1	04	01	H5525_826_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5525	827	0	1	04	01	H5525_827_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5525	830	0	1	04	01	H5525_830_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5525	831	0	1	04	01	H5525_831_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5526	004	0	1	04	01	H5526_004_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	2	2	3		2	1									1	2	2	2000.00	3		2					1	00011111					50	50	50	50	50	50	0	50	50	50			2		1	01000000	25.00	25.00															2	2
H5526	016	0	1	04	01	H5526_016_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	2	2	3		2	1									1	2	2	2000.00	3		2					1	00011111					50	50	50	50	50	50	0	50	50	50			2		1	01000000	30.00	30.00															2	2
H5526	018	0	1	04	01	H5526_018_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	0011111						2	1				2	1				2	1				2	2	2	3		2	1									1	2	2	2000.00	3		2					1	00011111					50	50	50	50	50	50	0	50	50	50			2		1	01000000	22.00	22.00															2	2
H5526	020	0	1	04	01	H5526_020_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	2	2	3		2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	0	50	50	50	50	50	2		1	01000000	30.00	30.00															2	2
H5526	021	0	1	04	01	H5526_021_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	2	2	3		2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	0	50	50	50	50	50	2		1	01000000	30.00	30.00															2	2
H5526	022	0	1	04	01	H5526_022_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1000.00	3		2				2		2												2		1	1111	2				20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	2	2	3		2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000010	40.00	40.00									20.00	20.00					2	2
H5526	023	0	1	04	01	H5526_023_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	2	2	3		2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	0	50	50	50	50	50	2		1	01000000	35.00	35.00															2	2
H5526	024	0	1	04	01	H5526_024_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	2	2	3		2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	0	50	50	50	50	50	2		1	01000000	35.00	35.00															2	2
H5526	806	0	1	04	01	H5526_806_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5526	808	0	1	04	01	H5526_808_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5526	813	0	1	04	01	H5526_813_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5528	807	0	1	04	01	H5528_807_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5528	815	0	1	04	01	H5528_815_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5533	003	0	1	04	01	H5533_003_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every year. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		1	1100	2				15.00	15.00					15.00	15.00	2	2	1	0101001	2	1									2	1														2	1									1	2	2	250.00	3		2					2																		2		1	01000000	50.00	50.00															2	2
H5533	005	0	1	04	01	H5533_005_0	10	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every year. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		1	1100	2				15.00	15.00					15.00	15.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	1000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	40.00	40.00															2	2
H5533	008	0	1	04	01	H5533_008_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every year. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		1	1100	2				15.00	15.00					15.00	15.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	2000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	40.00	40.00															2	2
H5533	009	0	1	04	01	H5533_009_0	10	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every year. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	5000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	30.00	30.00															2	2
H5533	011	0	1	04	01	H5533_011_0	10	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every year. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	4500.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	30.00	30.00															2	2
H5533	012	0	1	04	01	H5533_012_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	5000.00	3		2					1	01000000	20	20															2		2																		2	2
H5533	013	0	1	04	01	H5533_013_0	10	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	4000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															2	2
H5533	015	1	1	04	01	H5533_015_1	11	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	6000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	10.00	10.00															2	2
H5533	015	2	1	04	01	H5533_015_2	11	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	5000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	30.00	30.00															2	2
H5533	801	0	1	04	01	H5533_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5533	802	0	1	04	01	H5533_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5533	803	0	1	04	01	H5533_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5538	001	0	1	20	08	H5538_001_0	1	2																																																																																																																																																						
H5538	002	0	1	20	08	H5538_002_0	1	2																																																																																																																																																						
H5549	003	0	1	01	01	H5549_003_0	11	2																																																															1	1011000						2	2	2	3		2	2	2	3																	2	2	2	3		1		2	3000.00	3		2					2																		2		2																		2	2
H5549	011	0	1	01	01	H5549_011_0	10	2																																																															1	1011000						2	2	2	3		2	2	2	3																	2	2	2	3		1		2	2750.00	3		2					2																		2		2																		2	2
H5549	012	0	1	01	01	H5549_012_0	7	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1011001						2	2	2	3		2	2	2	3												2	2	2	3		2	2	2	3		1		1				2					2																		2		2																		1	2
H5577	002	0	1	01	01	H5577_002_0	7	2																																																															1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	3500.00	3		2					2																		2		2																		1	2
H5577	005	0	1	01	01	H5577_005_0	7	1	1111	2	2	1	1		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	2500.00	3		2					2																		2		2																		1	2
H5577	008	0	1	02	01	H5577_008_0	5	1	1111	2	2	1	1		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	3500.00	3		2					2																		2		2																		1	2
H5577	016	0	1	01	01	H5577_016_0	6	1	1111	2	2	1	1		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	2500.00	3		2					2																		2		2																		1	2
H5577	017	0	1	01	01	H5577_017_0	5	2																																																															1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	4500.00	3		2					2																		2		2																		1	2
H5577	029	0	1	01	01	H5577_029_0	6	2																																																															1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	2500.00	3		2					2																		2		2																		1	2
H5577	038	0	1	01	01	H5577_038_0	6	1	1111	2	2	1	1		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	3000.00	3		2					2																		2		2																		1	2
H5577	042	0	1	01	01	H5577_042_0	6	1	1111	2	2	1	1		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	2900.00	3		2					2																		2		2																		1	2
H5577	043	0	1	01	01	H5577_043_0	6	1	1111	2	2	1	1		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	1800.00	3		2					2																		2		2																		1	2
H5577	044	0	1	01	01	H5577_044_0	6	1	1111	2	2	1	1		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	3400.00	3		2					2																		2		2																		1	2
H5577	046	0	1	01	01	H5577_046_0	5	2																																																															1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	1200.00	3		2					2																		2		2																		1	2
H5577	051	0	1	01	01	H5577_051_0	5	1	1111	2	2	1	1		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	1600.00	3		2					2																		2		2																		1	2
H5577	052	0	1	01	01	H5577_052_0	6	1	1111	2	2	1	1		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	3000.00	3		2					2																		2		2																		1	2
H5577	053	0	1	01	01	H5577_053_0	5	1	1111	2	2	1	1		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	2500.00	3		2					2																		2		2																		1	2
H5577	054	1	1	01	01	H5577_054_1	4	2																																																															1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	1200.00	3		2					2																		2		2																		1	2
H5577	054	2	1	01	01	H5577_054_2	4	2																																																															1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	1200.00	3		2					2																		2		2																		1	2
H5577	054	3	1	01	01	H5577_054_3	4	2																																																															1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	1200.00	3		2					2																		2		2																		1	2
H5577	055	0	1	01	01	H5577_055_0	4	2																																																															1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	1000.00	3		2					2																		2		2																		1	2
H5577	056	1	1	01	01	H5577_056_1	5	1	1111	2	2	1	1		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	1500.00	3		2					2																		2		2																		1	2
H5577	056	2	1	01	01	H5577_056_2	5	1	1111	2	2	1	1		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	1500.00	3		2					2																		2		2																		1	2
H5577	057	0	1	01	01	H5577_057_0	6	1	1111	2	2	1	1		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	4		2	2	1	1		2	1				2	1				2	1				2	1				1		2	1500.00	3		2					2																		2		2																		1	2
H5577	801	0	1	01	01	H5577_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5577	802	0	1	01	01	H5577_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5577	809	0	1	01	01	H5577_809_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5577	818	0	1	01	01	H5577_818_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5577	820	0	1	01	01	H5577_820_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5577	821	0	1	01	01	H5577_821_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5577	822	0	1	01	01	H5577_822_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5577	824	0	1	01	01	H5577_824_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5577	827	0	1	01	01	H5577_827_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5577	829	0	1	01	01	H5577_829_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5577	830	0	1	01	01	H5577_830_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5577	831	0	1	01	01	H5577_831_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5580	001	0	1	01	01	H5580_001_0	3	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	5000.00	3		2					1	01000000	20	20															2		2																		2	2
H5580	004	0	1	01	01	H5580_004_0	3	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	5000.00	3		2					1	01000000	20	20															2		2																		2	2
H5580	005	0	1	01	01	H5580_005_0	3	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	5000.00	3		2					1	01000000	20	20															2		2																		2	2
H5587	002	0	1	01	01	H5587_002_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	3		2					2				2		2												2		2		2												2	2	1	0111111	2	1				2	1				2	1				2	1				2	1				2	1									1		2	4000.00	3		2					1	01000000	20	20															2		2																		2	2
H5590	008	0	1	01	01	H5590_008_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5590	009	0	1	01	01	H5590_009_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5591	003	0	1	01	01	H5591_003_0	4	1	1110	2	2	1	3		2	2	2	3							2	2	1	3		1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			20	20	20	20	50	50	20	20	20	20	20	20	50	50	2		2																		1	1
H5591	005	0	1	02	01	H5591_005_0	6	1	1110	2	2	1	3		2	2	2	3							2	2	1	3		1		1000.00	3		2				2		2												2		1		1	1110	50.00	50.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	11111111	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	1	1
H5591	006	1	1	02	01	H5591_006_1	6	1	1110	2	2	1	3		2	2	1	3							2	2	1	3		1		1000.00	3		2				2		2												2		1		1	1110	50.00	50.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	11111111	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	1	1
H5591	006	2	1	02	01	H5591_006_2	6	1	1110	2	2	1	3		2	2	2	3							2	2	1	3		1		1000.00	3		2				2		2												2		1		1	1110	50.00	50.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	11111111	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	1	1
H5591	006	4	1	02	01	H5591_006_4	6	1	1110	2	2	1	3		2	2	1	3							2	2	1	3		1		1000.00	3		2				2		2												2		1		1	1110	50.00	50.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	11111111	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	1	1
H5591	006	5	1	02	01	H5591_006_5	6	1	1110	2	2	1	3		2	2	2	3							2	2	1	3		1		1000.00	3		2				2		2												2		1		1	1110	50.00	50.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	11111111	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	1	1
H5591	009	0	1	02	01	H5591_009_0	6	1	1110	2	2	1	3		2	2	2	3							2	2	1	3		1		1000.00	3		2				2		2												2		1		1	1110	50.00	50.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	11111111	45.00	45.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	1	1
H5591	013	0	1	02	01	H5591_013_0	6	1	1110	2	2	1	3		2	2	2	3							2	2	1	3		1		1000.00	3		2				2		2												2		1		1	1110	50.00	50.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	11111111	45.00	45.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	1	1
H5591	015	1	1	02	01	H5591_015_1	6	1	1110	2	2	1	3		2	2	2	3							2	2	1	3		1		500.00	3		2				2		2												2		1		1	1110	50.00	50.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	11111111	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	1	1
H5591	015	2	1	02	01	H5591_015_2	6	1	1110	2	2	1	3		2	2	2	3							2	2	1	3		1		750.00	3		2				2		2												2		1		1	1110	50.00	50.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	11111111	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	50.00	1	1
H5591	801	0	1	02	01	H5591_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5591	802	0	1	02	01	H5591_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5593	001	0	1	01	01	H5593_001_0	6	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5593	801	0	1	01	01	H5593_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5593	802	0	1	01	01	H5593_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5594	001	0	1	01	01	H5594_001_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5594	002	0	1	01	01	H5594_002_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1101011	2	2	2	3							2	2	2	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	2	3		2	2	2	6	Number of visits is determined by the services listed in the notes section.	2						2					2																		2		1	11101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5594	016	0	1	01	01	H5594_016_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1101011	2	2	2	3							2	2	2	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	2	3		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2						2					2																		2		1	11101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5594	017	0	1	01	01	H5594_017_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1101011	2	2	2	3							2	2	2	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	2	3		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2						2					2																		2		1	11101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5594	019	0	1	01	01	H5594_019_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5594	022	0	1	01	01	H5594_022_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5594	026	0	1	01	01	H5594_026_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5594	028	0	1	01	01	H5594_028_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5594	029	0	1	01	01	H5594_029_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5594	030	0	1	01	01	H5594_030_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5594	031	0	1	01	01	H5594_031_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5594	032	0	1	01	01	H5594_032_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0101011	2	2	2	3							2	2	1	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	1	3							2						2					2																		2		1	01101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00			1	1
H5594	034	0	1	01	01	H5594_034_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0100001	2	2	2	3																						2	2	1	3							2						2					2																		2		1	01100001	0.00	0.00	0.00	0.00									0.00	0.00			2	1
H5594	035	0	1	01	01	H5594_035_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0100001	2	2	2	3																						2	2	1	3							2						2					2																		2		1	01100001	0.00	0.00	0.00	0.00									0.00	0.00			2	1
H5594	036	0	1	01	01	H5594_036_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Number of visits is determined by the services listed in the notes section.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1101011	2	2	2	3							2	2	2	3							2	2	7	6	Number of visits is determined by the services listed in the notes section.	2	2	2	3		2	2	2	6	Prosthodontics Services include:Partial or full denture – 1 per 5 yearsDenture align - 1 per year	2						2					2																		2		1	11101011	0.00	0.00	0.00	0.00			0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5599	001	0	1	01	01	H5599_001_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5599	002	0	1	02	01	H5599_002_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth.	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	2000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5599	003	0	1	01	01	H5599_003_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5599	004	0	1	01	01	H5599_004_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1500.00	3		2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5599	008	0	1	01	01	H5599_008_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5608	001	0	1	01	01	H5608_001_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	See details under Notes section.	1		5000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	2	3		2	2	1	6	See details under Notes section.	2	1				2	2	1	6	See details under Notes section.	2	1				2	2	1	6	See details under Notes section.	1		1				2					1	01000000	20	20															2		2																		2	2
H5608	002	0	1	01	01	H5608_002_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	See details under Notes section.	1		2000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	3		2	2	2	3							2	2	1	2		2	1									1		1				2					2																		2		1	01000000	15.00	15.00															2	2
H5610	001	0	1	20	08	H5610_001_0	1																																																																																																																																																							
H5610	003	0	1	20	08	H5610_003_0	1																																																																																																																																																							
H5619	001	0	1	01	01	H5619_001_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H5619	003	0	1	01	01	H5619_003_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010						2	2	1	1		2	1									2	2	2	1												1		1				2					1	01000000	20	20															2		1	00011010					0.00	0.00	0.00	0.00			0.00	0.00					1	2
H5619	012	0	1	01	01	H5619_012_0	8	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3					3					1		1				2					2																		2		1	01011010	0.00	0.00			0.00	0.00	0.00	0.00			0.00	0.00					1	1
H5619	015	0	1	01	01	H5619_015_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	10.00	10.00			0.00	0.00											1	1
H5619	016	0	1	01	01	H5619_016_0	5	1	1111	2	1				2	1				2	1				2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	021	0	1	01	01	H5619_021_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	026	0	1	01	01	H5619_026_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	10.00	10.00			0.00	0.00											1	1
H5619	029	0	1	01	01	H5619_029_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	5.00	5.00			0.00	0.00											1	1
H5619	032	0	1	01	01	H5619_032_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	0.00	0.00			0.00	0.00	25.00	25.00									1	1
H5619	038	0	1	01	01	H5619_038_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0011010						2	2	1	1		2	1									2	2	2	1												1		1				2					1	01000000	20	20															2		1	00011010					0.00	0.00	0.00	0.00			0.00	0.00					1	1
H5619	039	1	1	01	01	H5619_039_1	5	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	039	2	1	01	01	H5619_039_2	5	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	046	0	1	01	01	H5619_046_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	047	0	1	01	01	H5619_047_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative services include amalgam and/or composite filling up to unlimited per year, bridge recementation and crown recementation up to 1 every 5 years, crown and other restorative services - core	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	049	0	1	02	01	H5619_049_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative services-amalgam and/or composite filling up to unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services  up to 1/tooth per lifetime	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	051	0	1	02	01	H5619_051_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative service-amalgam and/or composite filling up to unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services up to 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	053	0	1	02	01	H5619_053_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative services-amalgam and/or composite filling unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	054	0	1	02	01	H5619_054_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	14	6	Denture adj, rebase, reline, repair and tissue cond. 1/year, bridge-crown 2/5 years, bridge-pontic, complete+part denture 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year, implant 1/tooth/life	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	055	0	1	01	01	H5619_055_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	45.00	45.00			0.00	0.00	25.00	25.00									1	2
H5619	056	0	1	01	01	H5619_056_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	1
H5619	057	0	1	01	01	H5619_057_0	8	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	059	0	1	01	01	H5619_059_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	40.00	40.00			0.00	0.00	0.00	0.00			0.00	0.00					1	1
H5619	060	0	1	01	01	H5619_060_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	65.00	65.00			0.00	0.00											1	1
H5619	061	0	1	01	01	H5619_061_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	3					3					1		1				2					2																		2		1	01011010	40.00	40.00			0.00	0.00	0.00	0.00			0.00	0.00					1	1
H5619	063	0	1	01	01	H5619_063_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	55.00	55.00			0.00	0.00											1	1
H5619	065	0	1	01	01	H5619_065_0	8	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	066	0	1	01	01	H5619_066_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
H5619	069	0	1	02	01	H5619_069_0	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	071	0	1	01	01	H5619_071_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling unlimited/year, bridge/crown recementation up to 1 every 5 years, crown/other services-core buildup, prefab post, core up to 1/ tooth/ lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adjust, rebase, reline, repair, tissue condit 1/year; bridges-crown 2/ 5 year; bridges-pontic, complete dentures, partial dentures 1/ 5 years, occlusal adjust 1/3 years, oral surgery 2/ year.	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	075	0	1	01	01	H5619_075_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, crown and bridge recementation 1/5 yrs, crown 1 per tooth per lifetime, other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1/yr. Bridges-crown 2/5 yrs. Bridges-pontic, complete/partial dentures 1/5 yrs. Occlusal adjustment 1/3 yrs. Oral surgery 2/year	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	077	0	1	01	01	H5619_077_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					1		2	2000.00	3		2					2																		2		1	01010000	40.00	40.00			0.00	0.00											1	2
H5619	082	0	1	01	01	H5619_082_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	11	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	083	0	1	01	01	H5619_083_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	45.00	45.00			0.00	0.00	25.00	25.00									1	2
H5619	089	0	1	01	01	H5619_089_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime...	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Denture adjustments, rebase, reline, and repair and tissue conditioning 1/yr. Complete/partial dentures 1/5 yrs. Occlusal adjustment 1/3 yrs. Oral surgery 2/yr.	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	090	0	1	01	01	H5619_090_0	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	091	0	1	01	01	H5619_091_0	5	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	093	0	1	01	01	H5619_093_0	5	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	095	0	1	01	01	H5619_095_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	100	0	1	01	01	H5619_100_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	50.00	50.00			0.00	0.00	25.00	25.00									1	1
H5619	111	0	1	02	01	H5619_111_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	113	0	1	02	01	H5619_113_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative services include fillings up to unlimited per year, bridge/crown recementation up to 1 every 5 years, crown/other restorative services up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	114	0	1	01	01	H5619_114_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	55.00	55.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	116	0	1	01	01	H5619_116_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	0.00	0.00			0.00	0.00	0.00	0.00			0.00	0.00					1	1
H5619	119	0	1	01	01	H5619_119_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	0.00	0.00			0.00	0.00											1	1
H5619	121	0	1	01	01	H5619_121_0	3	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	0.00	0.00			0.00	0.00	0.00	0.00			0.00	0.00					1	1
H5619	122	0	1	01	01	H5619_122_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H5619	123	0	1	02	01	H5619_123_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	126	0	1	02	01	H5619_126_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	128	0	1	01	01	H5619_128_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	40.00	40.00			0.00	0.00	25.00	25.00									1	2
H5619	130	1	1	01	01	H5619_130_1	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	10.00	10.00			0.00	0.00											1	1
H5619	130	2	1	01	01	H5619_130_2	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0010000	3					4	2	1	1		3					3					3					3					3					1		1				2					2																		2		1	01010000	0.00	0.00			0.00	0.00											1	1
H5619	131	0	1	01	01	H5619_131_0	4	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	133	0	1	01	01	H5619_133_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	134	0	1	01	01	H5619_134_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	135	0	1	01	01	H5619_135_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	45.00	45.00			0.00	0.00	25.00	25.00									1	2
H5619	136	1	1	01	01	H5619_136_1	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling unlimited per yr, bridge/crown recementation 1 every 5 yrs, crown/other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	136	2	1	01	01	H5619_136_2	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling unlimited per yr, bridge/crown recementation 1 every 5 yrs, crown/other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	136	3	1	01	01	H5619_136_3	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling unlimited per yr, bridge/crown recementation 1 every 5 yrs, crown/other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	136	4	1	01	01	H5619_136_4	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling unlimited per yr, bridge/crown recementation 1 every 5 yrs, crown/other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	137	0	1	01	01	H5619_137_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	35.00	35.00			0.00	0.00											1	2
H5619	138	0	1	01	01	H5619_138_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	5.00	5.00			0.00	0.00											1	1
H5619	143	0	1	01	01	H5619_143_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Amalgam and/or composite filling unlimited per yr, bridge/crown recementation 1 every 5 yrs, crown/other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	145	0	1	01	01	H5619_145_0	8	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	13	6	PrDenture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	146	0	1	01	01	H5619_146_0	4	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	147	0	1	01	01	H5619_147_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Amalgam and/or composite filling unlimited/yr; crown and other restorative services - core buildup and prefabricated post and core 1/tooth/lifetime; crown recementation 1/5 yrs.	4	2	2	6	Root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Denture adjustments, rebase, reline, and repair and tissue conditioning 1/yr; complete dentures and partial dentures 1/5 yrs; occlusal adjustment 1/3 yrs; oral surgery 2/yr	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	148	0	1	01	01	H5619_148_0	4	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	150	0	1	01	01	H5619_150_0	4	1	1111	4	1				4	1				4	1				4	1				1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	151	0	1	01	01	H5619_151_0	4	1	1111	4	2	2	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	4	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges up to 1 every 5 years, oral surgery up to 2 per year, occlusal adjustments up to 1 every 3 years.	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	152	0	1	01	01	H5619_152_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Include amalgam and/or composite filling up to unlimited/ year, crown + other rest. services - core buildup + prefab. post + core  1/per tooth/ lifetime, crown recementation up to 1 every 5 years	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	10	6	Include adj. to dentures/ rebase/ reline/denture repair/tissue conditioning  1 /year, complete and partial dentures 1/ 5 years, occlusal adjustment  1 /3 years, oral surgery 2/ year.	1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	153	0	1	01	01	H5619_153_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	2	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	154	0	1	01	01	H5619_154_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative includes fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adjustments, rebase, reline, repair/tissue conditioning 1 per yr, bridges-crown 2/ 5 yrs, complete/partial denture 1/ 5 yrs, occlusal adjustment up to 1/ 3 yrs, oral surgery up to 2 per yr.	1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	155	0	1	01	01	H5619_155_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling unlimited per yr, bridge/crown recementation 1 every 5 yrs, crown/other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Adj to dentures/denture rebase/reline/repair/tissue conditioning 1 per yr, bridges-crown 2/5 yrs, bridges-pontic/complete/partial dentures 1/5 yrs, occlusal adjustment 1/3 yrs, oral surgery 2 per yr.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	156	0	1	02	01	H5619_156_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	157	0	1	01	01	H5619_157_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	1		1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	158	0	1	02	01	H5619_158_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative services-amalgam and/or composite filling up to unlimited per year, bridge and crown recementation and up to 1 every 5 years, crown and other restorative services 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	159	0	1	01	01	H5619_159_0	4	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	14	6	Denture adj, rebase,reline,repair,tissue cond. 1/year, bridges-crown 2/5 years, bridges-pontic, complete/part dentures 1/5 years, occlusal. adj. 1/3 years, oral surgery 2/year, implant 1/tooth/life.	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H5619	160	0	1	01	01	H5619_160_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	amalgam/composite filling unlimited/ year, bridge + crown recementation 1/ 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	161	0	1	01	01	H5619_161_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	11	6	Dentures up to 1 set(s) every 5 years, denture work, tissue conditioning up to 1 per year, occlusal adjustments up to 1 every 3 years, oral surgery up to 2 per year, bridges up to 1 every 5 years.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	162	0	1	02	01	H5619_162_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	163	0	1	01	01	H5619_163_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	164	0	1	01	01	H5619_164_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Amalgam and/or composite filling unlimited per yr, bridge/crown recementation up to 1/5 yrs, crown/other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5619	802	0	1	01	01	H5619_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5619	803	0	1	01	01	H5619_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5619	805	0	1	01	01	H5619_805_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5619	806	0	1	01	01	H5619_806_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5622	001	0	1	20	08	H5622_001_0	1	2																																																																																																																																																						
H5622	002	0	1	20	08	H5622_002_0	1	2																																																																																																																																																						
H5628	001	0	1	01	01	H5628_001_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1150.00	3		2					2																		2		2																		2	2
H5628	007	0	1	01	01	H5628_007_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	300.00	3		2					2																		2		1	01000000	40.00	40.00															2	2
H5628	008	0	1	01	01	H5628_008_0	4	2																																																															2																																											2					2																		2		2																		2	2
H5628	010	0	1	01	01	H5628_010_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1200.00	3		2					2																		2		2																		2	2
H5628	011	0	1	01	01	H5628_011_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	800.00	3		2					2																		2		2																		2	2
H5628	012	0	1	01	01	H5628_012_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					2																		2		2																		2	2
H5629	001	0	1	20	08	H5629_001_0	1																																																																																																																																																							
H5629	002	0	1	20	08	H5629_002_0	2																																																																																																																																																							
H5644	801	0	1	01	01	H5644_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5644	802	0	1	01	01	H5644_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5644	803	0	1	01	01	H5644_803_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5649	001	0	1	01	01	H5649_001_0	7	1	1111	2	1				2	2	2	3		2	1				2	2	1	4		2					2				2		2												2		1	1111	2				0.00	17.00	0.00	0.00	0.00	13.00	0.00	41.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	166.00	0.00	15.00	0.00	424.00	0.00	0.00	0.00	0.00	0.00	237.00	0.00	2160.00	1	1
H5649	002	0	1	01	01	H5649_002_0	7	1	1111	2	1				2	2	2	3		2	1				2	2	1	4		2					2				2		2												2		1	1111	2				0.00	17.00	0.00	0.00	0.00	13.00	0.00	41.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	166.00	0.00	15.00	0.00	424.00	0.00	0.00	0.00	0.00	0.00	237.00	0.00	2160.00	1	1
H5649	006	0	1	01	01	H5649_006_0	7	1	1111	2	1				2	2	2	3		2	1				2	2	1	4		2					2				2		2												2		1	1111	2				0.00	17.00	0.00	0.00	0.00	13.00	0.00	41.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	166.00	0.00	15.00	0.00	424.00	0.00	0.00	0.00	0.00	0.00	237.00	0.00	2160.00	1	1
H5649	008	0	1	01	01	H5649_008_0	8	1	1111	2	1				2	2	2	3		2	1				2	2	1	4		2					2				2		2												2		1	1111	2				0.00	17.00	0.00	0.00	0.00	13.00	0.00	41.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	166.00	0.00	15.00	0.00	424.00	0.00	0.00	0.00	0.00	0.00	237.00	0.00	2160.00	1	1
H5649	009	0	1	01	01	H5649_009_0	7	1	1111	2	1				2	2	2	3		2	1				2	2	1	4		2					2				2		2												2		1	1111	2				0.00	17.00	0.00	0.00	0.00	13.00	0.00	41.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	166.00	0.00	15.00	0.00	424.00	0.00	0.00	0.00	0.00	0.00	237.00	0.00	2160.00	1	1
H5649	018	0	1	01	01	H5649_018_0	8	1	1111	2	1				2	2	2	3		2	1				2	2	1	4		2					2				2		2												2		1	1111	2				0.00	17.00	0.00	0.00	0.00	13.00	0.00	41.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	166.00	0.00	15.00	0.00	424.00	0.00	0.00	0.00	0.00	0.00	237.00	0.00	2160.00	1	1
H5649	019	0	1	01	01	H5649_019_0	8	1	1111	2	1				2	2	2	3		2	1				2	2	1	4		2					2				2		2												2		1	1111	2				0.00	17.00	0.00	0.00	0.00	13.00	0.00	41.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	166.00	0.00	15.00	0.00	424.00	0.00	0.00	0.00	0.00	0.00	237.00	0.00	2160.00	1	1
H5649	020	1	1	01	01	H5649_020_1	9	1	1111	2	1				2	2	2	3		2	1				2	2	1	4		2					2				2		2												2		1	1111	2				0.00	17.00	0.00	0.00	0.00	13.00	0.00	41.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	166.00	0.00	15.00	0.00	424.00	0.00	0.00	0.00	0.00	0.00	237.00	0.00	2160.00	1	1
H5649	020	2	1	01	01	H5649_020_2	8	1	1111	2	1				2	2	2	3		2	1				2	2	1	4		2					2				2		2												2		1	1111	2				0.00	17.00	0.00	0.00	0.00	13.00	0.00	41.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	166.00	0.00	15.00	0.00	424.00	0.00	0.00	0.00	0.00	0.00	237.00	0.00	2160.00	1	1
H5649	021	1	1	01	01	H5649_021_1	8	1	1111	2	1				2	2	2	3		2	1				2	2	1	4		2					2				2		2												2		1	1111	2				0.00	17.00	0.00	0.00	0.00	13.00	0.00	41.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	166.00	0.00	15.00	0.00	424.00	0.00	0.00	0.00	0.00	0.00	237.00	0.00	2160.00	1	1
H5649	021	2	1	01	01	H5649_021_2	8	1	1111	2	1				2	2	2	3		2	1				2	2	1	4		2					2				2		2												2		1	1111	2				0.00	17.00	0.00	0.00	0.00	13.00	0.00	41.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	166.00	0.00	15.00	0.00	424.00	0.00	0.00	0.00	0.00	0.00	237.00	0.00	2160.00	1	1
H5652	001	0	1	02	01	H5652_001_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5652	002	0	1	02	01	H5652_002_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5652	003	0	1	02	01	H5652_003_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	10000000															0	50	2		1	01111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5652	004	0	1	02	01	H5652_004_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H5652	006	0	1	02	01	H5652_006_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5652	008	0	1	02	01	H5652_008_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H5703	001	0	1	01	01	H5703_001_0	10	2																																																															1	1000000																															2	1				2						2					1	01000000	20	20															2		2																		1	2
H5774	003	0	1	01	01	H5774_003_0	4	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	1		2	2500.00	3		2					2																		2		2																		1	2
H5774	005	0	1	01	01	H5774_005_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	1		2	4250.00	3		2					2																		2		2																		1	2
H5774	022	0	1	01	01	H5774_022_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicityestablished by the American Dental Association(ADA).	2	2	1	6	Services are administered with the periodicityestablished by the American Dental Association(ADA).	2	2	1	6	Services are administered with the periodicityestablished by the American Dental Association(ADA).	2	2	1	6	Services are administered with the periodicityestablished by the American Dental Association(ADA).	2	2	1	6	Services are administered with the periodicityestablished by the American Dental Association(ADA).	1		2	3500.00	3		2					2																		2		2																		1	2
H5774	024	0	1	01	01	H5774_024_0	5	2																																																															1	1111111	2	1				2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	1		2	4000.00	3		2					2																		2		2																		1	2
H5774	026	0	1	01	01	H5774_026_0	4	2																																																															1	1111111	2	1				2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	1		2	2750.00	3		2					2																		2		2																		1	2
H5774	027	0	1	02	01	H5774_027_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	1		2	3250.00	3		2					2																		2		2																		1	2
H5774	028	0	1	01	01	H5774_028_0	5	2																																																															1	1111111	2	1				2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	1		2	2750.00	3		2					2																		2		2																		1	2
H5774	031	0	1	02	01	H5774_031_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	1		2	3800.00	3		2					2																		2		2																		1	2
H5774	035	0	1	01	01	H5774_035_0	5	2																																																															1	1111111	2	1				2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	1		2	2000.00	3		2					2																		2		2																		1	2
H5774	036	0	1	01	01	H5774_036_0	5	2																																																															1	1111111	2	1				2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicityestablished by the American Dental Association(ADA).	2	2	1	6	Services are administered with the periodicityestablished by the American Dental Association(ADA).	2	2	1	6	Services are administered with the periodicityestablished by the American Dental Association(ADA).	2	2	1	6	Services are administered with the periodicityestablished by the American Dental Association(ADA).	2	2	1	6	Services are administered with the periodicityestablished by the American Dental Association(ADA).	1		2	2000.00	3		2					2																		2		2																		1	2
H5774	037	0	1	01	01	H5774_037_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	1		2	2750.00	3		2					2																		2		2																		1	2
H5774	038	0	1	01	01	H5774_038_0	5	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicityestablished by the American Dental Association(ADA).	2	2	1	6	Services are administered with the periodicityestablished by the American Dental Association(ADA).	2	2	1	6	Services are administered with the periodicityestablished by the American Dental Association(ADA).	2	2	1	6	Services are administered with the periodicityestablished by the American Dental Association(ADA).	1		2	2250.00	3		2					2																		2		2																		1	2
H5774	040	0	1	01	01	H5774_040_0	4	2																																																															1	1111111	2	1				2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	2	2	1	6	Services are administered with the periodicity established by the American Dental Association (ADA).	1		2	5000.00	3		2					2																		2		2																		1	2
H5774	802	0	1	01	01	H5774_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5774	806	0	1	01	01	H5774_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5774	808	0	1	01	01	H5774_808_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5774	809	0	1	02	01	H5774_809_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5774	810	0	1	01	01	H5774_810_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5774	811	0	1	02	01	H5774_811_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5774	812	0	1	02	01	H5774_812_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5774	814	0	1	02	01	H5774_814_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5774	816	0	1	02	01	H5774_816_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5774	818	0	1	02	01	H5774_818_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5774	820	0	1	02	01	H5774_820_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5774	821	0	1	02	01	H5774_821_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5774	822	0	1	02	01	H5774_822_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5774	823	0	1	02	01	H5774_823_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5774	824	0	1	02	01	H5774_824_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5774	825	0	1	02	01	H5774_825_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5779	002	0	1	01	01	H5779_002_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5779	007	0	1	01	01	H5779_007_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					2																		2		1	11111111	15.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5779	009	0	1	01	01	H5779_009_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	Every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5793	001	0	1	02	01	H5793_001_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5793	010	0	1	02	01	H5793_010_0	10	1	1110	2	2	4	3		2	2	2	3							2	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	2																																											2					2																		2		1	01000000	45.00	45.00															1	2
H5793	014	0	1	02	01	H5793_014_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5793	015	0	1	01	01	H5793_015_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5793	016	0	1	02	01	H5793_016_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5793	017	0	1	02	01	H5793_017_0	9	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5793	018	0	1	02	01	H5793_018_0	10	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5793	019	0	1	02	01	H5793_019_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5793	020	0	1	02	01	H5793_020_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5793	801	0	1	01	01	H5793_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5793	802	0	1	01	01	H5793_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5810	014	0	1	01	01	H5810_014_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years	2					2				2		2												2		2		2												2	2	1	1101101	2	1									2	1				2	1									2	1				2	1				1		2	725.00	3		2					2																		2		1	01000000	20.00	20.00															2	2
H5810	015	0	1	01	01	H5810_015_0	4	2																																																															2																																											2					2																		2		1	01000000	50.00	50.00															2	2
H5822	001	0	1	20	08	H5822_001_0	2																																																																																																																																																							
H5822	002	0	1	20	08	H5822_002_0	2																																																																																																																																																							
H5823	006	0	1	01	01	H5823_006_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1200.00	3		2					2																		2		2																		2	2
H5823	010	0	1	01	01	H5823_010_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	800.00	3		2					2																		2		2																		2	2
H5823	012	1	1	01	01	H5823_012_1	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	600.00	3		2					2																		2		1	01000000	40.00	40.00															2	2
H5823	012	2	1	01	01	H5823_012_2	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	300.00	3		2					2																		2		2																		2	2
H5826	006	0	1	01	01	H5826_006_0	3	1	1111	2	1				2	1				2	1				2	1				2					2				2		2												2		2		2												1	1	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	500.00	3		2					1	01000000	20	20															2		2																		1	1
H5826	008	0	1	01	01	H5826_008_0	4	1	1111	2	1				2	1				2	1				2	1				2					2				2		2												2		2		2												1	1	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	500.00	3		2					1	01000000	20	20															2		2																		1	1
H5826	009	0	1	01	01	H5826_009_0	4	1	1111	2	1				2	1				2	1				2	1				2					2				2		2												2		2		2												1	1	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	500.00	3		2					1	01000000	20	20															2		2																		1	1
H5826	010	0	1	01	01	H5826_010_0	4	1	1111	2	1				2	1				2	1				2	1				2					2				2		2												2		2		2												1	1	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	500.00	3		2					1	01000000	20	20															2		2																		1	1
H5826	014	0	1	01	01	H5826_014_0	5	1	1111	2	1				2	1				2	1				2	1				1		5000.00	3		2				2		2												2		2		2												1	1	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	1
H5826	016	0	1	01	01	H5826_016_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												1	1	2																																											2					1	01000000	20	20															2		2																		1	1
H5826	017	0	1	01	01	H5826_017_0	5	1	1111	2	1				2	1				2	1				2	1				1		500.00	3		2				2		2												2		2		2												1	1	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	1
H5828	001	0	1	01	01	H5828_001_0	5	1	1111	2	1				2	1				2	1				2	1				1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5828	002	0	1	01	01	H5828_002_0	5	1	1111	2	1				2	1				2	1				2	1				1		5500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5828	008	0	1	01	01	H5828_008_0	8	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5828	012	1	1	02	01	H5828_012_1	8	1	1111	4	1				4	1				4	1				4	1				1		2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5828	012	2	1	02	01	H5828_012_2	8	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5828	012	3	1	02	01	H5828_012_3	8	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5843	001	0	1	01	01	H5843_001_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	6	Every 12 months	1		5000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H5843	002	0	1	01	01	H5843_002_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	6	Every 12 months	2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3					3											2					2																		2		2																		1	1
H5843	005	0	1	01	01	H5843_005_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	6	Every 12 months	1		5000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H5852	001	0	1	01	01	H5852_001_0	8	1	1111	2	1				2	2	2	3		2	2	2	3		2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1200.00	3		2					2																		2		2																		2	2
H5854	008	0	1	01	01	H5854_008_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5854	009	0	1	01	01	H5854_009_0	7	2		3					3					3					3																																														2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H5854	010	0	1	01	01	H5854_010_0	5	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H5854	011	0	1	01	01	H5854_011_0	6	1	1110	4	2	2	3		4	2	2	3		3					4	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	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H5854	012	0	1	02	01	H5854_012_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5854	013	0	1	01	01	H5854_013_0	9	1	1111	2	1				2	1				2	1				2	1				1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5854	014	0	1	01	01	H5854_014_0	6	1	1111	2	1				2	1				2	1				2	1				1		2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5854	801	0	1	01	01	H5854_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5854	803	0	1	01	01	H5854_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5854	806	0	2	01	01	H5854_806_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5854	807	0	2	01	01	H5854_807_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5854	809	0	1	01	01	H5854_809_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5854	811	0	2	01	01	H5854_811_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5859	001	0	1	02	01	H5859_001_0	9	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1500.00	3		2					1	01000000	20	20															2		2																		2	2
H5883	001	1	1	02	01	H5883_001_1	3	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams - 2 per calendar year.  X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep cleaning 1 per 24 months per quadrant	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	200.00															2	2
H5883	001	2	1	02	01	H5883_001_2	3	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams - 2 per calendar year.  X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep cleaning 1 per 24 months per quadrant	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	200.00															2	2
H5883	001	3	1	02	01	H5883_001_3	3	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams - 2 per calendar year.  X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep cleaning 1 per 24 months per quadrant	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	200.00															2	2
H5883	001	4	1	02	01	H5883_001_4	3	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams - 2 per calendar year.  X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep cleaning 1 per 24 months per quadrant	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	200.00															2	2
H5883	001	5	1	02	01	H5883_001_5	3	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams - 2 per calendar year.  X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep cleaning 1 per 24 months per quadrant	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	200.00															2	2
H5883	002	1	1	02	01	H5883_002_1	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	225.00															2	2
H5883	002	2	1	02	01	H5883_002_2	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	225.00															2	2
H5883	002	3	1	02	01	H5883_002_3	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	225.00															2	2
H5883	002	4	1	02	01	H5883_002_4	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	225.00															2	2
H5883	002	7	1	02	01	H5883_002_7	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	225.00															2	2
H5883	003	1	1	02	01	H5883_003_1	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime.	1		1				2					2																		2		1	01000000	0.00	200.00															2	2
H5883	003	2	1	02	01	H5883_003_2	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime.	1		1				2					2																		2		1	01000000	0.00	200.00															2	2
H5883	003	3	1	02	01	H5883_003_3	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime.	1		1				2					2																		2		1	01000000	0.00	200.00															2	2
H5883	003	4	1	02	01	H5883_003_4	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime.	1		1				2					2																		2		1	01000000	0.00	200.00															2	2
H5883	003	5	1	02	01	H5883_003_5	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime.	1		1				2					2																		2		1	01000000	0.00	200.00															2	2
H5883	007	0	1	01	01	H5883_007_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	225.00															2	2
H5883	012	1	1	02	01	H5883_012_1	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	225.00															2	2
H5883	012	2	1	02	01	H5883_012_2	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	225.00															2	2
H5883	014	1	1	02	01	H5883_014_1	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	275.00															2	2
H5883	014	2	1	02	01	H5883_014_2	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	275.00															2	2
H5883	014	3	1	02	01	H5883_014_3	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	275.00															2	2
H5883	014	4	1	02	01	H5883_014_4	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	275.00															2	2
H5883	014	5	1	02	01	H5883_014_5	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	275.00															2	2
H5883	015	0	1	01	01	H5883_015_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	2		1		1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	Oral exams – 2 per calendar year. X-rays- Once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	4	2	1	6	Fillings once per tooth/surface per 48 months, Crowns – once per permanent tooth per 84 months, Crown Repairs – 3 per permanent tooth per calendar year	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Once per tooth per lifetime	4	2	2	6	Brush Biopsy - 2 per calendar year. Oral Surgery - 2 per tooth per lifetime	1		1				2					2																		2		1	01000000	0.00	275.00															2	2
H5883	801	0	1	02	01	H5883_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5883	805	0	1	02	01	H5883_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5900	001	0	1	04	01	H5900_001_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	1500.00	3		2					1	10011111					25	25	25	25	25	25	25	25	25	25	25	25	2		1	01000000	40.00	40.00															2	2
H5900	002	0	1	04	01	H5900_002_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	2000.00	3		2					1	10011111					25	25	25	25	25	25	25	25	25	25	25	25	2		1	01000000	25.00	25.00															2	2
H5900	003	0	1	04	01	H5900_003_0	10	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1		1	1110	15.00	15.00									2	2	1	1001111											2	1				2	1				2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	2	1				2	1				1	2	2	1000.00	3		2					1	10001111							50	50	50	50	0	50	50	50	0	50	2		1	01000000	40.00	40.00															2	2
H5900	004	0	1	04	01	H5900_004_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	2					2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	1				2	1				2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	2	1				2	1				1	2	2	2000.00	3		2					1	10001111							25	50	50	50	0	50	50	50	0	50	2		1	01000000	30.00	30.00															2	2
H5900	005	0	1	04	01	H5900_005_0	11	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1		1	1110	15.00	15.00									2	2	1	1001111											2	1				2	1				2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	2	1				2	1				1	2	2	1250.00	3		2					1	10001111							25	50	50	50	0	50	50	50	0	50	2		1	01000000	20.00	40.00															2	2
H5900	006	0	1	04	01	H5900_006_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	1000.00	3		2					1	10011111					25	25	25	25	25	25	25	25	25	25	25	25	2		1	01000000	40.00	40.00															2	2
H5900	007	0	1	04	01	H5900_007_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1		1	1110	25.00	25.00									2	2	1	1001111											2	1				2	1				2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	2	1				2	1				1	2	2	500.00	3		2					1	10001111							50	50	50	50	0	50	50	50	0	50	2		1	01000000	40.00	40.00															2	2
H5900	801	0	1	04	01	H5900_801_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5900	802	0	1	04	01	H5900_802_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5902	001	0	1	20	08	H5902_001_0	1																																																																																																																																																							
H5902	002	0	1	20	08	H5902_002_0	1																																																																																																																																																							
H5926	001	0	1	01	01	H5926_001_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Non-Routine includes Scaling up to 4 quadrants per 24 mths, Full Mouth Debridement up to once every year, Periodontal Maintenance up to 2 per 12 mths, and Palliative Emergency Treatment up to 4 per yr	2	2	1	6	Up to 2 every calendar year based on procedure	2	2	1	6	Restorative Services: Up to 6 restorations per year, not to exceed a total of 12 surfaces per year. Up to 2 crowns per year no more than once per tooth every 5 years.	2	2	1	6	Endodontics covered one per tooth per year.	2	2	1	6	Periodontics up to 1 per year	2	2	1	6	Extractions: Simple extractions up to 8 per year. Surgical removal of erupted and impacted teeth up to 3 per year.	2	2	1	6	Unlimited based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.	1		2	4000.00	3		2					1	01000000	20	20															2		2																		1	2
H5926	005	0	1	01	01	H5926_005_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					2																		2		2																		2	2
H5926	006	0	1	01	01	H5926_006_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					2																		2		1	01000000	50.00	50.00															2	2
H5926	007	0	1	01	01	H5926_007_0	4	2																																																															2																																											2					2																		2		2																		2	2
H5928	004	0	1	01	01	H5928_004_0	3	1	1111	2	1				2	2	1	4		2	2	1	4		2	2	1	2		2					2				2		2												2		1	1001	2								5.00	5.00	0.00	5.00	2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11011111	0.00	5.00			0.00	8.00	16.00	300.00	15.00	475.00	0.00	375.00	20.00	150.00	0.00	570.00	1	1
H5928	010	0	1	01	01	H5928_010_0	4	1	1111	2	1				2	2	1	4		2	2	1	4		2	2	1	2		2					2				2		2												2		1	1001	2								5.00	5.00	0.00	5.00	2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11011111	0.00	20.00			0.00	8.00	16.00	300.00	15.00	475.00	0.00	375.00	20.00	150.00	0.00	570.00	1	1
H5932	001	0	1	01	01	H5932_001_0	6	1	1110	2	2	1	4		2	2	4	3							2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	1		8000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	4		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 2 per year, 1 crown in 5 years per tooth.	2	2	2	3		2	2	1	3		2	1				2	2	1	3		1		1				2					1	01000000	28	28															2		2																		1	2
H5932	009	0	1	01	01	H5932_009_0	5	1	1110	2	2	1	4		2	2	4	3							2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	4		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 1 per year, 1 crown in 5 years per tooth.	2	2	1	3		2	2	1	2		2	1				2	2	1	6	Dentures are covered one per arch every 5 years, including a full denture, a partial denture or an immediate denture and are not applied to the comprehensive maximum plan coverage amount.	1		2	3500.00	3		2					2																		2		1	01000000	25.00	250.00															1	2
H5932	012	0	1	01	01	H5932_012_0	6	1	1110	2	2	1	4		2	2	4	3							2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	1		8000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	4		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 2 per year, 1 crown in 5 years per tooth.	2	2	2	3		2	2	1	3		2	1				2	2	1	3		1		1				2					1	01000000	28	28															2		2																		1	2
H5932	013	0	1	01	01	H5932_013_0	5	1	1110	2	2	1	4		2	2	4	3							2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	4		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 1 per year, 1 crown in 5 years per tooth.	2	2	1	3		2	2	1	2		2	1				2	2	1	6	Dentures are covered one per arch every 5 years, including a full denture, a partial denture or an immediate denture and are not applied to the comprehensive maximum plan coverage amount.	1		2	3500.00	3		2					2																		2		1	01000000	25.00	250.00															1	2
H5934	001	0	1	20	08	H5934_001_0	1																																																																																																																																																							
H5934	002	0	1	20	08	H5934_002_0	1																																																																																																																																																							
H5937	001	0	1	01	01	H5937_001_0	9	1	1101	2	2	1	3							2	2	1	6	Plan covers one additional fluoride varnish per year for patients at high risk of cavities.	2	2	1	6	Plan provides panoramic xray once each year. Plan covers full mouth series x-ray per year.	2					2				2		2												2		2		2												2	2	1	0001110											2	2	3	3		2	2	2	3		2	2	1	3												2						2					1	01000000	20	20															2		2																		2	2
H5938	001	0	1	01	01	H5938_001_0	12	1	1111	2	1				2	1				2	1				2	1				1		600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	1
H5938	006	0	1	01	01	H5938_006_0	12	1	1111	2	1				2	1				2	1				2	1				1		800.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	1
H5938	008	0	1	01	01	H5938_008_0	12	1	1111	2	1				2	1				2	1				2	1				1		200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															1	1
H5938	802	0	1	01	01	H5938_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5938	803	0	1	01	01	H5938_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5938	804	0	1	01	01	H5938_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5938	805	0	1	01	01	H5938_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5943	001	0	1	02	01	H5943_001_0	6	1	1111	2	1				2	2	2	3		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					1	01000000	20	20															2		1	10101111			0.00	125.00			0.00	350.00	0.00	395.00	0.00	250.00	0.00	350.00	0.00	350.00	2	2
H5943	002	0	1	02	01	H5943_002_0	7	1	1111	2	1				2	2	2	3		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					1	01000000	20	20															2		1	10101111			0.00	125.00			0.00	350.00	0.00	395.00	0.00	250.00	0.00	350.00	0.00	350.00	2	2
H5945	001	0	1	01	01	H5945_001_0	7	1	1111	4	2	2	3		4	2	2	3		4	2	2	3		4	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		2																		2	2
H5945	002	0	1	01	01	H5945_002_0	7	1	1111	4	2	2	3		4	2	2	3		4	2	2	3		4	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		2																		2	2
H5945	008	0	1	01	01	H5945_008_0	7	1	1111	4	2	2	3		4	2	2	4		4	2	2	3		4	2	1	3		1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		2																		2	2
H5945	009	0	1	01	01	H5945_009_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H5945	013	0	1	01	01	H5945_013_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H5945	014	0	1	01	01	H5945_014_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H5945	016	0	1	01	01	H5945_016_0	6	1	1111	4	2	2	3		4	2	2	3		4	2	2	3		4	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		2																		2	2
H5945	017	0	1	01	01	H5945_017_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H5945	018	0	1	01	01	H5945_018_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H5945	020	0	1	01	01	H5945_020_0	5	1	1111	4	2	2	3		4	2	2	3		4	2	2	3		4	2	1	3		1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		2																		2	2
H5945	021	0	1	01	01	H5945_021_0	5	1	1111	4	2	2	3		4	2	2	3		4	2	2	3		4	2	1	3		1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		2																		2	2
H5945	027	0	1	01	01	H5945_027_0	6	1	1111	4	2	2	3		4	2	2	3		4	2	2	3		4	2	1	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		2																		2	2
H5945	801	0	1	01	01	H5945_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5945	802	0	1	01	01	H5945_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5945	804	0	1	01	01	H5945_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5945	805	0	1	01	01	H5945_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H5959	009	0	1	04	01	H5959_009_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												1	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							30	30	50	50	0	50	50	50	50	50	2		1	01000000	30.00	30.00															1	2
H5959	010	1	1	04	01	H5959_010_1	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												1	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							30	30	50	50	0	50	50	50	50	50	2		1	01000000	20.00	20.00															1	2
H5959	010	2	1	04	01	H5959_010_2	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												1	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							30	30	50	50	0	50	50	50	50	50	2		1	01000000	20.00	20.00															1	2
H5959	011	0	1	04	01	H5959_011_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												1	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							30	30	50	50	0	50	50	50	50	50	2		1	01000000	20.00	20.00															1	2
H5959	012	0	1	04	01	H5959_012_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												1	2	1	0000010																					2	2	2	3												1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H5959	013	1	1	04	01	H5959_013_1	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												1	2	1	0000010																					2	2	2	3												1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H5959	013	2	1	04	01	H5959_013_2	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												1	2	1	0000010																					2	2	2	3												1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H5959	014	1	1	04	01	H5959_014_1	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												1	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							30	30	50	50	0	50	50	50	50	50	2		1	01000000	30.00	30.00															1	2
H5959	014	2	1	04	01	H5959_014_2	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1500.00	3		2				2		2												2		2		2												1	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							30	30	50	50	0	50	50	50	50	50	2		1	01000000	30.00	30.00															1	2
H5959	015	0	1	04	01	H5959_015_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												1	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							30	30	50	50	0	50	50	50	50	50	2		1	01000000	30.00	30.00															1	2
H5959	016	0	1	04	01	H5959_016_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1500.00	3		2				2		2												2		2		2												1	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							30	30	50	50	0	50	50	50	50	50	2		1	01000000	30.00	30.00															1	2
H5959	018	0	1	04	01	H5959_018_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2500.00	3		2				2		2												2		2		2												1	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							20	20	20	20	0	20	20	20	20	20	2		1	01000000	30.00	30.00															1	2
H5959	801	0	1	04	01	H5959_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5959	807	0	1	04	01	H5959_807_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5959	808	0	1	04	01	H5959_808_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5959	809	0	1	04	01	H5959_809_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H5965	002	0	1	04	01	H5965_002_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1500.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5965	003	0	1	04	01	H5965_003_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	50.00	50.00															1	2
H5965	004	0	1	04	01	H5965_004_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5965	005	0	1	04	01	H5965_005_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1000.00	3		2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5969	002	0	1	01	01	H5969_002_0	3	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		1		1500.00	3		2				1		1	1111	20	20									2		2		2												2	2	1	0010000						2	1																													1		1				2					1	01010000	20	20			20	20											2		2																		2	2
H5969	003	0	1	01	01	H5969_003_0	3	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		1		1500.00	3		2				1		1	1111	20	20									2		2		2												2	2	1	0010000						2	1																													1		1				2					1	01010000	20	20			20	20											2		2																		2	2
H5970	001	0	1	04	01	H5970_001_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	1500.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1	2	2	1500.00	3		2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	35.00	35.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H5970	015	0	1	04	01	H5970_015_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5970	016	0	1	04	01	H5970_016_0	3	1	1111	4	2	3	1		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	2		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5970	018	0	1	04	01	H5970_018_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	40.00	40.00			0.00	0.00											1	2
H5970	020	0	1	04	01	H5970_020_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1	2	2	1000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5970	024	1	1	04	01	H5970_024_1	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	35.00	35.00			0.00	0.00											1	2
H5970	024	2	1	04	01	H5970_024_2	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	35.00	35.00			0.00	0.00											1	2
H5970	025	0	1	04	01	H5970_025_0	9	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1	2	2	1500.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5970	026	0	1	04	01	H5970_026_0	8	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H5970	027	0	1	04	01	H5970_027_0	9	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
H5970	801	0	1	04	01	H5970_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5970	802	0	1	04	01	H5970_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5970	805	0	2	04	01	H5970_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5970	806	0	2	04	01	H5970_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5970	816	0	1	04	01	H5970_816_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5970	817	0	1	04	01	H5970_817_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5970	818	0	1	04	01	H5970_818_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5970	819	0	1	04	01	H5970_819_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5970	822	0	1	04	01	H5970_822_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5970	823	0	1	04	01	H5970_823_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5970	828	0	1	04	01	H5970_828_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5970	829	0	1	04	01	H5970_829_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H5978	001	0	1	20	08	H5978_001_0	1																																																																																																																																																							
H5978	002	0	1	20	08	H5978_002_0	1																																																																																																																																																							
H5989	011	0	1	01	01	H5989_011_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Dental X-rays: 1 set per year	1		2500.00	3		2				2		2												2		2		2												1	2	1	1111111	2	2	1	6	Limits vary by procedure.	2	2	1	6	Limits vary by procedure.	2	2	1	6	Restorative Services: Limits vary by procedure, ranging from once every 24 months to once every 60 months per tooth.	2	2	1	6	Endodontics are limited to one surgery per tooth per lifetime.	2	2	1	6	Limits vary by procedure. Periodontic scaling and root planing is covered once every 24 months, per area.	2	2	1	6	Extractions are limited to one surgery per tooth per lifetime.	2	2	1	6	Prosthodontic limits vary by procedure. Dentures are limited to one set every 5 years. Crowns are limited to once every 5 years for each tooth.	1		1				2					2																		2		2																		1	2
H5991	010	0	1	01	01	H5991_010_0	11	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	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	1	1001111											2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2	2	1	6	Root Canal - 1 per tooth per lifetime	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantOsseous surgery – 1 every 60 months per quadrant	2	2	1	6	Soft tissue – 1 per lifetimeBony impacted – 1 per lifetime	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsComplete /partial Dentures - 1 per arch per 60 months	2						2					1	01000000	20	20															2		2																		1	2
H5991	012	1	1	01	01	H5991_012_1	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	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	1	1001111											2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2	2	1	6	Root Canal - 1 per tooth per lifetime	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantOsseous surgery – 1 every 60 months per quadrant	2	2	1	6	Soft tissue – 1 per lifetimeBony impacted – 1 per lifetime	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsComplete /partial Dentures - 1 per arch per 60 months	2						2					1	01000000	20	20															2		2																		1	2
H5991	012	2	1	01	01	H5991_012_2	11	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	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	1	1001111											2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2	2	1	6	Root Canal - 1 per tooth per lifetime	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantOsseous surgery – 1 every 60 months per quadrant	2	2	1	6	Soft tissue – 1 per lifetimeBony impacted – 1 per lifetime	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsComplete /partial Dentures - 1 per arch per 60 months	2						2					1	01000000	20	20															2		2																		1	2
H5992	007	0	1	01	01	H5992_007_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1050.00	3		2					1	01000000	20	20															2		2																		2	2
H5992	009	1	1	01	01	H5992_009_1	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1100.00	3		2					1	01000000	20	20															2		2																		2	2
H5992	009	2	1	01	01	H5992_009_2	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1100.00	3		2					1	01000000	20	20															2		2																		2	2
H5993	001	0	1	20	08	H5993_001_0	1	2																																																																																																																																																						
H5993	002	0	1	20	08	H5993_002_0	1	2																																																																																																																																																						
H5995	001	0	1	01	01	H5995_001_0	10	1	1111	2	1				2	1				2	1				2	1				1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H6018	001	0	1	04	01	H6018_001_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	5000.00	3		2					2																		2		1	01000000	30.00	30.00															1	2
H6018	002	0	1	04	01	H6018_002_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	7500.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H6018	003	0	1	04	01	H6018_003_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H6019	001	0	1	01	01	H6019_001_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6059	001	0	1	20	08	H6059_001_0	1																																																																																																																																																							
H6059	002	0	1	20	08	H6059_002_0	1																																																																																																																																																							
H6067	001	1	1	01	01	H6067_001_1	7	1	1111	2	2	1	6	Frequencies vary based on type of services from once a day to once per three years.	2	2	2	3		2	2	1	6	- TOPICAL APPLICATION OF FLUORIDE VARNISH, TOPICAL APPLICATION OF FLUORIDE—EXCLUDING VARNISH: only one of the codes twice a year	2	2	1	6	Frequencies vary based on type of services from once a day, up to six a day, one set a year, to once every three years.	2					2				2		2												2		1	1111	2				10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	2	2	2																																											2					2																		2		1	01000000	40.00	40.00															1	2
H6067	001	2	1	01	01	H6067_001_2	7	1	1111	2	2	1	6	Frequencies vary based on type of services from once a day to once per three years.	2	2	2	3		2	2	1	6	- TOPICAL APPLICATION OF FLUORIDE VARNISH, TOPICAL APPLICATION OF FLUORIDE—EXCLUDING VARNISH: only one of the codes twice a year	2	2	1	6	Frequencies vary based on type of services from once a day, up to six a day, one set a year, to once every three years.	2					2				2		2												2		1	1111	2				10.00	10.00	10.00	10.00	10.00	10.00	10.00	10.00	2	2	2																																											2					2																		2		1	01000000	40.00	40.00															1	2
H6067	002	1	1	01	01	H6067_002_1	7	1	1111	2	2	1	6	Frequencies vary based on type of services from once a day to once per three years.	2	2	2	3		2	2	1	6	- TOPICAL APPLICATION OF FLUORIDE VARNISH, TOPICAL APPLICATION OF FLUORIDE—EXCLUDING VARNISH: only one of the codes twice a year	2	2	1	6	Frequencies vary based on type of services from once a day, up to six a day, one set a year, to once every three years.	2					2				2		2												2		1	1111	2				5.00	5.00	5.00	5.00	5.00	5.00	5.00	5.00	2	2	1	1101111	2	2	1	6	Frequencies vary based on type of service from as needed, twice per year, to once per surface per lifetime.						2	2	1	6	Frequencies vary based on services from one surface per 12 months, once per tooth every 1 to 5 years, once every 12 months, once every 5 years, to as needed.	2	2	1	6	Frequencies vary by type of service from as needed to once per tooth per lifetime.	2	2	1	6	Frequencies vary from once every 24 or 36 months, once every 5 years, to twice per year.	2	2	1	6	Once per tooth per lifetime for each type of service.	2	2	1	6	Frequencies vary by type of service from once every 5 years, once every 12 months, once every 36 months, once per tooth per lifetime, to as needed.	1		2	800.00	3		2					2																		2		1	11101111	20.00	20.00	15.00	30.00			15.00	500.00	100.00	200.00	50.00	300.00	40.00	100.00	30.00	700.00	1	2
H6067	002	2	1	01	01	H6067_002_2	7	1	1111	2	2	1	6	Frequencies vary based on type of services from once a day to once per three years.	2	2	2	3		2	2	1	6	- TOPICAL APPLICATION OF FLUORIDE VARNISH, TOPICAL APPLICATION OF FLUORIDE—EXCLUDING VARNISH: only one of the codes twice a year	2	2	1	6	Frequencies vary based on type of services from once a day, up to six a day, one set a year, to once every three years.	2					2				2		2												2		1	1111	2				5.00	5.00	5.00	5.00	5.00	5.00	5.00	5.00	2	2	1	1101111	2	2	1	6	Frequencies vary based on type of service from as needed, twice per year, to once per surface per lifetime.						2	2	1	6	Frequencies vary based on services from one surface per 12 months, once per tooth every 1 to 5 years, once every 12 months, once every 5 years, to as needed.	2	2	1	6	Frequencies vary by type of service from as needed to once per tooth per lifetime.	2	2	1	6	Frequencies vary from once every 24 or 36 months, once every 5 years, to twice per year.	2	2	1	6	Once per tooth per lifetime for each type of service.	2	2	1	6	Frequencies vary by type of service from once every 5 years, once every 12 months, once every 36 months, once per tooth per lifetime, to as needed.	1		2	800.00	3		2					2																		2		1	11101111	20.00	20.00	15.00	30.00			15.00	500.00	100.00	200.00	50.00	300.00	40.00	100.00	30.00	700.00	1	2
H6067	801	0	1	01	01	H6067_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6067	802	0	1	01	01	H6067_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6067	803	0	1	01	01	H6067_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6067	804	0	1	01	01	H6067_804_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6078	801	0	1	04	01	H6078_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6078	802	0	1	04	01	H6078_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6078	803	0	1	04	01	H6078_803_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6078	804	0	1	04	01	H6078_804_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6078	805	0	2	04	01	H6078_805_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6078	806	0	2	04	01	H6078_806_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6079	001	0	1	20	08	H6079_001_0	1																																																																																																																																																							
H6079	002	0	1	20	08	H6079_002_0	1																																																																																																																																																							
H6080	001	0	1	48	05	H6080_001_0	15	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	The plan covers dental x-rays. Actual number and frequency of services may vary based on medical necessity.	2					2				2		2												2		2		2												1	2	1	1011111						2	2	999	6	As medically necessary	2	2	999	6	As medically necessary	2	2	999	6	As medically necessary	2	2	999	6	As medically necessary	2	2	999	6	As medically necessary	2	2	999	6	As medically necessary	2						2					2																		2		2																		1	2
H6130	801	0		07	02	H6130_801_0	1																																																																																																																																																							
H6130	802	0		07	02	H6130_802_0	1																																																																																																																																																							
H6130	803	0		07	02	H6130_803_0	1																																																																																																																																																							
H6130	804	0		07	02	H6130_804_0	1																																																																																																																																																							
H6130	805	0		07	02	H6130_805_0	1																																																																																																																																																							
H6130	806	0		07	02	H6130_806_0	1																																																																																																																																																							
H6130	807	0		07	02	H6130_807_0	1																																																																																																																																																							
H6130	808	0		07	02	H6130_808_0	1																																																																																																																																																							
H6130	809	0		07	02	H6130_809_0	1																																																																																																																																																							
H6130	810	0		07	02	H6130_810_0	1																																																																																																																																																							
H6130	811	0		07	02	H6130_811_0	1																																																																																																																																																							
H6130	812	0		07	02	H6130_812_0	1																																																																																																																																																							
H6130	813	0		07	02	H6130_813_0	1																																																																																																																																																							
H6130	814	0		07	02	H6130_814_0	1																																																																																																																																																							
H6130	815	0		07	02	H6130_815_0	1																																																																																																																																																							
H6147	001	0	1	20	08	H6147_001_0	1	2																																																																																																																																																						
H6147	002	0	1	20	08	H6147_002_0	1	2																																																																																																																																																						
H6154	001	0	1	02	01	H6154_001_0	6	1	1111	2	1				2	1				2	1				2	1				1		400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H6158	001	0	1	01	01	H6158_001_0	4	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	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	1	1001111											2	2	2	3		2	2	1	3		2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	2	1				2	2	2	6	Periodicities for covered services range from every year to every five years depending on the service.	1		1				2					1	10001111							20	20	20	20	20	20	20	20	20	20	2		1	01000000	30.00	30.00															2	2
H6158	003	0	1	01	01	H6158_003_0	3	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	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	1	1001111											2	2	2	3		2	2	1	3		2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	2	1				2	2	2	6	Periodicities for covered services range from every year to every five years depending on the service.	1		1				2					1	10001111							20	20	20	20	20	20	20	20	20	20	2		1	01000000	25.00	25.00															2	2
H6170	001	0	1	01	01	H6170_001_0	7	1	1111	2	2	2	6	See benefit notes.	2	2	2	6	See benefit notes.	2	2	2	3		2	2	1	6	See benefit notes.	1		3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	1	6	See benefit notes.	2	2	1	6	See benefit notes.	2	2	1	6	See benefit notes.	2	2	1	6	Extractions and coronectomy-20%, 1 per tooth/lifetime.	2	2	1	6	See benefit notes.	1		1				2					1	10001111							20	40	40	40	40	40	20	20	20	40	2		1	01000000	0.00	0.00															1	1
H6170	002	0	1	01	01	H6170_002_0	7	1	1111	2	2	2	6	See benefit notes.	2	2	2	6	See benefit notes.	2	2	2	3		2	2	1	6	See benefit notes.	1		3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	1	6	See benefit notes.	2	2	1	6	See benefit notes.	2	2	1	6	See benefit notes.	2	2	1	6	Extractions and coronectomy-20%, 1 per tooth/lifetime.	2	2	1	6	See benefit notes.	1		1				2					1	10001111							20	40	40	40	40	40	20	20	20	40	2		1	01000000	0.00	0.00															1	1
H6170	003	0	1	01	01	H6170_003_0	7	1	1111	2	2	2	6	See benefit notes.	2	2	2	6	See benefit notes.	2	2	2	3		2	2	1	6	See benefit notes.	1		3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	1	6	See benefit notes.	2	2	1	6	See benefit notes.	2	2	1	6	See benefit notes.	2	2	1	6	Extractions and coronectomy-20%, 1 per tooth/lifetime.	2	2	1	6	See benefit notes.	1		1				2					1	10001111							20	40	40	40	40	40	20	20	20	40	2		1	01000000	0.00	0.00															1	1
H6188	001	0	1	20	08	H6188_001_0	1																																																																																																																																																							
H6188	002	0	1	20	08	H6188_002_0	1																																																																																																																																																							
H6193	001	0	1	01	01	H6193_001_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6200	001	0	1	04	01	H6200_001_0	4	1	1111	2	2	2	6	Periodic, extensive oral and re-evaluation problem focused-two every calendar yearLimited oral-3 every calendar yearComprehensive oral and periodontal evaluation-1 every 3 years.	2	2	2	3		2	2	2	3		2	2	1	3		1	2	5000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H6200	002	0	1	04	01	H6200_002_0	4	1	1111	2	2	2	6	Periodic, extensive oral and re-evaluation problem focused-two every calendar yearLimited oral-3 every calendar yearComprehensive oral and periodontal evaluation-1 every 3 years.	2	2	2	3		2	2	2	3		2	2	1	3		1	2	7000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H6200	003	0	1	04	01	H6200_003_0	4	1	1111	2	2	2	6	Periodic, extensive oral and re-evaluation problem focused-two every calendar yearLimited oral-3 every calendar yearComprehensive oral and periodontal evaluation-1 every 3 years.	2	2	2	3		2	2	2	3		2	2	1	3		1	2	5000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H6200	004	0	1	04	01	H6200_004_0	4	1	1111	2	2	2	6	Periodic, extensive oral and re-evaluation problem focused-two every calendar yearLimited oral-3 every calendar yearComprehensive oral and periodontal evaluation-1 every 3 years.	2	2	2	3		2	2	2	3		2	2	1	3		1	2	5000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H6200	005	0	1	04	01	H6200_005_0	4	1	1111	2	2	2	6	Periodic, extensive oral and re-evaluation problem focused-two every calendar yearLimited oral-3 every calendar yearComprehensive oral and periodontal evaluation-1 every 3 years.	2	2	2	3		2	2	2	3		2	2	1	3		1	2	5000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H6200	006	0	1	04	01	H6200_006_0	4	1	1111	2	2	2	6	Periodic, extensive oral and re-evaluation problem focused-two every calendar yearLimited oral-3 every calendar yearComprehensive oral and periodontal evaluation-1 every 3 years.	2	2	2	3		2	2	2	3		2	2	1	3		1	2	7000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H6200	007	0	1	04	01	H6200_007_0	5	1	1111	2	2	2	6	Periodic, extensive oral and re-evaluation problem focused-two every calendar yearLimited oral-3 every calendar yearComprehensive oral and periodontal evaluation-1 every 3 years.	2	2	2	3		2	2	2	3		2	2	1	3		1	2	5000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H6200	801	0	1	04	01	H6200_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H6200	802	0	1	04	01	H6200_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H6200	803	0	1	04	01	H6200_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H6200	804	0	1	04	01	H6200_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H6202	001	0	1	04	01	H6202_001_0	13	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	750.00	3		2					1	10011111					25	25	25	25	25	25	25	25	25	25	25	25	2		1	01000000	40.00	40.00															2	2
H6202	002	0	1	04	01	H6202_002_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	1200.00	3		2					1	10011111					25	25	25	25	25	25	25	25	25	25	25	25	2		1	01000000	25.00	25.00															2	2
H6202	003	0	1	04	01	H6202_003_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	1000.00	3		2					1	10011111					25	25	25	25	25	25	25	25	25	25	25	25	2		1	01000000	25.00	25.00															2	2
H6202	801	0	1	04	01	H6202_801_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6202	802	0	1	04	01	H6202_802_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6202	803	0	1	04	01	H6202_803_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6202	804	0	1	04	01	H6202_804_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6231	001	0	1	20	08	H6231_001_0	1																																																																																																																																																							
H6231	002	0	1	20	08	H6231_002_0	1																																																																																																																																																							
H6237	006	0	1	01	01	H6237_006_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	25.00	25.00			0.00	0.00											2	2
H6237	007	1	1	01	01	H6237_007_1	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											2	2
H6237	007	3	1	01	01	H6237_007_3	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											2	2
H6237	007	4	1	01	01	H6237_007_4	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											2	2
H6237	008	1	1	01	01	H6237_008_1	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	25.00	25.00			0.00	0.00											2	2
H6237	008	3	1	01	01	H6237_008_3	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		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	1	1011111						2	2	1	1		2	2	2	3		2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	6	Periodicity varies by type of service	1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											2	2
H6248	001	0	1	01	01	H6248_001_0	7	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H6306	005	0	1	01	01	H6306_005_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		1		1	1111	0.00	30.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	425.00	0.00	425.00	0.00	425.00	20.00	350.00	15.00	375.00	15.00	375.00	126.00	425.00	20.00	425.00	1	1
H6306	013	0	1	02	01	H6306_013_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			30	50	50	50	30	50	50	50	50	50	50	50	50	50	2		1	11111111	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	2	2
H6306	014	0	1	02	01	H6306_014_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10111111			30	50	50	50	30	50	50	50	50	50	50	50	50	50	2		1	11111111	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	35.00	2	2
H6306	015	0	1	02	01	H6306_015_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	10101111			20	20			20	20	20	20	20	20	20	20	20	40	2		1	01000000	35.00	35.00															2	2
H6306	016	0	1	02	01	H6306_016_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															2	2
H6306	017	0	1	02	01	H6306_017_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															2	2
H6306	018	0	1	02	01	H6306_018_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															2	2
H6306	801	0	1	02	01	H6306_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6306	802	0	1	02	01	H6306_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6306	803	0	1	02	01	H6306_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6316	002	0	1	01	01	H6316_002_0	5	1	1111	2	1				2	1				2	1				2	1				1		5500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6317	001	0	1	20	08	H6317_001_0	1																																																																																																																																																							
H6317	002	0	1	20	08	H6317_002_0	1																																																																																																																																																							
H6322	001	0	1	01	01	H6322_001_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing: once/calendar year; Panoramic or full mouth (which include bitewing x-rays): once per 5 year period.  Bitewing not separately payable in same calendar year as full mouth.	1		1500.00	3		2				2		2												2		2		2												2	2	1	1001011						3					4	1				3					4	1				4	1				4	1				1		1				2					1	00001011							50	50			0	50	50	50			2		1	01000000	40.00	40.00															2	2
H6322	002	0	1	01	01	H6322_002_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing: once/calendar year; Panoramic or full mouth (which include bitewing x-rays): once per 5 year period.  Bitewing not separately payable in same calendar year as full mouth.	1		1500.00	3		2				2		2												2		2		2												2	2	1	1001011						3					4	1				3					4	1				4	1				4	1				1		1				2					1	00001011							50	50			0	50	50	50			2		1	01000000	30.00	30.00															2	2
H6322	003	1	1	02	01	H6322_003_1	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing: once/calendar year; Panoramic or full mouth (which include bitewing x-rays): once per 5 year period.  Bitewing not separately payable in same calendar year as full mouth.	1		1500.00	3		2				2		2												2		2		2												2	2	1	1001011						3					4	1				3					4	1				4	1				4	1				1		1				2					1	00001011							50	50			0	50	50	50			2		1	01000000	30.00	30.00															2	2
H6322	003	2	1	02	01	H6322_003_2	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing: once/calendar year; Panoramic or full mouth (which include bitewing x-rays): once per 5 year period.  Bitewing not separately payable in same calendar year as full mouth.	1		1500.00	3		2				2		2												2		2		2												2	2	1	1001011						3					4	1				3					4	1				4	1				4	1				1		1				2					1	00001011							50	50			0	50	50	50			2		1	01000000	30.00	30.00															2	2
H6322	004	0	1	01	01	H6322_004_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Bitewing: once/calendar year; Panoramic or full mouth (which include bitewing x-rays): once per 5 year period.  Bitewing not separately payable in same calendar year as full mouth.	1		1000.00	3		2				2		2												2		2		2												2	2	1	1011011						2	1				2	1									2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H6328	001	0	1	04	01	H6328_001_0	11	1	1111	2	2	2	6	See notes for detail.	2	2	2	6	See notes for detail	2	2	2	6	Topical application of fluoride varnish, topical fluoride-2 every 12 months.	2	2	1	6	See notes for detail.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Service dependent. See notes for detail.	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail.	1		1				2					2																		2		2																		1	2
H6328	002	0	1	04	01	H6328_002_0	11	1	1111	2	2	2	6	See notes for detail.	2	2	2	6	See notes for detail	2	2	2	6	Topical application of fluoride varnish, topical fluoride-2 every 12 months.	2	2	1	6	See notes for detail	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Service dependent. See notes for detail.	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail.	1		1				2					2																		2		2																		1	2
H6328	003	0	1	04	01	H6328_003_0	11	1	1111	2	2	2	6	See notes for detail.	2	2	2	6	See notes for detail	2	2	2	6	Topical application of fluoride varnish, topical fluoride-2 every 12 months.	2	2	1	6	See notes for detail.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Service dependent. See notes for detail.	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail.	1		1				2					2																		2		2																		1	2
H6328	005	0	1	04	01	H6328_005_0	5	1	1111	2	2	2	3		2	2	2	6	See notes for detail.	2	2	2	6	Topical application of fluoride varnish, topical fluoride-2 every 12 months.	2	2	1	6	See notes for detail.	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Service dependent. See notes for detail.	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail	2	2	1	6	Service dependent. See notes for detail.	1		1				2					2																		2		2																		1	2
H6328	801	0	1	04	01	H6328_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6328	802	0	1	04	01	H6328_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6328	803	0	1	04	01	H6328_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6328	804	0	1	04	01	H6328_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6342	001	0	1	20	08	H6342_001_0	1																																																																																																																																																							
H6342	002	0	1	20	08	H6342_002_0	1																																																																																																																																																							
H6345	001	0	1	01	01	H6345_001_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6345	002	0	1	01	01	H6345_002_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6348	002	0	1	04	01	H6348_002_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime.  OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6348	005	0	1	04	01	H6348_005_0	15	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1	2	2	1500.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	40.00	40.00															1	2
H6348	006	0	1	04	01	H6348_006_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6348	007	0	1	04	01	H6348_007_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6351	001	0	1	01	01	H6351_001_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6351	004	0	1	01	01	H6351_004_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1110111	2	1				2	1									2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H6351	005	0	1	01	01	H6351_005_0	5	1	1110	2	1				2	1									2	1				1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H6371	001	0	1	20	08	H6371_001_0	1																																																																																																																																																							
H6371	002	0	1	20	08	H6371_002_0	1																																																																																																																																																							
H6378	001	0	1	01	01	H6378_001_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	4	6	1 every 5 years per member per year.	2					2				2		2												2		2		2												2	2	1	1101111	2	2	1	3							2	2	1	3		2	2	1	6	Varies by service, 1 per tooth per lifetime	2	2	1	6	Varies by service, 1 per 24 mo. per quadrant. Debridement once per year.	2	2	1	3		2	2	1	6	Periodicity varies by procedure	2						2					2																		2		2																		2	2
H6379	001	0	1	01	01	H6379_001_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					2																		2		2																		2	2
H6379	002	0	1	01	01	H6379_002_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					2																		2		1	01000000	30.00	30.00															2	2
H6396	005	0	1	01	01	H6396_005_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	3		1		6000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H6396	014	0	1	01	01	H6396_014_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	3		1		6000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H6396	015	0	1	01	01	H6396_015_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	3		1		6000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H6399	001	0	1	01	01	H6399_001_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6408	001	0	1	01	01	H6408_001_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	35.00	35.00			0.00	0.00											2	2
H6408	002	0	1	01	01	H6408_002_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011001						2	1				2	1														2	1									1		1				2					1	00001001							50	50					50	50			2		1	01010000	40.00	40.00			0.00	0.00											2	2
H6408	003	0	1	01	01	H6408_003_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	35.00	35.00			0.00	0.00											2	2
H6408	801	0	1	01	01	H6408_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6408	802	0	1	01	01	H6408_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6425	001	0	1	20	08	H6425_001_0	1																																																																																																																																																							
H6425	002	0	1	20	08	H6425_002_0	1																																																																																																																																																							
H6446	001	0	1	01	01	H6446_001_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6446	010	0	1	01	01	H6446_010_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	35.00	35.00															1	2
H6446	014	0	1	01	01	H6446_014_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6446	016	0	1	01	01	H6446_016_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6446	017	0	1	01	01	H6446_017_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	0.00	0.00															1	2
H6453	011	0	1	02	01	H6453_011_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6453	013	1	1	02	01	H6453_013_1	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6453	013	2	1	02	01	H6453_013_2	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6453	013	3	1	02	01	H6453_013_3	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6453	013	4	1	02	01	H6453_013_4	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6453	013	5	1	02	01	H6453_013_5	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6453	017	1	1	02	01	H6453_017_1	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	1		2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6453	017	2	1	02	01	H6453_017_2	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	1		2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6453	018	1	1	02	01	H6453_018_1	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6453	018	2	1	02	01	H6453_018_2	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6453	019	0	1	02	01	H6453_019_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	1		3800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6453	801	0	1	01	01	H6453_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6453	802	0	1	01	01	H6453_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6453	803	0	1	01	01	H6453_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6453	804	0	1	02	01	H6453_804_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6474	001	0	1	01	01	H6474_001_0	7	1	1111	2	2	2	6	See benefit notes.	2	2	2	6	See benefit notes.	2	2	2	3		2	2	1	6	See benefit notes.	1		3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	1	6	See benefit notes.	2	2	1	6	See benefit notes.	2	2	1	6	See benefit notes.	2	2	1	6	Extractions and coronectomy-20%, 1 per tooth/lifetime.	2	2	1	6	See benefit notes.	1		1				2					1	10001111							20	40	40	40	40	40	20	20	20	40	2		1	01000000	0.00	0.00															1	1
H6474	002	0	1	01	01	H6474_002_0	7	1	1111	2	2	2	6	See benefit notes.	2	2	2	6	See benefit notes.	2	2	2	3		2	2	1	6	See benefit notes.	1		3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	1	6	See benefit notes.	2	2	1	6	See benefit notes.	2	2	1	6	See benefit notes.	2	2	1	6	Extractions and coronectomy-20%, 1 per tooth/lifetime.	2	2	1	6	See benefit notes.	1		1				2					1	10001111							20	40	40	40	40	40	20	20	20	40	2		1	01000000	0.00	0.00															1	1
H6474	003	0	1	01	01	H6474_003_0	7	1	1111	2	2	2	6	See benefit notes.	2	2	2	6	See benefit notes.	2	2	2	3		2	2	1	6	See benefit notes.	1		3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1001111											2	2	1	6	See benefit notes.	2	2	1	6	See benefit notes.	2	2	1	6	See benefit notes.	2	2	1	6	Extractions and coronectomy-20%, 1 per tooth/lifetime.	2	2	1	6	See benefit notes.	1		1				2					1	10001111							20	40	40	40	40	40	20	20	20	40	2		1	01000000	0.00	0.00															1	1
H6502	002	0	1	04	01	H6502_002_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	0111111	2	1				2	1				2	1				2	1				2	1				2	1									1		1				2					1	00111111			50	50	50	50	50	50	50	50	50	50	50	50			2		1	01000000	30.00	30.00															1	2
H6502	003	0	1	04	01	H6502_003_0	4	1	1111	4	1				4	1				4	1				4	1				1	2	1000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6502	004	0	1	04	01	H6502_004_0	7	1	1111	4	1				4	1				4	1				4	1				1	2	2500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6502	005	0	1	04	01	H6502_005_0	7	2																																																															2																																											2					2																		2		1	01000000	30.00	30.00															2	2
H6502	801	0	1	04	01	H6502_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6502	802	0	1	04	01	H6502_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6502	803	0	1	04	01	H6502_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6502	804	0	1	04	01	H6502_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6526	001	0	1	02	01	H6526_001_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H6526	002	0	1	02	01	H6526_002_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H6529	001	1	1	01	01	H6529_001_1	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H6529	001	2	1	01	01	H6529_001_2	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H6529	002	0	1	01	01	H6529_002_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H6541	001	0	1	20	08	H6541_001_0	1																																																																																																																																																							
H6541	002	0	1	20	08	H6541_002_0	1																																																																																																																																																							
H6545	001	0	1	04	01	H6545_001_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	7500.00	3		2					2																		2		1	01000000	20.00	20.00															1	2
H6550	003	0	1	01	01	H6550_003_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6550	004	0	1	01	01	H6550_004_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	every 12 to 84 months per tooth.	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	5000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6550	006	0	1	01	01	H6550_006_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth.	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6550	007	0	1	01	01	H6550_007_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	50.00	50.00															1	2
H6550	009	0	1	01	01	H6550_009_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 months.Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6551	001	0	1	20	08	H6551_001_0	2																																																																																																																																																							
H6551	002	0	1	20	08	H6551_002_0	2																																																																																																																																																							
H6586	001	0	1	04	01	H6586_001_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	7500.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H6586	002	0	1	04	01	H6586_002_0	12	1	1111	2	1				2	1				2	1				2	1				1	2	1750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H6586	003	0	1	04	01	H6586_003_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	5000.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H6586	005	0	1	04	01	H6586_005_0	7	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H6586	006	0	1	04	01	H6586_006_0	10	1	1111	2	1				2	1				2	1				2	1				1	2	250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H6594	001	0	1	04	01	H6594_001_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6594	002	0	1	04	01	H6594_002_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H6594	003	0	1	04	01	H6594_003_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6594	004	0	1	04	01	H6594_004_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6595	003	0	1	02	01	H6595_003_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H6595	004	0	1	02	01	H6595_004_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6596	001	0	1	20	08	H6596_001_0	1																																																																																																																																																							
H6596	002	0	1	20	08	H6596_002_0	1																																																																																																																																																							
H6605	001	0	1	04	01	H6605_001_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H6605	002	0	1	04	01	H6605_002_0	14	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	50.00	50.00															1	2
H6605	003	0	1	04	01	H6605_003_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	40.00	40.00															1	2
H6605	004	0	1	04	01	H6605_004_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	45.00	45.00															1	2
H6622	001	0	1	01	01	H6622_001_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Include amalgam and/or composite filling unlimited/year, crown/other restorative svc-core buildup and prefabricated post and core up to 1/tooth per lifetime, crown recementation 1/every 5 yrs.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Include adjustments to dentures, rebase, reline, repair, tissue conditioning up to 1/ year, complete and partial dentures up to 1/5 years, occlusal adjustment up to 1/3 years, oral surgery up to 2/yr	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	004	0	1	01	01	H6622_004_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	007	0	1	01	01	H6622_007_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative srvc incl amalgam and/or composite filling unlimited/yr, bridge/crown recementation 1/ 5 yrs, crown/other restorative services - core buildup, prefab post and core 1/tooth/lifetime	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	srvc incl adj to dentures, denture rebase/reline/repair, tissue conditioning 1/yr, bridges-crown 2/ 5 yrs, bridges-pontic, complete and prtl dentures 1/ 5 yrs, occlusal adj 1/ 3 yrs, oral surgery 2/yr	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	008	0	1	01	01	H6622_008_0	8	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	010	0	1	02	01	H6622_010_0	5	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	013	0	1	02	01	H6622_013_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Amalgam and/or composite filling unlimited/ year, bridge + crown recementation 1/ 5 years, crown and other restorative services - core buildup and prefabricated post and core 1/ tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	014	0	1	02	01	H6622_014_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	amalgam/composite filling unlimited/ year, bridge + crown recementation 1/ 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	015	0	1	01	01	H6622_015_0	5	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	017	0	1	01	01	H6622_017_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	45.00	45.00			0.00	0.00	25.00	25.00									1	2
H6622	018	0	1	01	01	H6622_018_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	019	0	1	01	01	H6622_019_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	20.00	20.00			0.00	0.00	25.00	25.00									1	2
H6622	021	1	1	02	01	H6622_021_1	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Include fillings $25 up to unlimited year, recementation of crown and bridges $25 up to 1 every 5 years, crown and other restorative services 50% up to 1 per tooth per lifetime.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges-crown up to 2/5 yrs, bridges-pontic up to 1/5 yrs, occlusal adjustment up to 1/3 yrs, oral surgery up to 2 per yr	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	45.00	45.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H6622	021	2	1	02	01	H6622_021_2	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	022	0	1	02	01	H6622_022_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.  Combined max benefit coverage applies to both IN/OON	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative srvc: amalgam and/or composite filling unlimited/year, bridge/crown recementation up to 1 every 5 years, crown/other services-core buildup, prefab post, core up to 1/ tooth/ lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Prosthodontics, Other oral services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	023	0	1	02	01	H6622_023_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years. The combined maximum benefit coverage applies to both	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	See notes section below.	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	4	6	See notes section below.	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	025	0	1	02	01	H6622_025_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	026	0	1	02	01	H6622_026_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	027	0	1	02	01	H6622_027_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	028	0	1	01	01	H6622_028_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	20.00	20.00			0.00	0.00											1	1
H6622	029	0	1	01	01	H6622_029_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	6	6	amalgam and/or composite filling up to 2/yr, bridge/crown recementation up to 1/5 yrs, crown & other restorative services- core buildup and prefabricated post & core up to 1/tooth/lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	2	2	3		4	2	6	6	bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	0.00	0.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	1
H6622	030	0	1	01	01	H6622_030_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	0.00	0.00			0.00	0.00											1	1
H6622	032	0	1	01	01	H6622_032_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	033	0	1	01	01	H6622_033_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	035	0	1	01	01	H6622_035_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	036	0	1	01	01	H6622_036_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	037	0	1	01	01	H6622_037_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	047	0	1	01	01	H6622_047_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	048	0	1	01	01	H6622_048_0	5	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	051	0	1	01	01	H6622_051_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	052	0	1	01	01	H6622_052_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	35.00	35.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H6622	054	0	1	01	01	H6622_054_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		3000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings $25 unlimited per year, bridge and crown recementation $25 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 50% 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	30.00	30.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
H6622	055	0	1	01	01	H6622_055_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	6	Scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years	3					3					1		1				2					2																		2		1	01011010	35.00	35.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
H6622	056	0	1	01	01	H6622_056_0	5	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H6622	057	0	1	02	01	H6622_057_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	060	0	1	02	01	H6622_060_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	061	0	1	02	01	H6622_061_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	063	0	1	01	01	H6622_063_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					1	00010000					0	0											2		1	01001010	20.00	20.00					25.00	25.00			25.00	25.00					1	2
H6622	066	0	1	01	01	H6622_066_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Fillings unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	4	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	071	0	1	01	01	H6622_071_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include partial dentures and complete dentures etc	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	073	0	1	02	01	H6622_073_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	partial/complete dentures 1 every 5 years. oral surgery 2/ year. denture adjustment, denture reline, denture repair, tissue conditioning 1/year. occlusal adj 1 every 3 years	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	075	0	1	01	01	H6622_075_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	40.00	40.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
H6622	078	1	1	01	01	H6622_078_1	8	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	078	2	1	01	01	H6622_078_2	8	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	079	0	1	01	01	H6622_079_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings unlimited per year, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime, crown recementation 1 every 5 years.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adj., rebase, reline, repair, and tissue conditioning 1 per year, complete and partial dentures 1 set(s) every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H6622	081	0	1	01	01	H6622_081_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	082	0	1	01	01	H6622_082_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Amalgam/composite fillings unlimited per year, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime, crown recementation 1 every 5 years.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Denture adjustments, rebase, reline, repair/tissue conditioning 1 per yr, complete/partial denture 1/ 5 yrs, occlusal adjustment up to 1/ 3 yrs, oral surgery up to 2 per yr.	1		1				2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H6622	083	0	1	01	01	H6622_083_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	084	0	1	01	01	H6622_084_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	4	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics - Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	085	0	1	01	01	H6622_085_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	partial+complete dentures 1 / 5 years, denture adj, reline, repair, rebase, tissue conditioning up to 1/year, occlusal adjustments up to 1/ 3 years, oral surgery up to 2/ year, bridges up to 1/ 5 yrs	1		2	2000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	086	0	1	01	01	H6622_086_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime.	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	087	0	1	01	01	H6622_087_0	6	1	1111	2	2	2	6	Oral Exams services include emergency diagnostic exam up to 1 per year, periodic oral exam up to 2 per year.	2	2	2	6	Prophylaxis (cleaning) services include periodontal maintenance up to 4 per year, prophylaxis (cleaning) up to 2 per year.	2	2	2	3		2	2	1	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	1	6	Amalgam and/or composite filling - unlimited,Bridge & Crown recementation - 1 every 5 yrs, Crown & other restorative services (core buildup & prefabricated post & core) - 1 per tooth per lifetime	2	2	1	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	1	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	2	1				2	2	1	6	See Notes below	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	088	0	1	02	01	H6622_088_0	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6622	801	0	1	01	01	H6622_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H6622	802	0	1	01	01	H6622_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H6622	804	0	1	01	01	H6622_804_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H6622	805	0	1	01	01	H6622_805_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H6652	001	0	1	01	01	H6652_001_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6672	001	0	1	01	01	H6672_001_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	4000.00	3		2					1	01000000	20	20															2		2																		2	2
H6672	003	0	1	01	01	H6672_003_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					2																		2		1	01000000	30.00	30.00															2	2
H6672	005	0	1	01	01	H6672_005_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	3000.00	3		2					2																		2		1	01000000	40.00	40.00															2	2
H6678	003	0	1	01	01	H6678_003_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H6678	004	0	1	01	01	H6678_004_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	2000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	30.00	30.00															1	2
H6706	001	0	1	02	01	H6706_001_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H6713	001	0	1	04	01	H6713_001_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 Months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	30.00	30.00															1	2
H6713	002	0	1	04	01	H6713_002_0	21	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1	2	2	1000.00	3		2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6723	001	1	1	01	01	H6723_001_1	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		1500.00	3		2				2		2												2		2		2												2	2	1	0111111	4	1				4	1				4	1				4	1				4	1				4	1									1		1				2					1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		1	01000000	35.00	35.00															2	2
H6723	001	2	1	01	01	H6723_001_2	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3																2					2																		2		1	01000000	45.00	45.00															2	2
H6723	001	3	1	01	01	H6723_001_3	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		1500.00	3		2				2		2												2		2		2												2	2	1	0111111	4	1				4	1				4	1				4	1				4	1				4	1									1		1				2					1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		1	01000000	40.00	40.00															2	2
H6723	002	1	1	01	01	H6723_002_1	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3																2					2																		2		1	01000000	40.00	40.00															2	2
H6723	002	2	1	01	01	H6723_002_2	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3																2					2																		2		1	01000000	40.00	40.00															2	2
H6723	002	3	1	01	01	H6723_002_3	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3																2					2																		2		1	01000000	40.00	40.00															2	2
H6723	003	1	1	01	01	H6723_003_1	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	0111111	4	1				4	1				4	1				4	1				4	1				4	1									1		1				2					1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		1	01000000	25.00	25.00															2	2
H6723	003	2	1	01	01	H6723_003_2	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3																2					2																		2		1	01000000	25.00	25.00															2	2
H6723	003	3	1	01	01	H6723_003_3	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3																2					2																		2		1	01000000	25.00	25.00															2	2
H6723	005	1	1	01	01	H6723_005_1	10	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		1500.00	3		2				2		2												2		2		2												2	2	1	0111111	4	1				4	1				4	1				4	1				4	1				4	1									1		1				2					1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		1	01000000	20.00	20.00															2	2
H6723	005	2	1	01	01	H6723_005_2	10	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		500.00	3		2				2		2												2		2		2												2	2	1	0111111	4	1				4	1				4	1				4	1				4	1				4	1									1		1				2					1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		1	01000000	30.00	30.00															2	2
H6723	006	6	1	01	01	H6723_006_6	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				2	1				1		1				2					1	10111111			30	30	30	30	30	30	50	50	50	50	30	30	50	50	2		2																		2	2
H6723	006	7	1	01	01	H6723_006_7	12	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	0111111	4	1				4	1				4	1				4	1				4	1				4	1									1		1				2					1	00111111			30	30	30	30	30	30	50	50	50	50	30	30			2		1	01000000	35.00	35.00															2	2
H6723	801	0	1	01	01	H6723_801_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6723	802	0	1	01	01	H6723_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6723	803	0	1	01	01	H6723_803_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6727	001	0	1	04	01	H6727_001_0	6	1	1111	2	2	2	6	Periodic oral evaluation-two every calendar yearLimited oral-As needed for diagnosis in emergency situationsComprehensive oral -two every calendar year	2	2	2	3		2	2	2	3		2	2	1	3		1	2	1500.00	3		2				1	1000	2										0	50	2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							50	70	50	50	0	50	50	50	0	50	2		1	01000000	45.00	45.00															1	2
H6727	801	0	1	04	01	H6727_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H6727	802	0	1	04	01	H6727_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H6727	803	0	1	04	01	H6727_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H6727	804	0	1	04	01	H6727_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H6743	001	0	1	04	01	H6743_001_0	12	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															2	2
H6743	007	0	1	04	01	H6743_007_0	11	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H6743	023	1	1	04	01	H6743_023_1	9	1	1111	2	1				2	1				2	1				2	1				1	2	1750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															2	2
H6743	023	3	1	04	01	H6743_023_3	12	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H6743	024	1	1	04	01	H6743_024_1	10	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															2	2
H6743	024	3	1	04	01	H6743_024_3	9	1	1111	2	1				2	1				2	1				2	1				1	2	750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															2	2
H6743	025	0	1	04	01	H6743_025_0	9	1	1111	2	1				2	1				2	1				2	1				1	2	1750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H6743	026	0	1	04	01	H6743_026_0	9	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H6743	027	0	1	04	01	H6743_027_0	11	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															2	2
H6750	005	0	1	01	01	H6750_005_0	7	1	1111	2	1				2	1				2	1				2	1				1		1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6750	012	1	1	01	01	H6750_012_1	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6750	012	2	1	01	01	H6750_012_2	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6750	013	0	1	01	01	H6750_013_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6750	014	0	1	02	01	H6750_014_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H6750	807	0	1	01	01	H6750_807_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6750	808	0	1	01	01	H6750_808_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6750	809	0	1	01	01	H6750_809_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6750	810	0	1	01	01	H6750_810_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6750	811	0	1	02	01	H6750_811_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6750	812	0	1	02	01	H6750_812_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6750	813	0	1	02	01	H6750_813_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6750	814	0	1	02	01	H6750_814_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6759	001	0	1	20	08	H6759_001_0	2																																																																																																																																																							
H6759	002	0	1	20	08	H6759_002_0	2																																																																																																																																																							
H6765	001	0	1	01	01	H6765_001_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6776	001	0	1	01	01	H6776_001_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6776	002	0	1	01	01	H6776_002_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6787	001	0	1	20	08	H6787_001_0	1																																																																																																																																																							
H6787	002	0	1	20	08	H6787_002_0	1																																																																																																																																																							
H6813	001	0	1	04	01	H6813_001_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies.  For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H6813	002	0	1	04	01	H6813_002_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies.  For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	4000.00	3		2					2																		2		1	01000000	40.00	40.00															1	2
H6815	037	0	1	01	01	H6815_037_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1500.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6815	038	0	1	01	01	H6815_038_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	45.00	45.00															1	2
H6815	039	0	1	01	01	H6815_039_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1500.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	45.00	45.00															1	2
H6830	001	0	1	04	01	H6830_001_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	35.00	35.00															1	2
H6832	001	0	1	01	01	H6832_001_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		2	3000.00	3		2					1	01000000	20	20															2		2																		1	2
H6832	002	0	1	01	01	H6832_002_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		2	2000.00	3		2					1	01000000	20	20															2		2																		1	2
H6832	003	0	1	02	01	H6832_003_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is a covered benefit every year.One panoramic radiograph or One complete series is a covered benefit once every three years.Continued in notes.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		2	2000.00	3		2					1	01000000	20	20															2		2																		1	2
H6846	001	0	1	20	08	H6846_001_0	1																																																																																																																																																							
H6846	002	0	1	20	08	H6846_002_0	1																																																																																																																																																							
H6847	001	0	1	02	01	H6847_001_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	3		2	2	1	3		2	2	2	3		2	1				2	2	1	3		1		2	2000.00	3		2					2																		2		1	01000000	40.00	40.00															2	2
H6847	801	0	1	02	01	H6847_801_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6851	001	0	1	01	01	H6851_001_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1500.00	3		2					1	01000000	20	20															2		2																		2	2
H6851	002	0	1	01	01	H6851_002_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1500.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	30.00	30.00															2	2
H6851	003	0	1	01	01	H6851_003_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	2500.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	25.00	25.00															2	2
H6851	004	0	1	01	01	H6851_004_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	2	2																																											2					2																		2		1	01000000	50.00	50.00															2	2
H6852	001	0	1	01	01	H6852_001_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	6500.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H6852	002	0	1	01	01	H6852_002_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	2500.00	3		2					2																		2		1	01000000	45.00	45.00															1	2
H6868	001	0	1	20	08	H6868_001_0	1	2																																																																																																																																																						
H6868	002	0	1	20	08	H6868_002_0	1	2																																																																																																																																																						
H6870	001	0	1	48	05	H6870_001_0	15	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H6874	001	0	1	04	01	H6874_001_0	13	1	1111	4	2	1	3		4	2	1	3		2	1				4	2	1	3		2					2				2		2												2		2		2												2	2	1	0000010	3					3					3					3					4	2	1	3		3					3					2						2					2																		2		2																		2	2
H6874	003	0	1	04	01	H6874_003_0	6	1	1111	4	2	1	3		4	2	1	3		2	1				4	2	1	3		2					2				2		2												2		2		2												2	2	1	0000010	3					3					3					3					4	2	1	3		3					3					2						2					2																		2		2																		2	2
H6876	001	0	1	04	01	H6876_001_0	12	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6876	002	0	1	04	01	H6876_002_0	11	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1	2	1500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6876	003	0	1	04	01	H6876_003_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6876	004	0	1	04	01	H6876_004_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1	2	1500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6876	005	0	1	04	01	H6876_005_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1	2	1500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6876	006	0	1	04	01	H6876_006_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1	2	2500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6876	801	0	1	04	01	H6876_801_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6876	802	0	1	04	01	H6876_802_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6876	803	0	1	04	01	H6876_803_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6876	804	0	1	04	01	H6876_804_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6887	001	0	1	20	08	H6887_001_0	1																																																																																																																																																							
H6887	002	0	1	20	08	H6887_002_0	1																																																																																																																																																							
H6891	001	0	1	01	01	H6891_001_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6898	001	0	1	04	01	H6898_001_0	9	1	1111	2	2	3	3		2	2	3	3		2	2	1	3		2	2	1	3		2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	1150.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	45.00	45.00															2	2
H6898	002	0	1	04	01	H6898_002_0	10	1	1111	2	2	3	3		2	2	3	3		2	2	1	3		2	2	1	3		2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	1500.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	30.00	30.00															2	2
H6898	003	0	1	04	01	H6898_003_0	7	1	1111	2	2	3	3		2	2	3	3		2	2	1	3		2	2	1	3		2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	1250.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	30.00	30.00															2	2
H6898	801	0	1	04	01	H6898_801_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6898	802	0	1	04	01	H6898_802_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6898	803	0	1	04	01	H6898_803_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6898	804	0	1	04	01	H6898_804_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6910	001	0	1	01	01	H6910_001_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	30.00	30.00			0.00	0.00											2	2
H6910	004	0	1	01	01	H6910_004_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	25.00	25.00			0.00	0.00											2	2
H6910	005	0	1	01	01	H6910_005_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011001						2	1				2	1														2	1									1		1				2					1	00001001							50	50					50	50			2		1	01010000	40.00	40.00			0.00	0.00											2	2
H6910	801	0	1	01	01	H6910_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6910	802	0	1	01	01	H6910_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H6941	001	0	1	20	08	H6941_001_0	1																																																																																																																																																							
H6941	002	0	1	20	08	H6941_002_0	1																																																																																																																																																							
H6959	001	0	1	01	01	H6959_001_0	6	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	6	Refer to the Notes for periodicity details.	1		970.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Refer to the Notes for periodicity details.	2	1				2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	2	2	1	6	Refer to the Notes for periodicity details.	1		1				2					1	01000000	20	20															2		2																		1	2
H6959	002	0	1	01	01	H6959_002_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H6975	002	0	1	01	01	H6975_002_0	20	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 months.Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6975	003	0	1	01	01	H6975_003_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6975	004	0	1	01	01	H6975_004_0	20	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 months.Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6975	005	0	1	01	01	H6975_005_0	20	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	15.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6975	007	0	1	01	01	H6975_007_0	20	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	5000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H6988	001	0	1	01	01	H6988_001_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Fillings limited to 1 per 24 months per tooth	2	2	1	6	Endodontics limited to 1 per lifetime per tooth	2	2	1	6	Gingivectomies limited to 1 per 36 months per quadrantPerio maintenance limited to 1 per 6 months	2	1				2	2	1	6	Crowns & Posts (1 per 60 mths per tooth)Scaling (1 per 6 mths per quadrant)Dentures (1 per 36 mths)Denture Repairs & Occlusal Guards (1 per 12 mths)Prosthodontic Services (1 per 36 mths per arch)	1		2	2000.00	3		2					2																		2		2																		2	2
H6988	002	0	1	01	01	H6988_002_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Fillings limited to 1 per 24 months per tooth	2	2	1	6	Endodontics limited to 1 per lifetime per tooth	2	2	1	6	Perio maintenance limited to 1 per 6 monthsGingivectomies limited to 1 per 36 months per quadrant	2	1				2	2	1	6	Crowns & Posts (1 per 60 mths per tooth)Scaling (1 per 6 mths per quadrant)Dentures (1 per 36 mths)Denture Repairs & Occlusal Guards (1 per 12 mths)Prosthodontic Services (1 per 36 mths per arch)	1		2	2000.00	3		2					2																		2		2																		2	2
H6988	003	0	1	01	01	H6988_003_0	10	1	1110	2	2	1	3		2	2	1	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2																																											2					2																		2		2																		2	2
H6988	004	0	1	01	01	H6988_004_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Fillings limited to 1 per 24 months per tooth	2	2	1	6	Endodontics limited to 1 per lifetime per tooth	2	2	1	6	Perio maintenance limited to 1 per 6 monthsGingivectomies limited to 1 per 36 months per quadrant	2	1				2	2	1	6	Crowns & Posts (1 per 60 mths per tooth)Scaling (1 per 6 mths per quadrant)Dentures (1 per 36 mths)Denture Repairs & Occlusal Guards (1 per 12 mths)Prosthodontic Services (1 per 36 mths per arch)	1		2	2000.00	3		2					2																		2		2																		2	2
H7003	001	0	1	20	08	H7003_001_0	1																																																																																																																																																							
H7003	002	0	1	20	08	H7003_002_0	1																																																																																																																																																							
H7006	003	0	1	04	01	H7006_003_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															2	2
H7006	007	0	1	04	01	H7006_007_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H7006	010	0	1	04	01	H7006_010_0	9	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H7006	011	0	1	04	01	H7006_011_0	13	1	1111	2	1				2	1				2	1				2	1				1	2	4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H7006	014	0	1	04	01	H7006_014_0	12	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H7006	015	0	1	04	01	H7006_015_0	12	1	1111	2	1				2	1				2	1				2	1				1	2	4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H7006	016	0	1	04	01	H7006_016_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H7006	017	0	1	04	01	H7006_017_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H7006	018	0	1	04	01	H7006_018_0	11	1	1111	2	1				2	1				2	1				2	1				1	2	4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H7006	019	0	1	04	01	H7006_019_0	11	1	1111	2	1				2	1				2	1				2	1				1	2	4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H7006	020	0	1	04	01	H7006_020_0	11	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H7006	021	0	1	04	01	H7006_021_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H7020	004	0	1	01	01	H7020_004_0	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H7020	005	0	1	01	01	H7020_005_0	5	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H7020	006	0	1	01	01	H7020_006_0	7	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H7020	008	0	1	01	01	H7020_008_0	7	1	1111	2	1				2	1				2	1				2	1				1		1300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7020	009	0	1	01	01	H7020_009_0	7	1	1111	2	1				2	1				2	1				2	1				1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7020	801	0	1	01	01	H7020_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7027	001	0	1	20	08	H7027_001_0	1	2																																																																																																																																																						
H7027	002	0	1	20	08	H7027_002_0	1	2																																																																																																																																																						
H7028	001	0	1	04	01	H7028_001_0	11	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H7028	002	0	1	04	01	H7028_002_0	11	1	1111	2	1				2	1				2	1				2	1				1	2	500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7063	001	0	1	04	01	H7063_001_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		1	2	1750.00	3		2				2		2												2		2		2												2	2	1	1001111											4	2	2	3		4	2	2	3		4	2	2	3		4	2	2	3		4	2	2	3		1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	40.00	40.00															2	2
H7063	006	0	1	04	01	H7063_006_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	45.00	45.00															2	2
H7063	007	0	1	04	01	H7063_007_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1001111											4	2	1	3		4	2	1	3		4	2	1	3		4	2	1	3		4	2	1	3		1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															2	2
H7063	012	0	1	04	01	H7063_012_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		1	2	1750.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	30.00	30.00															2	2
H7063	013	0	1	04	01	H7063_013_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		1		1				2					1	10001111							50	50	50	50	50	50	50	50	50	50	2		1	01000000	45.00	45.00															2	2
H7063	801	0	1	04	01	H7063_801_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7063	802	0	1	04	01	H7063_802_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7074	001	0	1	04	01	H7074_001_0	11	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				1	2	1000.00	3		2																		2		2																		2	2
H7074	801	0	1	04	01	H7074_801_0	2	2																																																															2																																											2					2																		2		2																		1	2
H7074	802	0	1	04	01	H7074_802_0	2	2																																																															2																																											2					2																		2		2																		1	2
H7074	803	0	1	04	01	H7074_803_0	2	2																																																															2																																											2					2																		2		2																		1	2
H7074	804	0	1	04	01	H7074_804_0	2	2																																																															2																																											2					2																		2		2																		1	2
H7093	001	0	1	04	01	H7093_001_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7093	002	0	1	04	01	H7093_002_0	8	1	1111	4	1				4	1				4	1				4	1				1	2	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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					1	10101111			50	50			50	50	70	70	70	70	50	50	70	70	2		1	01010000	0.00	0.00			0.00	0.00											1	2
H7114	001	0	1	20	08	H7114_001_0	1																																																																																																																																																							
H7114	002	0	1	20	08	H7114_002_0	1																																																																																																																																																							
H7115	001	0	1	01	01	H7115_001_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		1		3000.00	3		2				1	1111	2				0	20	0	20	0	20	0	20	2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	6	See notes	2	2	1	6	See notes	2	2	1	6	See notes	2	1				2	2	1	6	See notes	1		1				2					1	10111111			0	50	0	20	50	50	50	50	50	50	50	50	0	50	2		1	11001111	20.00	20.00					8.00	200.00	9.00	331.00	5.00	183.00	22.00	94.00	4.00	1027.00	2	2
H7115	004	0	1	01	01	H7115_004_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		1		2500.00	3		2				1	1111	2				0	20	0	20	0	20	0	20	2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	6	see notes	2	2	1	6	see notes	2	2	1	6	see notes	2	1				2	2	1	6	see notes	1		1				2					1	10111111			0	50	0	20	50	50	50	50	50	50	50	50	0	50	2		1	11001111	20.00	20.00					8.00	200.00	9.00	331.00	5.00	183.00	22.00	94.00	4.00	1027.00	2	2
H7115	005	0	1	01	01	H7115_005_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	6	see notes	2	2	1	6	see notes	2	2	1	6	see notes	2	1				2	2	1	6	see notes	1		1				2					1	01000000	20	20															2		2																		2	2
H7115	006	0	1	01	01	H7115_006_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		1		2000.00	3		2				1	1111	2				0	20	0	20	0	20	0	20	2		2		2												2	2	1	1111111	2	1				2	1				2	2	1	6	see notes	2	2	1	6	see notes	2	2	1	6	see notes	2	1				2	2	1	6	see notes	1		1				2					1	10111111			0	50	0	20	50	50	50	50	50	50	50	50	0	50	2		1	11001111	30.00	30.00					8.00	200.00	9.00	331.00	5.00	183.00	22.00	94.00	4.00	1027.00	2	2
H7115	805	0	1	01	01	H7115_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7115	806	0	1	01	01	H7115_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7115	807	0	1	01	01	H7115_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7123	001	0	1	01	01	H7123_001_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	4000.00	3		2					1	01000000	20	20															2		2																		2	2
H7147	001	0	1	02	01	H7147_001_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3000.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H7147	003	0	1	02	01	H7147_003_0	12	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	5000.00	3		2					2																		2		2																		1	2
H7147	004	0	1	02	01	H7147_004_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	4000.00	3		2					2																		2		1	01000000	20.00	20.00															1	2
H7147	005	0	1	02	01	H7147_005_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7147	007	0	1	02	01	H7147_007_0	12	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	5000.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H7149	001	0	1	02	01	H7149_001_0	7	1	1111	2	1				2	1				2	1				2	1				1		2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7149	006	0	1	01	01	H7149_006_0	6	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7149	007	0	1	02	01	H7149_007_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7149	008	0	1	02	01	H7149_008_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7149	009	0	1	02	01	H7149_009_0	7	1	1111	2	1				2	1				2	1				2	1				1		2400.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7149	801	0	1	01	01	H7149_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7149	802	0	1	01	01	H7149_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7151	001	0	1	01	01	H7151_001_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	7500.00	3		2					2																		2		1	01000000	15.00	15.00															1	2
H7151	003	0	1	01	01	H7151_003_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7163	002	0	1	02	01	H7163_002_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or  1 full mouth x-ray every 3 years.	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H7163	003	0	1	02	01	H7163_003_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	1		3800.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H7163	004	0	1	02	01	H7163_004_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	1		2200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H7163	005	0	1	02	01	H7163_005_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	1 bitewing x-ray per year or 1 full mouth x-ray every 3 years.	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H7163	801	0	1	02	01	H7163_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7165	001	0	1	01	01	H7165_001_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2																																											2					2																		2		1	01000000	50.00	50.00															2	2
H7165	002	0	1	01	01	H7165_002_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2																																											2					2																		2		1	01000000	50.00	50.00															2	2
H7165	805	0	1	01	01	H7165_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7165	806	0	1	01	01	H7165_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7169	001	0	1	04	01	H7169_001_0	20	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months.	1	2	2	1000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7169	003	0	1	04	01	H7169_003_0	20	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS once per tooth	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7172	001	0	1	48	05	H7172_001_0	3	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	4		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		2																		1	2
H7175	001	0	1	04	01	H7175_001_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7175	002	0	1	04	01	H7175_002_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7175	003	0	1	04	01	H7175_003_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	25.00	25.00															1	2
H7175	004	0	1	04	01	H7175_004_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H7175	005	0	1	04	01	H7175_005_0	14	2																																																															2																																											2					2																		2		1	01000000	40.00	40.00															1	2
H7195	001	0	1	20	08	H7195_001_0	1																																																																																																																																																							
H7195	002	0	1	20	08	H7195_002_0	1																																																																																																																																																							
H7199	001	0	1	04	01	H7199_001_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	3000.00	3		2					2																		2		1	01000000	30.00	30.00															1	2
H7199	002	0	1	04	01	H7199_002_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	4000.00	3		2					2																		2		1	01000000	20.00	20.00															1	2
H7220	002	0	1	01	01	H7220_002_0	2	1	1110	2	2	2	3		2	2	2	3							2	2	2	6	Bitewing X-rays are payable twice per calendar year. Panoramic or full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period.	1		1000.00	3		2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	0011001						2	1				4	1				3					3					2	1				3					1		1				2					1	00011001					0	50	50	50					50	50			2		2																		2	2
H7220	004	0	1	02	01	H7220_004_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	2	6	Bitewing X-rays are payable twice per calendar year. Panoramic or full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period.	1		1000.00	3		2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	0011001						2	1				4	1				3					3					2	1				3					1		1				2					1	00011001					0	50	50	50					50	50			2		2																		2	2
H7220	009	1	1	01	01	H7220_009_1	3	1	1110	2	2	2	3		2	2	2	3							2	2	2	6	Bitewing X-rays are payable twice per calendar year. Panoramic or full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period.	1		1000.00	3		2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	0011001						2	1				4	1				3					3					2	1				3					1		1				2					1	00011001					0	50	50	50					50	50			2		2																		2	2
H7220	009	2	1	01	01	H7220_009_2	3	1	1110	2	2	2	3		2	2	2	3							2	2	2	6	Bitewing X-rays are payable twice per calendar year. Panoramic or full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period.	1		1000.00	3		2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	0011001						2	1				4	1				3					3					2	1				3					1		1				2					1	00011001					0	50	50	50					50	50			2		2																		2	2
H7220	009	3	1	01	01	H7220_009_3	3	1	1110	2	2	2	3		2	2	2	3							2	2	2	6	Bitewing X-rays are payable twice per calendar year. Panoramic or full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period.	1		1000.00	3		2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	0011001						2	1				4	1				3					3					2	1				3					1		1				2					1	00011001					0	50	50	50					50	50			2		2																		2	2
H7220	010	0	1	01	01	H7220_010_0	3	1	1110	2	2	2	3		2	2	2	3							2	2	2	6	Bitewing X-rays are payable twice per calendar year. Panoramic or full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period.	1		1000.00	3		2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	0011001						2	1				4	1				3					3					2	1				3					1		1				2					1	00011001					0	50	50	50					50	50			2		2																		2	2
H7220	011	0	1	02	01	H7220_011_0	3	1	1110	2	2	2	3		2	2	2	3							2	2	2	6	Bitewing X-rays are payable twice per calendar year. Panoramic or full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period.	1		1000.00	3		2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	0011001						2	1				4	1				3					3					2	1				3					1		1				2					1	00011001					0	50	50	50					50	50			2		2																		2	2
H7220	012	0	1	01	01	H7220_012_0	3	1	1110	2	2	2	3		2	2	2	3							2	2	2	6	Bitewing X-rays are payable twice per calendar year. Panoramic or full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period.	1		1000.00	3		2				1	1110	2				0	0	0	0			0	0	2		2		2												2	2	1	0011001						2	1				4	1				3					3					2	1				3					1		1				2					1	00011001					0	50	50	50					50	50			2		2																		2	2
H7220	806	0	1	02	01	H7220_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7220	807	0	1	02	01	H7220_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7220	808	0	1	01	01	H7220_808_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7220	809	0	1	01	01	H7220_809_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7245	001	0	1	01	01	H7245_001_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Bitewing x-rays covered once per year. Full mouth and panoramic film x-rays covered once every 60 months.	1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	2	1	6	One upper and/or lower complete denture every 7 years. One upper and/or lower partial denture every 7 years.	1		1				2					2																		1	25.00	1	01000000	45.00	45.00															2	2
H7245	002	0	1	01	01	H7245_002_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Bitewing x-rays covered once per year. Full mouth and panoramic film x-rays covered once every 60 months.	1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	2	1	6	One upper and/or lower complete denture every 7 years. One upper and/or lower partial denture every 7 years.	1		1				2					2																		1	25.00	1	01000000	30.00	30.00															2	2
H7245	005	0	1	01	01	H7245_005_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Bitewing x-rays covered once per year. Full mouth and panoramic film x-rays covered once every 60 months.	1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	2	1	6	One upper and/or lower complete denture every 7 years. One upper and/or lower partial denture every 7 years.	1		1				2					2																		1	25.00	1	01000000	30.00	30.00															2	2
H7262	001	0	1	20	08	H7262_001_0	2																																																																																																																																																							
H7262	002	0	1	20	08	H7262_002_0	2																																																																																																																																																							
H7273	001	0	1	04	01	H7273_001_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	6	every 12 months	2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3					3											2					2																		2		2																		1	1
H7273	002	0	1	04	01	H7273_002_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	6	Every 12 months	2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3					3											2					2																		2		2																		1	1
H7273	005	0	1	04	01	H7273_005_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	6	Every 12 months	2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3					3											2					2																		2		2																		1	1
H7284	001	0	1	04	01	H7284_001_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010						2	2	1	1		2	1									2	2	2	6	Periodontics include periodontal scaling and root planing up to 1 per quadrant every 3 years, and scaling for moderate inflammation up to 1 per year.											1		1				2					2																		2		1	01011010	20.00	20.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
H7284	003	0	1	04	01	H7284_003_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7284	006	0	1	04	01	H7284_006_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111011	2	1				2	1				2	1									2	1				2	1				2	1				1		1				2					2																		2		1	11111011	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7284	007	0	1	04	01	H7284_007_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7284	008	0	1	04	01	H7284_008_0	5	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	5	6	Restorative services include amalgam and/or composite filling up to unlimited per year, bridge recementation and crown recementation up to 1 every 5 years, crown and other restorative services - core	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	12	6	services include adjustments to dentures, denture rebase, denture reline, denture repair and tissue conditioning up to 1 per year, bridges-crown up to 2 every 5 years, bridges-pontic, complete denture	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7284	009	0	1	04	01	H7284_009_0	11	1	1111	2	1				2	1				2	1				2	1				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	1	1111011	2	1				2	1				2	1									2	1				2	1				2	1				1		1				2					2																		2		1	11111011	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00			0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7284	010	0	1	04	01	H7284_010_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	2	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	11	6	Adjustments to dentures, denture rebase, denture reline, denture repair and tissue conditioning 1 per year, complete/partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years.	1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7301	002	0	1	04	01	H7301_002_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7301	006	0	1	04	01	H7301_006_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1950.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7301	007	0	1	04	01	H7301_007_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7301	009	0	1	04	01	H7301_009_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7301	013	0	1	04	01	H7301_013_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	3750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7301	014	0	1	04	01	H7301_014_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7301	015	0	1	04	01	H7301_015_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7301	016	0	1	04	01	H7301_016_0	7	1	1110	2	2	4	3		2	2	2	3							2	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	2																																											2					2																		2		1	01000000	50.00	50.00															1	2
H7301	017	0	1	04	01	H7301_017_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1850.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7301	021	0	1	04	01	H7301_021_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7301	801	0	1	04	01	H7301_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7301	803	0	1	04	01	H7301_803_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7323	002	0	1	04	01	H7323_002_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7323	003	0	1	04	01	H7323_003_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7323	005	0	1	04	01	H7323_005_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7323	006	0	1	04	01	H7323_006_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	40.00	40.00	0.00	0.00	0.00	0.00											1	2
H7323	007	0	1	04	01	H7323_007_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															1	2
H7323	009	0	1	04	01	H7323_009_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7323	010	0	1	04	01	H7323_010_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															1	2
H7323	011	0	1	04	01	H7323_011_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	0.00	0.00	0.00	0.00	0.00	0.00											1	2
H7323	012	0	1	04	01	H7323_012_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	0.00	0.00	0.00	0.00	0.00	0.00											1	2
H7326	001	0	1	04	01	H7326_001_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7326	003	0	1	04	01	H7326_003_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H7326	006	0	1	04	01	H7326_006_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 months.Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7326	007	0	1	04	01	H7326_007_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7330	001	0	1	01	01	H7330_001_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		2500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7330	003	0	1	01	01	H7330_003_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		2500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7330	004	0	1	01	01	H7330_004_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7330	007	0	1	01	01	H7330_007_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	1	3		1		3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	2	1	3		2	2	1	3		1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7330	801	0	1	01	01	H7330_801_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7330	802	0	1	01	01	H7330_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7330	803	0	1	01	01	H7330_803_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7330	804	0	1	01	01	H7330_804_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7360	001	0	1	04	01	H7360_001_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1	2	2	1500.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	50.00	50.00															1	2
H7366	001	0	1	20	08	H7366_001_0	1																																																																																																																																																							
H7366	002	0	1	20	08	H7366_002_0	1																																																																																																																																																							
H7379	801	0	1	04	01	H7379_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7379	802	0	1	04	01	H7379_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7379	803	0	1	04	01	H7379_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7379	804	0	1	04	01	H7379_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7389	001	0	1	01	01	H7389_001_0	8	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	20.00	20.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H7389	002	0	1	01	01	H7389_002_0	8	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	25.00	25.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H7389	003	0	1	01	01	H7389_003_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	35.00	35.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H7389	004	0	1	01	01	H7389_004_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	40.00	40.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H7389	008	0	1	01	01	H7389_008_0	7	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H7389	009	0	1	01	01	H7389_009_0	8	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H7389	010	0	1	01	01	H7389_010_0	8	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H7389	011	0	1	01	01	H7389_011_0	8	1	1111	2	1				2	1				2	1				2	1				1		1300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H7399	001	0	1	01	01	H7399_001_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H7404	001	0	1	04	01	H7404_001_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H7404	002	0	1	04	01	H7404_002_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H7404	004	0	1	04	01	H7404_004_0	7	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H7404	005	0	1	04	01	H7404_005_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H7404	006	0	1	04	01	H7404_006_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H7404	011	0	1	04	01	H7404_011_0	4	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H7404	012	0	1	04	01	H7404_012_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H7404	014	0	1	04	01	H7404_014_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H7404	015	0	1	04	01	H7404_015_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H7404	018	0	1	04	01	H7404_018_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H7404	019	0	1	04	01	H7404_019_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H7404	020	0	1	04	01	H7404_020_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H7404	021	0	1	04	01	H7404_021_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H7404	022	0	1	04	01	H7404_022_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H7404	023	0	1	04	01	H7404_023_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H7404	024	0	1	04	01	H7404_024_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H7404	025	0	1	04	01	H7404_025_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H7419	001	0	1	48	05	H7419_001_0	2	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	2		2					2				2		2												2		2		2												1	2	1	1111111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		2						2					2																		2		2																		1	2
H7464	001	0	1	02	01	H7464_001_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7464	005	0	1	02	01	H7464_005_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7464	006	0	1	02	01	H7464_006_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7464	007	0	1	02	01	H7464_007_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7464	008	1	1	02	01	H7464_008_1	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7464	008	2	1	02	01	H7464_008_2	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7464	010	0	1	01	01	H7464_010_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7464	011	0	1	02	01	H7464_011_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H7464	012	0	1	02	01	H7464_012_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7464	013	0	1	02	01	H7464_013_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H7469	001	0	1	20	08	H7469_001_0	1																																																																																																																																																							
H7469	002	0	1	20	08	H7469_002_0	1																																																																																																																																																							
H7501	001	0	1	20	08	H7501_001_0	1																																																																																																																																																							
H7501	002	0	1	20	08	H7501_002_0	2																																																																																																																																																							
H7511	001	0	1	01	01	H7511_001_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Limit once every 5 years	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every two years.	1		2	2000.00	3		2					1	01000000	20	20															2		2																		2	2
H7511	002	0	1	01	01	H7511_002_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Limit once every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every two years.	1		2	2000.00	3		2					1	01000000	20	20															2		2																		2	2
H7512	801	0	1	04	01	H7512_801_0	12	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7518	001	0	1	04	01	H7518_001_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 months. Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7518	002	0	1	04	01	H7518_002_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1500.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7518	003	0	1	04	01	H7518_003_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	5000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7518	004	0	1	04	01	H7518_004_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 months. Other Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H7522	801	0	1	04	01	H7522_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7522	802	0	1	04	01	H7522_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7522	804	0	1	04	01	H7522_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7522	805	0	1	04	01	H7522_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7522	806	0	1	04	01	H7522_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7522	807	0	1	04	01	H7522_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7522	808	0	1	04	01	H7522_808_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7522	809	0	1	04	01	H7522_809_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7522	810	0	1	04	01	H7522_810_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7522	811	0	1	04	01	H7522_811_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7522	812	0	1	04	01	H7522_812_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7522	813	0	1	04	01	H7522_813_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7524	001	0	1	01	01	H7524_001_0	6	2																																																															1	1000100																2	1														2	1				2						2					1	01000000	20	20															2		2																		2	2
H7524	002	0	1	01	01	H7524_002_0	7	2																																																															1	1000100																2	1														2	1				2						2					1	01000000	20	20															2		2																		2	2
H7524	003	0	1	01	01	H7524_003_0	6	2																																																															1	1000100																2	1														2	1				2						2					1	01000000	20	20															2		2																		2	2
H7524	004	0	1	01	01	H7524_004_0	7	2																																																															1	1000100																2	1														2	1				2						2					1	01000000	20	20															2		2																		2	2
H7557	001	0	1	01	01	H7557_001_0	8	1	1111	2	1				2	1				2	1				2	1				1		10000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H7559	001	0	1	01	01	H7559_001_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1050.00	3		2					1	01000000	20	20															2		2																		2	2
H7559	002	0	1	01	01	H7559_002_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1050.00	3		2					2																		2		2																		2	2
H7559	003	0	1	01	01	H7559_003_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1050.00	3		2					2																		2		2																		2	2
H7598	003	0	1	01	01	H7598_003_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	2	1	0111111	2	1				2	1				2	1				2	1				2	1				2	1									1		2	1000.00	3		2					1	01000000	20	20															2		2																		1	2
H7605	001	0	1	01	01	H7605_001_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	5000.00	3		2					2																		2		1	01000000	20.00	20.00															1	2
H7605	002	0	1	01	01	H7605_002_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7605	003	0	1	01	01	H7605_003_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	5500.00	3		2					2																		2		1	01000000	15.00	15.00															1	2
H7605	004	0	1	01	01	H7605_004_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	5000.00	3		2					2																		2		1	01000000	15.00	15.00															1	2
H7605	005	0	1	01	01	H7605_005_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7605	006	0	1	01	01	H7605_006_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	4000.00	3		2					2																		2		1	01000000	15.00	15.00															1	2
H7605	007	0	1	01	01	H7605_007_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	5000.00	3		2					2																		2		1	01000000	15.00	15.00															1	2
H7605	008	0	1	01	01	H7605_008_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7605	009	0	1	01	01	H7605_009_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	5000.00	3		2					2																		2		1	01000000	20.00	20.00															1	2
H7605	010	0	1	01	01	H7605_010_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	5000.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H7607	002	1	1	01	01	H7607_002_1	15	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		600.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	002	2	1	01	01	H7607_002_2	15	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		600.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	002	3	1	01	01	H7607_002_3	15	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		600.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	002	4	1	01	01	H7607_002_4	15	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		600.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	002	5	1	01	01	H7607_002_5	15	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		600.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	007	1	1	01	01	H7607_007_1	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		300.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	007	2	1	01	01	H7607_007_2	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		300.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	007	3	1	01	01	H7607_007_3	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		300.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	007	4	1	01	01	H7607_007_4	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		300.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	007	5	1	01	01	H7607_007_5	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		300.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	008	1	1	01	01	H7607_008_1	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		200.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	008	2	1	01	01	H7607_008_2	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		200.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	008	3	1	01	01	H7607_008_3	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		200.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	008	4	1	01	01	H7607_008_4	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		200.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	008	5	1	01	01	H7607_008_5	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		200.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	011	1	1	01	01	H7607_011_1	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		575.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	011	2	1	01	01	H7607_011_2	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		575.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	011	4	1	01	01	H7607_011_4	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		575.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7607	011	5	1	01	01	H7607_011_5	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		575.00	5		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	1
H7617	801	0	1	04	01	H7617_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7617	802	0	1	04	01	H7617_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7617	803	0	2	04	01	H7617_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7617	804	0	2	04	01	H7617_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7617	805	0	1	04	01	H7617_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7617	806	0	1	04	01	H7617_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7617	807	0	1	04	01	H7617_807_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7617	808	0	1	04	01	H7617_808_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7617	811	0	1	04	01	H7617_811_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7617	812	0	1	04	01	H7617_812_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7617	817	0	1	04	01	H7617_817_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7617	818	0	1	04	01	H7617_818_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7619	001	0	1	20	08	H7619_001_0	2																																																																																																																																																							
H7619	002	0	1	20	08	H7619_002_0	2																																																																																																																																																							
H7621	002	0	1	01	01	H7621_002_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	0.00	0.00			0.00	0.00											1	1
H7621	003	0	1	01	01	H7621_003_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	0.00	0.00			0.00	0.00											1	1
H7646	001	0	1	02	01	H7646_001_0	5	1	1111	2	2	2	6	Periodic oral evaluation-two every calendar yearLimited oral-As needed for diagnosis in emergency situationsComprehensive oral -two every calendar year	2	2	2	3		2	2	2	3		2	2	1	6	Bitewing x-rays – 1 every calendar year Intraoral complete series, Panoramic radiographic image, – 1 every 3 calendar years	1		1000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							20	50	50	50	0	50	20	20	0	50	1	100.00	1	01000000	30.00	30.00															1	2
H7646	002	0	1	02	01	H7646_002_0	5	1	1111	2	2	2	6	Periodic oral evaluation-two every calendar yearLimited oral-As needed for diagnosis in emergency situationsComprehensive oral -two every calendar year	2	2	2	3		2	2	2	3		2	2	1	6	Bitewing x-rays – 1 every calendar year Intraoral complete series, Panoramic radiographic image, – 1 every 3 calendar years	1		1000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							20	50	50	50	0	50	20	20	0	50	1	100.00	1	01000000	30.00	30.00															1	2
H7646	004	0	1	02	01	H7646_004_0	5	1	1111	2	2	2	6	Periodic oral evaluation-two every calendar yearLimited oral-As needed for diagnosis in emergency situationsComprehensive oral -two every calendar year	2	2	2	3		2	2	2	3		2	2	1	6	Bitewing x-rays – 1 every calendar yearIntraoral complete series, Panoramic radiographic image, – 1 every 3 calendar years	1		2000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							0	50	50	50	0	50	20	20	0	50	1	100.00	1	01000000	30.00	30.00															1	2
H7646	005	0	1	02	01	H7646_005_0	5	1	1111	2	2	2	6	Periodic oral evaluation-two every calendar yearLimited oral-As needed for diagnosis in emergency situationsComprehensive oral -two every calendar year	2	2	2	3		2	2	2	3		2	2	1	6	Bitewing x-rays – 1 every calendar yearIntraoral complete series, Panoramic radiographic image, – 1 every 3 calendar years	1		2000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							0	50	50	50	0	50	20	20	0	50	1	100.00	1	01000000	30.00	30.00															1	2
H7646	007	0	1	02	01	H7646_007_0	5	1	1111	2	2	2	6	Periodic oral evaluation-two every calendar yearLimited oral-As needed for diagnosis in emergency situationsComprehensive oral -two every calendar year	2	2	2	3		2	2	2	3		2	2	1	6	Bitewing x-rays – 1 every calendar year Intraoral complete series, Panoramic radiographic image, – 1 every 3 calendar years	1		1000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							20	50	50	50	0	50	20	20	0	50	1	100.00	1	01000000	30.00	30.00															1	2
H7646	008	0	1	02	01	H7646_008_0	5	1	1111	2	2	2	6	Periodic oral evaluation-two every calendar yearLimited oral-As needed for diagnosis in emergency situationsComprehensive oral -two every calendar year	2	2	2	3		2	2	2	3		2	2	1	6	Bitewing x-rays – 1 every calendar yearIntraoral complete series, Panoramic radiographic image, – 1 every 3 calendar years	1		2000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	1				2	1				2	1				2	1				2	1				1		1				2					1	10001111							0	50	50	50	0	50	20	20	0	50	1	100.00	1	01000000	30.00	30.00															1	2
H7646	801	0	1	02	01	H7646_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7646	802	0	1	02	01	H7646_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7646	803	0	1	02	01	H7646_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7646	804	0	1	02	01	H7646_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7646	805	0	1	02	01	H7646_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7660	001	0	1	20	08	H7660_001_0	1																																																																																																																																																							
H7660	002	0	1	20	08	H7660_002_0	1																																																																																																																																																							
H7670	001	0	1	01	01	H7670_001_0	7	1	1111	2	2	2	6	Periodic oral evaluations are covered twice every 12 months.  Comprehensive oral exam is covered once every 36 months.	2	2	2	3		2	2	2	3		2	2	1	6	One vertical bitewing imaging and one panoramic imaging covered once every 36 mos. Intraoral occlucal imaging is covered twice every 24 mos. Intraoral-complete series is covered once every 36 mos.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	3		2	2	1	2		2	2	1	6	Basic and resin restorative services are covered at one per tooth, once in 24 months.	2	2	1	1		2	2	1	6	Extractions are covered once per tooth per lifetime.	2	2	1	6	Once per tooth per lifetime.	1		2	1500.00	3		2					2																		2		1	01000000	40.00	40.00															2	2
H7670	002	0	1	01	01	H7670_002_0	6	1	1111	2	2	2	6	Periodic oral evaluations are covered twice every 12 months.  Comprehensive oral exam is covered once every 36 months.	2	2	2	3		2	2	2	3		2	2	1	6	One vertical bitewing imaging and one panoramic imaging covered once every 36 mos. Intraoral occlucal imaging is covered twice every 24 mos. Intraoral-complete series is covered once every 36 mos.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	3		2	2	1	2		2	2	1	6	Basic and resin restorative services are covered at one per tooth, once in 24 months.	2	2	1	1		2	2	1	6	Extractions are covered once per tooth per lifetime.	2	2	1	6	Once per tooth per lifetime.	1		2	2000.00	3		2					2																		2		1	01000000	20.00	20.00															2	2
H7678	001	0	1	01	01	H7678_001_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1050.00	3		2					1	01000000	20	20															2		2																		2	2
H7678	004	0	1	01	01	H7678_004_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1050.00	3		2					2																		2		2																		2	2
H7678	005	0	1	01	01	H7678_005_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	1				2					2				2		2												2		2		2												2	2	1	1101101	2	1									2	1				2	1									2	1				2	1				1		2	1050.00	3		2					2																		2		1	01000000	40.00	40.00															2	2
H7680	001	0	1	01	01	H7680_001_0	7	1	1111	4	2	2	3		4	2	2	3		4	2	2	3		4	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		2																		2	2
H7680	002	0	1	01	01	H7680_002_0	8	1	1111	4	2	2	3		4	2	2	3		4	2	2	3		4	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		2																		2	2
H7680	007	0	1	01	01	H7680_007_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H7680	009	0	1	01	01	H7680_009_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H7680	011	0	1	01	01	H7680_011_0	6	1	1111	4	2	2	3		4	2	2	3		4	2	2	3		4	2	1	3		1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		2																		2	2
H7680	012	0	1	01	01	H7680_012_0	6	1	1111	4	2	2	3		4	2	2	3		4	2	2	3		4	2	1	3		1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		2																		2	2
H7680	014	0	1	01	01	H7680_014_0	7	1	1111	4	2	2	3		4	2	2	3		4	2	2	3		4	2	1	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		2																		2	2
H7680	801	0	1	01	01	H7680_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7746	001	0	1	01	01	H7746_001_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing: once/calendar year; Panoramic or full mouth (which include bitewing x-rays): once per 5 year period.  Bitewing not separately payable in same calendar year as full mouth.	1		1500.00	3		2				2		2												2		2		2												2	2	1	1001011						3					4	1				3					4	1				4	1				4	1				1		1				2					1	00001011							50	50			0	50	50	50			2		1	01000000	40.00	40.00															2	2
H7746	002	0	1	01	01	H7746_002_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing: once/calendar year; Panoramic or full mouth (which include bitewing x-rays): once per 5 year period.  Bitewing not separately payable in same calendar year as full mouth.	1		1500.00	3		2				2		2												2		2		2												2	2	1	1001011						3					4	1				3					4	1				4	1				4	1				1		1				2					1	00001011							50	50			0	50	50	50			2		1	01000000	40.00	40.00															2	2
H7746	003	0	1	02	01	H7746_003_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing: once/calendar year; Panoramic or full mouth (which include bitewing x-rays): once per 5 year period.  Bitewing not separately payable in same calendar year as full mouth.	1		1500.00	3		2				2		2												2		2		2												2	2	1	1001011						3					4	1				3					4	1				4	1				4	1				1		1				2					1	00001011							50	50			0	50	50	50			2		1	01000000	40.00	40.00															2	2
H7778	001	0	1	01	01	H7778_001_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H7779	001	0	1	01	01	H7779_001_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7787	001	0	1	04	01	H7787_001_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7787	002	0	1	04	01	H7787_002_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7787	801	0	1	04	01	H7787_801_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	802	0	1	04	01	H7787_802_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	803	0	1	04	01	H7787_803_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	804	0	1	04	01	H7787_804_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	805	0	1	04	01	H7787_805_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	806	0	1	04	01	H7787_806_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	807	0	1	04	01	H7787_807_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	808	0	1	04	01	H7787_808_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	809	0	1	04	01	H7787_809_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	810	0	1	04	01	H7787_810_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	811	0	1	04	01	H7787_811_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	812	0	1	04	01	H7787_812_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	813	0	1	04	01	H7787_813_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	814	0	1	04	01	H7787_814_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	815	0	1	04	01	H7787_815_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	816	0	1	04	01	H7787_816_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	817	0	1	04	01	H7787_817_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	818	0	1	04	01	H7787_818_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	819	0	1	04	01	H7787_819_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	820	0	1	04	01	H7787_820_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	821	0	1	04	01	H7787_821_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	822	0	1	04	01	H7787_822_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	823	0	1	04	01	H7787_823_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7787	824	0	1	04	01	H7787_824_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7813	001	0	1	01	01	H7813_001_0	5	2																																																															2																																											2					2																		2		2																		2	2
H7831	001	0	1	20	08	H7831_001_0	1																																																																																																																																																							
H7831	002	0	1	20	08	H7831_002_0	1																																																																																																																																																							
H7833	001	0	1	48	05	H7833_001_0	4	1	1110	2	2	1	3		2	2	1	3							2	2	1	6	Eligible members aged 21 years and older may receive preventive dental services once per calendar year, including routine exam and cleaning, and a full-mouth x-ray.	1		1000.00	3		2				2		2												2		2		2												2	2	2																																											2					2																		2		2																		2	2
H7844	001	0	1	48	05	H7844_001_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	6	6	Per lifetime.	2	2	1	6	Every 12months: Bitewing Radiographs Every 3yrs per arch (under age 21): Occlusal Radiograph Every 5yrs (over age 5): Panoramic Radiograph, Full mouth/Complete series everyday, with medical necessity.	2					2				2		2												2		2		2												2	2	1	1011011						2	1				2	1									2	2	1	3		2	2	999	6	Everyday, based on medical necessity	2	2	1	6	Prosthodontics(removable)-Once per 5yrs per arch when prognosis of complete/partial denture is at least 5yrs: Complete/partial dentures. Every day per medical need: Other Oral/Maxillofacial Surgery.	2						2					2																		2		2																		2	2
H7849	001	0	1	04	01	H7849_001_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	002	0	1	04	01	H7849_002_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	003	0	1	04	01	H7849_003_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	006	0	1	04	01	H7849_006_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	013	0	1	04	01	H7849_013_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	014	0	1	04	01	H7849_014_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	015	0	1	04	01	H7849_015_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	017	0	1	04	01	H7849_017_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	018	0	1	04	01	H7849_018_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H7849	020	0	1	04	01	H7849_020_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7849	021	0	1	04	01	H7849_021_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	022	0	1	04	01	H7849_022_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	023	0	1	04	01	H7849_023_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	024	0	1	04	01	H7849_024_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	026	0	1	04	01	H7849_026_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	027	0	1	04	01	H7849_027_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	029	0	1	04	01	H7849_029_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	030	0	1	04	01	H7849_030_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H7849	031	0	1	04	01	H7849_031_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7849	033	0	1	04	01	H7849_033_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	034	0	1	04	01	H7849_034_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	037	0	1	04	01	H7849_037_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7849	038	0	1	04	01	H7849_038_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	039	0	1	04	01	H7849_039_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2800.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	041	0	1	04	01	H7849_041_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	042	0	1	04	01	H7849_042_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H7849	044	0	1	04	01	H7849_044_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	045	0	1	04	01	H7849_045_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	047	0	1	04	01	H7849_047_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	048	0	1	04	01	H7849_048_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	050	0	1	04	01	H7849_050_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	051	0	1	04	01	H7849_051_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	052	0	1	04	01	H7849_052_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	054	0	1	04	01	H7849_054_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	055	0	1	04	01	H7849_055_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H7849	056	0	1	04	01	H7849_056_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1800.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	057	0	1	04	01	H7849_057_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7849	058	0	1	04	01	H7849_058_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7849	059	0	1	04	01	H7849_059_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7849	060	0	1	04	01	H7849_060_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	064	1	1	04	01	H7849_064_1	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	064	2	1	04	01	H7849_064_2	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	064	3	1	04	01	H7849_064_3	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	064	4	1	04	01	H7849_064_4	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	065	0	1	04	01	H7849_065_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	066	0	1	04	01	H7849_066_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7849	067	0	1	04	01	H7849_067_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	068	0	1	04	01	H7849_068_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	070	0	1	04	01	H7849_070_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	071	0	1	04	01	H7849_071_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H7849	072	0	1	04	01	H7849_072_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H7849	073	0	1	04	01	H7849_073_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	074	0	1	04	01	H7849_074_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	076	0	1	04	01	H7849_076_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H7849	077	0	1	04	01	H7849_077_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H7849	078	0	1	04	01	H7849_078_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7849	080	0	1	04	01	H7849_080_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H7849	081	0	1	04	01	H7849_081_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	800.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7849	082	0	1	04	01	H7849_082_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7849	083	0	1	04	01	H7849_083_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7849	084	0	1	04	01	H7849_084_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	085	0	1	04	01	H7849_085_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	086	0	1	04	01	H7849_086_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	087	0	1	04	01	H7849_087_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7849	088	0	1	04	01	H7849_088_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7849	089	0	1	04	01	H7849_089_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	101	0	1	04	01	H7849_101_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1800.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	102	1	1	04	01	H7849_102_1	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	102	2	1	04	01	H7849_102_2	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	102	3	1	04	01	H7849_102_3	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	102	4	1	04	01	H7849_102_4	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	103	0	1	04	01	H7849_103_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2800.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	104	0	1	04	01	H7849_104_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	105	0	1	04	01	H7849_105_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	106	0	1	04	01	H7849_106_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H7849	107	0	1	04	01	H7849_107_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H7849	108	0	1	04	01	H7849_108_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	109	0	1	04	01	H7849_109_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H7849	110	0	1	04	01	H7849_110_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7849	111	0	1	04	01	H7849_111_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	112	1	1	04	01	H7849_112_1	7	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	112	2	1	04	01	H7849_112_2	7	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	113	1	1	04	01	H7849_113_1	7	1	1111	2	1				2	1				2	1				2	1				1	2	1400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	113	2	1	04	01	H7849_113_2	7	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	113	3	1	04	01	H7849_113_3	7	1	1111	2	1				2	1				2	1				2	1				1	2	1400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	113	4	1	04	01	H7849_113_4	7	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	114	0	1	04	01	H7849_114_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	900.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H7849	115	0	1	04	01	H7849_115_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	116	0	1	04	01	H7849_116_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	117	1	1	04	01	H7849_117_1	7	1	1111	2	1				2	1				2	1				2	1				1	2	1400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H7849	117	2	1	04	01	H7849_117_2	7	1	1111	2	1				2	1				2	1				2	1				1	2	1400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H7849	118	0	1	04	01	H7849_118_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H7849	119	0	1	04	01	H7849_119_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H7849	120	0	1	04	01	H7849_120_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H7849	121	0	1	04	01	H7849_121_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H7849	122	0	1	04	01	H7849_122_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H7849	123	0	1	04	01	H7849_123_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	124	1	1	04	01	H7849_124_1	7	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H7849	124	2	1	04	01	H7849_124_2	7	1	1111	2	1				2	1				2	1				2	1				1	2	1400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H7849	125	0	1	04	01	H7849_125_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	126	0	1	04	01	H7849_126_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	127	0	1	04	01	H7849_127_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	128	0	1	04	01	H7849_128_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	129	0	1	04	01	H7849_129_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7849	130	0	1	04	01	H7849_130_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H7849	131	0	1	04	01	H7849_131_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	2300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H7849	132	0	1	04	01	H7849_132_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	2400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H7849	133	1	1	04	01	H7849_133_1	7	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	133	2	1	04	01	H7849_133_2	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	133	3	1	04	01	H7849_133_3	7	1	1111	2	1				2	1				2	1				2	1				1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	134	1	1	04	01	H7849_134_1	7	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	134	2	1	04	01	H7849_134_2	7	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7849	835	0	1	04	01	H7849_835_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7849	836	0	1	04	01	H7849_836_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H7855	001	0	1	20	08	H7855_001_0	1																																																																																																																																																							
H7855	002	0	1	20	08	H7855_002_0	1																																																																																																																																																							
H7917	009	0	1	04	01	H7917_009_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	4500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See Notes Below	2	2	1	6	Please see notes below	2	2	1	6	See notes below.	2	2	1	6	See Notes Below	2	1				2	2	1	6	See Notes Below	1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H7917	010	0	1	04	01	H7917_010_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	4500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See notes below.	2	2	1	6	Please see notes below	2	2	1	6	See notes below.	2	2	1	6	See Notes Below	2	1				2	2	1	6	See Notes Below	1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H7917	011	0	1	04	01	H7917_011_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	4500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See notes below.	2	2	1	6	Please see notes below	2	2	1	6	See notes below.	2	2	1	6	See Notes Below	2	1				2	2	1	6	See Notes Below	1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H7917	012	0	1	04	01	H7917_012_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See Note Below	2	2	1	6	See Note Below	2	2	1	6	See Note Below	2	2	1	6	See Note Below	2	1				2	2	1	6	See Note Below	1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H7917	013	0	1	04	01	H7917_013_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See Note Below	2	2	1	6	See Note Below	2	2	1	6	See Note Below	2	2	1	6	See Note Below	2	1				2	2	1	6	See Note Below	1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H7917	014	0	1	04	01	H7917_014_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	2750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See Note Below	2	2	1	6	See Note Below	2	2	1	6	See Note Below	2	2	1	6	See Note Below	2	1				2	2	1	6	See Note Below	1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H7917	015	0	1	04	01	H7917_015_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See Note Below	2	2	1	6	See Note Below	2	2	1	6	See Note Below	2	2	1	6	See Note Below	2	1				2	2	1	6	See Note Below	1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H7917	030	0	1	04	01	H7917_030_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	2750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See Notes Below	2	2	1	6	See Notes Below	2	2	1	6	See Notes Below	2	2	1	6	See Notes Below	2	1				2	2	1	6	See Notes Below	1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7917	031	0	1	04	01	H7917_031_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	3250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See Notes Below	2	2	1	6	See Notes Below	2	2	1	6	See Notes Below	2	2	1	6	See Notes Below	2	1				2	2	1	6	See Notes Below	1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7917	032	0	1	04	01	H7917_032_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	1				2	2	1	6	See notes below.	1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7917	033	0	1	04	01	H7917_033_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	1				2	2	1	6	See notes below.	1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7917	034	0	1	04	01	H7917_034_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	1				2	2	1	6	See notes below.	1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7917	035	0	1	04	01	H7917_035_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	1100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	1				2	2	1	6	See notes below.	1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7917	036	0	1	04	01	H7917_036_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	1				2	2	1	6	See notes below.	1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7917	037	0	1	04	01	H7917_037_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	2250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	1				2	2	1	6	See notes below.	1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H7917	038	0	1	04	01	H7917_038_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	2750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See Notes Below	2	2	1	6	See Notes Below	2	2	1	6	See Notes Below	2	2	1	6	See Notes Below	2	1				2	2	1	6	See Notes Below	1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7917	039	0	1	04	01	H7917_039_0	2	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	1				2	2	1	6	See notes below.	1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H7917	040	0	1	04	01	H7917_040_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	2750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See Notes Below	2	2	1	6	See Notes Below	2	2	1	6	See Notes Below	2	2	1	6	See Notes Below	2	1				2	2	1	6	See Notes Below	1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H7917	041	0	1	04	01	H7917_041_0	3	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	See Notes Below	2	2	1	6	See Notes Below	2	2	1	6	See Notes Below	2	2	1	6	See Notes Below	2	1				2	2	1	6	See Notes Below	1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H7917	801	0	1	04	01	H7917_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7917	802	0	1	04	01	H7917_802_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7917	803	0	1	04	01	H7917_803_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H7925	002	0	1	01	01	H7925_002_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	RESTORATIVE SERVICES 3 crowns or bridge units every 12 months, 1 per tooth every 84 monthsOther Restorative every 12 to 84 months	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS every 8 to 12 months, once per tooth	2	2	3	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					1	10111111			30	30	30	30	30	30	30	30	30	30	30	30	30	30	2		1	01000000	30.00	30.00															1	2
H7993	001	0	1	01	01	H7993_001_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	4000.00	3		2					2																		2		1	01000000	20.00	20.00															1	2
H7993	002	0	1	01	01	H7993_002_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	5000.00	3		2					2																		2		1	01000000	20.00	20.00															1	2
H7993	003	0	1	01	01	H7993_003_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	3500.00	3		2					2																		2		1	01000000	15.00	15.00															1	2
H7993	004	0	1	01	01	H7993_004_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	5000.00	3		2					2																		2		1	01000000	10.00	10.00															1	2
H7993	005	0	1	01	01	H7993_005_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	4000.00	3		2					2																		2		1	01000000	10.00	10.00															1	2
H7993	006	0	1	01	01	H7993_006_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year. .	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H7993	007	0	1	01	01	H7993_007_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime. .	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	2500.00	3		2					2																		2		1	01000000	20.00	20.00															1	2
H7993	008	0	1	01	01	H7993_008_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H8003	001	0	1	04	01	H8003_001_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	3500.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	50.00	50.00															2	2
H8003	002	0	1	04	01	H8003_002_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	3500.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	50.00	50.00															2	2
H8003	003	0	1	04	01	H8003_003_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	3500.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	50.00	50.00															2	2
H8003	004	0	1	04	01	H8003_004_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	2000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	50.00	50.00															2	2
H8003	005	0	1	04	01	H8003_005_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	2000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	50.00	50.00															2	2
H8003	006	0	1	04	01	H8003_006_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	2000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	50.00	50.00															2	2
H8003	007	0	1	04	01	H8003_007_0	6	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	2000.00	3		2					1	10111111			50	50	50	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	50.00	50.00															2	2
H8003	801	0	1	04	01	H8003_801_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8003	802	0	1	04	01	H8003_802_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8003	803	0	1	04	01	H8003_803_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8003	804	0	1	04	01	H8003_804_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8010	002	0	1	01	01	H8010_002_0	11	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		1		1500.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Resin fillings-1 per tooth per 24 months Inlays/Onlays-1 per tooth per 60 monthsCrowns-1 per tooth per 60 monthsRe-cement-1 per tooth per 24 monthsProtective restoration-1 per tooth per lifetime	2	2	1	6	Pulpal debridement-1 per tooth per lifetime Treatment of root canals-1 per tooth per lifetime Apicoectomy/periadicular services-1 per tooth per lifetime Retrograde filling--1 per tooth per lifetime	2	2	1	6	osseous surgery-1 per quadrant per 36 monthsDebridement- full mouth per 36 monthsFull mouth scaling if gingival inflammation-2 per calendar yearPeriodontal Maintenance-4 per calendar year	2	2	1	6	Extractions, coronectomy-1 per tooth per lifetime	2	2	1	6	Removable complete & partial dentures-1 every 60 monthsDenture adjustments-2 per 12 monthsDenture rebase or relines-1 per 36 monthsFixed denture repair-1 per 24 months	1		1				2					2																		2		1	11001111	25.00	25.00					20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H8010	003	0	1	01	01	H8010_003_0	9	1	1111	2	2	1	3		2	2	2	3		2	2	2	3		2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Resin fillings-1 per tooth per 24 months Inlays/Onlays-1 per tooth per 60 monthsCrowns-1 per tooth per 60 monthsRe-cement-1 per tooth per 24 monthsProtective restoration-1 per tooth per lifetime	2	2	1	6	Pulpal debridement-1 per tooth per lifetime Treatment of root canals-1 per tooth per lifetime Apicoectomy/periadicular services-1 per tooth per lifetime Retrograde filling--1 per tooth per lifetime	2	2	1	6	osseous surgery-1 per quadrant per 36 monthsDebridement- full mouth per 36 monthsFull mouth scaling if gingival inflammation-2 per calendar yearPeriodontal Maintenance-4 per calendar year	2	2	1	6	Extractions, coronectomy-1 per tooth per lifetime	2	2	1	6	Removable complete & partial dentures-1 every 60 monthsDenture adjustments-2 per 12 monthsDenture rebase or relines-1 per 36 monthsFixed denture repair-1 per 24 months	1		1				2					2																		2		1	11001111	10.00	10.00					20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	20.00	2	2
H8014	001	0	1	04	01	H8014_001_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	1500.00	3		2					2																		2		2																		2	2
H8014	002	0	1	04	01	H8014_002_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	2000.00	3		2					2																		2		1	01000000	45.00	45.00															2	2
H8019	002	0	1	02	01	H8019_002_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	once per 36 month period	2	2	1	6	Diagnostic x-ray: Once per calendar yearPeriodontal maintenance: Twice per year	2	1				2	1				2	2	1	6	Surgical periodontal services: Once per 36 monthsRoot planing and scaling: once per quadrant every 24 months.	2	1				2	2	1	6	Services are limited to once in a five-year period per tooth.	1		1				2					1	10111111			50	50	0	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	35.00	35.00															2	2
H8019	003	0	1	02	01	H8019_003_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	once per 36 month period	2	2	1	6	Diagnostic x-ray: Once per calendar yearPeriodontal maintenance: Twice per year	2	1				2	1				2	2	1	6	Surgical periodontal services: Once per 36 monthsRoot planing and scaling: once per quadrant every 24 months	2	1				2	2	1	6	Services are limited to once in a five-year period per tooth.	1		1				2					1	10111111			50	50	0	50	50	50	50	50	50	50	50	50	50	50	2		1	01000000	40.00	40.00															2	2
H8019	006	0	1	01	01	H8019_006_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	once per 36 month period	2	2	1	6	Diagnostic x-ray: Once per calendar yearPeriodontal maintenance: Twice per year	2	1				2	1				2	2	1	6	Surgical periodontal services: Once per 36 monthsRoot planing and scaling: once per quadrant every 24 months.	2	1				2	2	1	6	Services are limited to once in a five-year period per tooth.	1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H8019	007	0	1	02	01	H8019_007_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	once per 36 month period	2	2	1	6	Diagnostic x-ray: Once per calendar yearPeriodontal maintenance: Twice per year	2	1				2	1				2	2	1	6	Surgical periodontal services: Once per 36 monthsRoot planing and scaling: once per quadrant every 24 months.	2	1				2	2	1	6	Services are limited to once in a five-year period per tooth.	1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H8019	008	0	1	02	01	H8019_008_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	once per 36 month period	2	2	1	6	Diagnostic x-ray: Once per calendar yearPeriodontal maintenance: Twice per year	2	1				2	1				2	2	1	6	Surgical periodontal services: Once per 36 monthsRoot planing and scaling: once per quadrant every 24 months.	2	1				2	2	1	6	Services are limited to once in a five-year period per tooth.	1		1				2					2																		2		2																		2	2
H8019	801	0	1	01	01	H8019_801_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8019	802	0	1	01	01	H8019_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8019	803	0	1	01	01	H8019_803_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8019	804	0	1	02	01	H8019_804_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8019	805	0	1	02	01	H8019_805_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8019	806	0	1	02	01	H8019_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8026	001	0	1	48	05	H8026_001_0	4	1	1111	2	2	1	4		2	2	1	4		2	2	6	6	Per lifetime	2	2	1	6	Every 12months: Bitewing Radiographs Every 3yrs per arch (under age 21): Occlusal Radiograph Every 5yrs (over age 5): Panoramic Radiograph, Full mouth/Complete series Everyday, with medical necessity	2					2				2		2												2		2		2												2	2	1	1011011						2	1				2	1									2	2	1	3		2	2	999	6	Everyday, based on medical necessity	2	2	1	6	Prosthodontics(removable)-Once per 5yrs per arch when prognosis of complete/partial denture is at least 5yrs: Complete/partial dentures. Every day per medical need: Other Oral/Maxillofacial Surgery.	2						2					2																		2		2																		1	2
H8046	001	0	1	48	05	H8046_001_0	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		600.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2	2	999	6	As medically necessary.	2						2					2																		2		2																		1	2
H8064	002	0	1	04	01	H8064_002_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	4500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															2	2
H8064	801	0	1	04	01	H8064_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8064	802	0	1	04	01	H8064_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8064	803	0	1	04	01	H8064_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8067	001	0	1	01	01	H8067_001_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		1		5000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H8067	003	0	1	01	01	H8067_003_0	5	1	1111	2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H8070	001	0	1	04	01	H8070_001_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H8070	002	0	1	04	01	H8070_002_0	8	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H8070	801	0	1	04	01	H8070_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8082	001	0	1	20	08	H8082_001_0	1																																																																																																																																																							
H8082	002	0	1	20	08	H8082_002_0	1																																																																																																																																																							
H8093	001	0	1	01	01	H8093_001_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8093	002	0	1	01	01	H8093_002_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8095	001	0	1	01	01	H8095_001_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	1500.00	3		2					1	10011111					25	25	25	25	25	25	25	25	25	25	25	25	2		1	01000000	35.00	35.00															2	2
H8095	801	0	1	01	01	H8095_801_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8095	802	0	1	01	01	H8095_802_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8095	807	0	1	02	01	H8095_807_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8095	808	0	1	02	01	H8095_808_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8096	001	0	1	20	08	H8096_001_0	1																																																																																																																																																							
H8096	002	0	1	20	08	H8096_002_0	1																																																																																																																																																							
H8099	001	0	1	20	08	H8099_001_0	1	2																																																																																																																																																						
H8099	002	0	1	20	08	H8099_002_0	1	2																																																																																																																																																						
H8121	801	0	1	04	01	H8121_801_0	12	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H8133	001	0	1	01	01	H8133_001_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H8133	005	0	1	01	01	H8133_005_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1		2	2000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H8142	001	0	1	02	01	H8142_001_0	17	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Full mouth x-rays 1x every 60 months.  Bite-wing x-rays 1x every 12 months.	1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	4		2	2	1	6	Up to 8 periapical x-rays per visit.	2	2	1	6	Dentures 1x/5 years at 0% coinsurance.  Fillings 1x/24 months 0% coinsurance.Crown/inlays/onlays/bridges/implants (one per tooth position) 1x/10 years at 50% coinsurance.	2	2	1	6	Root canal one per tooth per lifetime.	2	2	1	6	Periodontal surgery 1x every 36 months.  Periodontal maintenance up to 4x every calendar year.  Scaling and root planing 1x every 24 months.	2	1				2	2	1	6	Dentures through Prosthodontist 1x every 5 calendar years at 0% coinsurance.Bridges covered through Prosthodontist 1x every 10 calendar years at 50% coinsurance.	1		1				2					1	10101110			0	50			0	50	50	50	50	50			0	50	2		2																		2	2
H8142	002	0	1	02	01	H8142_002_0	17	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Full mouth x-rays 1x every 60 months.  Bite-wing x-rays 1x every 12 months.	1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	4		2	2	1	6	Up to 8 periapical x-rays per visit.	2	2	1	6	Dentures 1x/5 years at 0% coinsurance.  Fillings 1x/24 months 0% coinsurance.Crown/inlays/onlays/bridges/implants (one per tooth position) 1x/10 years at 50% coinsurance.	2	2	1	6	Root canal one per tooth per lifetime.	2	2	1	6	Periodontal surgery 1x every 36 months.  Periodontal maintenance up to 4x every calendar year.  Scaling and root planing 1x every 24 months.	2	1				2	2	1	6	Dentures through Prosthodontist 1x every 5 calendar years at 0% coinsurance.Bridges covered through Prosthodontist 1x every 10 calendar years at 50% coinsurance.	1		1				2					1	10101110			0	50			0	50	50	50	50	50			0	50	2		2																		2	2
H8142	003	0	1	02	01	H8142_003_0	10	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Full mouth x-rays 1x every 60 months.  Bite-wing x-rays 1x every 12 months.	1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	4		2	2	1	6	Up to 8 periapical x-rays per visit.	2	2	1	6	Dentures 1x/5 years at 0% coinsurance  Fillings 1x/24 months 0% coinsurance.Crown/inlays/onlays/bridges/implants (one per tooth position) 1x/10 years at 50% coinsurance.	2	2	1	6	Root canal one per tooth per lifetime.	2	2	1	6	Periodontal surgery 1x every 36 months.  Periodontal maintenance up to 4x every calendar year.  Scaling and root planing 1x every 24 months.	2	1				2	2	1	6	Dentures through Prosthodontist 1x every 5 calendar years at 0% coinsurance.Bridges covered through Prosthodontist 1x every 10 calendar years at 50% coinsurance.	1		1				2					1	10101110			0	50			0	50	50	50	50	50			0	50	2		2																		2	2
H8142	004	0	1	02	01	H8142_004_0	16	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Full mouth x-rays 1x every 60 months.  Bite-wing x-rays 1x every 12 months.	1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	4		2	2	1	6	Up to 8 periapical x-rays per visit.	2	2	1	6	Dentures 1x/5 years at 0% coinsurance.  Fillings 1x/24 months 0% coinsurance.Crown/inlays/onlays/bridges/implants (one per tooth position) 1x/10 years at 50% coinsurance.	2	2	1	6	Root canal one per tooth per lifetime.	2	2	1	6	Periodontal surgery 1x every 36 months.  Periodontal maintenance up to 4x every calendar year.  Scaling and root planing 1x every 24 months.	2	1				2	2	1	6	Dentures through Prosthodontist 1x every 5 calendar years at 0% coinsurance.Bridges covered through Prosthodontist 1x every 10 calendar years at 50% coinsurance.	1		1				2					1	10101110			0	50			0	50	50	50	50	50			0	50	2		2																		2	2
H8142	005	0	1	02	01	H8142_005_0	17	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Full mouth x-rays 1x every 60 months.  Bite-wing x-rays 1x every 12 months.	1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	4		2	2	1	6	Up to 8 periapical x-rays per visit.	2	2	1	6	Dentures 1x/5 years at 0% coinsurance.  Fillings 1x/24 months 0% coinsurance.Crown/inlays/onlays/bridges/implants (one per tooth position) 1x/10 years at 50% coinsurance.  .	2	2	1	6	Root canal one per tooth per lifetime.	2	2	1	6	Periodontal surgery 1x every 36 months.  Periodontal maintenance up to 4x every calendar year.  Scaling and root planing 1x every 24 months.	2	1				2	2	1	6	Dentures through Prosthodontist 1x every 5 calendar years at 0% coinsurance.Bridges covered through Prosthodontist 1x every 10 calendar years at 50% coinsurance.	1		1				2					1	10101110			0	50			0	50	50	50	50	50			0	50	2		2																		2	2
H8142	006	0	1	02	01	H8142_006_0	11	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Full mouth x-rays 1x every 60 months.  Bite-wing x-rays 1x every 12 months.	1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	4		2	2	1	6	Up to 8 periapical x-rays per visit.	2	2	1	6	Dentures 1x/5 years at 0% coinsurance.  Fillings 1x/24 months 0% coinsurance.Crown/inlays/onlays/bridges/implants (one per tooth position) 1x/10 years at 50% coinsurance.	2	2	1	6	Root canal one per tooth per lifetime.	2	2	1	6	Periodontal surgery 1x every 36 months.  Periodontal maintenance up to 4x every calendar year.  Scaling and root planing 1x every 24 months.	2	1				2	2	1	6	Dentures through Prosthodontist 1x every 5 calendar years at 0% coinsurance.Bridges covered through Prosthodontist 1x every 10 calendar years at 50% coinsurance.	1		1				2					1	10101110			0	50			0	50	50	50	50	50			0	50	2		2																		2	2
H8142	007	0	1	02	01	H8142_007_0	20	1	1110	2	2	1	4		2	2	3	3							2	2	1	6	Full mouth x-rays 1x every 60 months.  Bite-wing x-rays 1x every 12 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	4		2	2	1	6	Up to 8 periapical x-rays per visit.	2	2	1	6	Dentures 1x/5 years at 0% coinsurance.  Fillings 1x/24 months 0% coinsurance.Crown/inlays/onlays/bridges/implants (one per tooth position) 1x/10 years at 50% coinsurance.	2	2	1	6	Root canal one per tooth per lifetime.	2	2	1	6	Periodontal surgery 1x every 36 months.  Periodontal maintenance up to 4x every calendar year.  Scaling and root planing 1x every 24 months.	2	1				2	2	1	6	Dentures through Prosthodontist 1x every 5 calendar years at 0% coinsurance.Bridges covered through Prosthodontist 1x every 10 calendar years 50% coinsurance.	1		2	3500.00	3		2					1	10101110			0	50			0	50	50	50	50	50			0	50	2		2																		2	2
H8142	008	0	1	02	01	H8142_008_0	16	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Full mouth x-rays 1x every 60 months.  Bite-wing x-rays 1x every 12 months.	1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	4		2	2	1	6	Up to 8 periapical x-rays per visit.	2	2	1	6	Dentures 1x/5 years at 0% coinsurance.  Fillings 1x/24 months 0% coinsurance.Crown/inlays/onlays/bridges/implants (one per tooth position) 1x/10 years at 50% coinsurance.	2	2	1	6	Root canal one per tooth per lifetime.	2	2	1	6	Periodontal surgery 1x every 36 months.  Periodontal maintenance up to 4x every calendar year.  Scaling and root planing 1x every 24 months.	2	1				2	2	1	6	Dentures through Prosthodontist 1x every 5 calendar years at 0% coinsurance.Bridges covered through Prosthodontist 1x every 10 calendar years at 50% coinsurance.	1		1				2					1	10101110			0	50			0	50	50	50	50	50			0	50	2		2																		2	2
H8142	009	0	1	02	01	H8142_009_0	17	1	1110	2	2	1	4		2	2	1	4							2	2	1	6	Full mouth x-rays 1x every 60 months.  Bite-wing x-rays 1x every 12 months.	1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	4		2	2	1	6	Up to 8 periapical x-rays per visit.	2	2	1	6	Dentures 1x/5 years at 0% coinsurance.  Fillings 1x/24 months 0% coinsurance.Crown/inlays/onlays/bridges/implants (one per tooth position) 1x/10 years at 50% coinsurance.	2	2	1	6	Root canal one per tooth per lifetime.	2	2	1	6	Periodontal surgery 1x every 36 months.  Periodontal maintenance up to 4x every calendar year.  Scaling and root planing 1x every 24 months.	2	1				2	2	1	6	Dentures through Prosthodontist 1x every 5 calendar years at 0% coinsurance.Bridges covered through Prosthodontist 1x every 10 calendar years at 50% coinsurance.	1		1				2					1	10101110			0	50			0	50	50	50	50	50			0	50	2		2																		2	2
H8142	010	0	1	02	01	H8142_010_0	21	1	1110	2	2	1	4		2	2	3	3							2	2	1	6	Full mouth x-rays 1x every 60 months.  Bite-wing x-rays 1x every 12 months.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	4		2	2	1	6	Up to 8 periapical x-rays per visit.	2	2	1	6	Dentures 1x/5 years at 0% coinsurance.  Fillings 1x/24 months 0% coinsurance.Crown/inlays/onlays/bridges/implants (one per tooth position) 1x/10 years at 50% coinsurance.	2	2	1	6	Root canal one per tooth per lifetime.	2	2	1	6	Periodontal surgery 1x every 36 months.  Periodontal maintenance up to 4x every calendar year.  Scaling and root planing 1x every 24 months.	2	1				2	2	1	6	Dentures through Prosthodontist 1x every 5 calendar years at 0% coinsurance.Bridges covered through Prosthodontist 1x every 10 calendar years at 50% coinsurance.	1		2	3500.00	3		2					1	10101110			0	50			0	50	50	50	50	50			0	50	2		2																		2	2
H8142	801	0	1	02	01	H8142_801_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8142	802	0	1	02	01	H8142_802_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8142	803	0	1	02	01	H8142_803_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8142	804	0	1	02	01	H8142_804_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8145	004	0	1	09	04	H8145_004_0	4	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	2	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year.	1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H8145	006	0	1	09	04	H8145_006_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H8145	032	0	1	09	04	H8145_032_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative service-amalgam and/or composite filling up to unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services up to 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	30.00	30.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			2	2
H8145	042	0	1	09	04	H8145_042_0	8	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H8145	052	0	1	09	04	H8145_052_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											2	2
H8145	055	0	1	09	04	H8145_055_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	30.00	30.00			0.00	0.00	0.00	0.00			0.00	0.00					2	2
H8145	069	0	1	09	04	H8145_069_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown and recementation of dentures up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	11	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include adjustments to dentures, denture rebase, denture reline, denture repair and tissue conditioning up to 1 per year	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H8145	084	0	1	09	04	H8145_084_0	11	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					2	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	40.00	40.00			0.00	0.00											2	2
H8145	091	0	1	09	04	H8145_091_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	bitewing x-rays1 set(s) per yearintraoral x-rays1 set(s) per yearpanoramic film or diagnostic x-rays 1 every 5 years	1	2	2000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	6	6	amalgam and/or composite filling 2/yr; bridge recementation and crown recementation 1/5 yrs; crown and other restorative services - core buildup and prefabricated post and core 1/tooth/lifetime.	4	2	2	6	root canal 1 per tooth per lifetimeroot canal retreatment 1 per tooth per lifetime	4	2	2	6	scaling and root planing (deep cleaning) 1 per quadrant every 3 years, and scaling for moderate inflammation 1 every 3 years	4	2	2	3		4	2	6	6	bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	35.00	35.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			2	2
H8145	122	0	1	09	04	H8145_122_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H8145	123	0	1	09	04	H8145_123_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											2	2
H8145	126	0	1	09	04	H8145_126_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Restorative services include fillings up to unlimited per year, recementation of crown up to 1 every 5 years, crown up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal,  root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Prosthodontics, Otr Oral/Maxillofacial Surg, Othr Svs include partial dentures andcomplete dentures up to 1evy 5yrs, oral surg up to 2per yr, denture adj,  up to 1per yr, occlusal adj up to 1evy 3yrs.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H8145	163	0	1	09	04	H8145_163_0	3	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Bitewing x-rays 1 set(s) per yearIntraoral x-rays 1 set(s) per yearPanoramic film or diagnostic x-rays 1 every 5 years	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	0.00	0.00			0.00	0.00											2	2
H8166	001	0	1	04	01	H8166_001_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years	1	2	2000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. Periodontal cleaning limited to 3 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	30.00	30.00															1	2
H8166	002	0	1	04	01	H8166_002_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years	1	2	3500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. Periodontal cleaning limited to 3 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	11111111	40	40	40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		2																		1	2
H8166	003	0	1	04	01	H8166_003_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years	1	2	3000.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. Periodontal cleaning limited to 3 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	10.00	10.00															1	2
H8166	004	0	1	04	01	H8166_004_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	6	Members are limited to one set of bitewing x-rays once per calendar year and full mouth x-rays every five years	1	2	2500.00	3		2				2		2												2		1		1	1111	0.00	0.00									2	2	1	1111111	2	1				2	1				2	2	1	2		2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2	2	1	6	Gingival flap including root planing, osseous surgery and scaling/root planing limited to 1 per 24 months per area. Periodontal cleaning limited to 3 per calendar year	2	2	1	3		2	2	1	6	Prosthodontics are limited to one every 5 years. Denture relining, rebasing, and denture repairs are limited to six months following insertion.	1		1				2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	20.00	20.00															1	2
H8166	801	0	1	04	01	H8166_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8166	802	0	1	04	01	H8166_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8166	803	0	1	04	01	H8166_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8166	804	0	1	04	01	H8166_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8173	001	0	1	01	01	H8173_001_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies.  For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years. .	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	7500.00	3		2					2																		2		1	01000000	15.00	15.00															1	2
H8173	002	0	1	01	01	H8173_002_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	7500.00	3		2					2																		2		1	01000000	5.00	5.00															1	2
H8173	005	0	1	01	01	H8173_005_0	8	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	7500.00	3		2					2																		2		1	01000000	40.00	40.00															1	2
H8173	007	0	1	01	01	H8173_007_0	10	1	1111	2	1				2	1				2	1				2	1				1		2100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H8173	011	0	1	01	01	H8173_011_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	7500.00	3		2					2																		2		1	01000000	15.00	15.00															1	2
H8173	013	0	1	01	01	H8173_013_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	35.00	35.00															1	2
H8173	014	0	1	01	01	H8173_014_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	7500.00	3		2					2																		2		1	01000000	15.00	15.00															1	2
H8173	016	0	1	01	01	H8173_016_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1		2	5000.00	3		2					2																		2		1	01000000	20.00	20.00															1	2
H8173	019	0	1	01	01	H8173_019_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies.  For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1		1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H8176	001	0	1	01	01	H8176_001_0	5	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H8176	003	0	1	01	01	H8176_003_0	6	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H8181	001	0	1	04	01	H8181_001_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1	2	1750.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	2	1	6	Number of visits depends on services received, see notes for details.	2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H8181	002	0	1	04	01	H8181_002_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1	2	1350.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	2	1	6	Number of visits depends on services received, see notes for details.	2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H8181	801	0	1	04	01	H8181_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8181	802	0	1	04	01	H8181_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8181	803	0	1	04	01	H8181_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8181	804	0	1	04	01	H8181_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8189	001	0	1	01	01	H8189_001_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 60 months per tooth	2	2	1	6	ENDODONTICS once per tooth per lifetime	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth per lifetime	2	2	1	6	PROSTHODONTICS every 12 to 60 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H8189	007	0	1	01	01	H8189_007_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	2	1	6	Every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 60 months per tooth	2	2	1	6	ENDODONTICS once per tooth per lifetime	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth per lifetime	2	2	1	6	PROSTHODONTICS every 12 to 60 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	2						2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2
H8197	002	1	1	48	05	H8197_002_1	4	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H8197	002	2	1	48	05	H8197_002_2	6	1	1111	2	1				2	1				2	1				2	1				1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H8211	001	0	1	04	01	H8211_001_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8211	002	0	1	04	01	H8211_002_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8211	005	0	1	04	01	H8211_005_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8211	006	0	1	04	01	H8211_006_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8211	007	0	1	04	01	H8211_007_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8211	009	0	1	04	01	H8211_009_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8211	010	0	1	04	01	H8211_010_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8211	011	0	1	04	01	H8211_011_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8213	001	0	1	48	05	H8213_001_0	5	2																																																															2																																											2					2																		2		2																		2	2
H8225	003	0	1	01	01	H8225_003_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	5000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8244	002	0	1	04	01	H8244_002_0	15	2																																																															2		3					3					3					3					3					3					3											2					2																		2		2																		2	2
H8244	801	0	1	04	01	H8244_801_0	2	2																																																															2																																											2					2																		2		2																		1	2
H8244	802	0	1	04	01	H8244_802_0	2	2																																																															2																																											2					2																		2		2																		1	2
H8244	803	0	1	04	01	H8244_803_0	2	2																																																															2																																											2					2																		2		2																		1	2
H8244	804	0	1	04	01	H8244_804_0	2	2																																																															2																																											2					2																		2		2																		1	2
H8293	001	0	1	01	01	H8293_001_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	1500.00	3		2					2																		2		1	01000000	25.00	25.00															2	2
H8293	002	0	1	01	01	H8293_002_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					2																		2		1	01000000	30.00	30.00															2	2
H8298	001	0	1	01	01	H8298_001_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8330	001	0	1	01	01	H8330_001_0	8	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8330	002	0	1	01	01	H8330_002_0	8	2																																																															1	1000000																															2	2	4	6	Up to four implants covered per member per year. Each implant is covered once per tooth every five years.	2						2					1	01000000	20	20															2		2																		1	2
H8332	001	0	1	01	01	H8332_001_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below	2	2	4	6	Varies by procedure, see note below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see note below.	1		2	3000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	25.00	25.00			0.00	0.00											1	2
H8332	002	0	1	01	01	H8332_002_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below	2	2	4	6	Varies by procedure, see note below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see note below.	1		2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	25.00	25.00			0.00	0.00											1	2
H8332	003	0	1	01	01	H8332_003_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below	2	2	4	6	Varies by procedure, see note below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see note below.	1		2	3500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	20.00	20.00			0.00	0.00											1	2
H8332	004	0	1	01	01	H8332_004_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below	2	2	4	6	Varies by procedure, see note below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see note below.	1		2	3500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	20.00	20.00			0.00	0.00											1	2
H8332	005	0	1	01	01	H8332_005_0	8	1	1110	2	2	4	3		2	2	2	3							2	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	1	1111111	2	1				2	2	1	6	Plan will cover 1 full mouth series or 1 panoramic image every 3 years and periapical x-rays as medically necessary.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below	2	2	4	6	Varies by procedure, see note below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see note below.	1		2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	30.00	30.00			0.00	0.00											1	2
H8332	801	0	1	01	01	H8332_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8332	802	0	1	01	01	H8332_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8379	001	0	1	01	01	H8379_001_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	1		2500.00	3		2				2		2												2		2		2												2	2	1	1001011											2	2	1	6	Minor restorative services include fillings. Composite resin (white) restorations are covered services on posterior teeth. Fillings are covered once in any 2 year period, same tooth and same surface.						2	2	4	6	Four periodontal maintenance procedures per calendar year. Periodontal non-surgical procedures are covered. See full description below.	2	2	1	6	The mandatory supplemental dental benefit includes surgical extraction of teeth (once per tooth per lifetime) & simple extractions (once per tooth per lifetime).	2	2	1	6	Dentures and bridges payable once in a five year period, relines and repairs for dentures and bridges once every 36 months, anesthesia with qualifying dental procedures and one brush biopsy per year.	1		1				2					1	01000000	0	35															2		2																		1	2
H8379	002	0	1	01	01	H8379_002_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	1		4000.00	3		2				2		2												2		2		2												2	2	1	1001011											2	2	1	6	Minor restorative services include fillings. Composite resin (white) restorations are covered services on posterior teeth. Fillings are covered once in any 2 year period, same tooth and same surface.						2	2	4	6	Four periodontal maintenance procedures per calendar year. Periodontal non-surgical procedures are covered. See full description below.	2	2	1	6	The mandatory supplemental dental benefit includes surgical extraction of teeth (once per tooth per lifetime) & simple extractions (once per tooth per lifetime).	2	2	1	6	Dentures and bridges payable once in a five year period, relines and repairs for dentures and bridges once every 36 months, anesthesia with qualifying dental procedures and one brush biopsy per year.	1		1				2					1	01000000	0	35															2		2																		1	2
H8385	001	0	1	04	01	H8385_001_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	One bitewing x-ray per year. One full mouth x-ray every 5 years.	2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	2		2	2	1	6	Root canal therapy - 1 per lifetime	2	2	1	1		2	1				2	2	1	6	Oral surgery (alveoloplasty, osseous, osteoperiosteal, or cartilage graft) - 1 per lifetimeCrowns - 1 per 5 years	1	2	2	2000.00	3		2					2																		2		2																		2	2
H8385	002	0	1	04	01	H8385_002_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	One bitewing x-ray per year. One full mouth x-ray every 5 years.	2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	2		2	2	1	6	Root canal therapy - 1 per lifetime	2	2	1	1		2	1				2	2	1	6	Oral surgery (alveoloplasty, osseous, osteoperiosteal or cartilage graft) - 1 per lifetimeCrowns - 1 per 5 years	1	2	2	2000.00	3		2					2																		2		2																		2	2
H8385	003	0	1	04	01	H8385_003_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	One bitewing x-ray per year. One full mouth x-ray every 5 years.	2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	2		2	2	1	6	Root canal therapy - 1 per lifetime	2	2	1	1		2	1				2	2	1	6	Oral surgery (alveoloplasty, osseous, osteoperiosteal, or cartilage graft) - 1 per lifetimeCrowns - 1 per 5 years	1	2	2	1750.00	3		2					2																		2		2																		2	2
H8385	004	0	1	04	01	H8385_004_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	2		2	2	1	6	Root canal therapy - 1 per lifetime	2	2	1	1		2	1				2	2	1	6	Oral surgery (alveoloplasty, osseous, osteoperiosteal or cartilage graft) - 1 per lifetimeCrowns - 1 per 5 years	1	2	2	1750.00	3		2					2																		2		2																		2	2
H8390	015	0	1	01	01	H8390_015_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	3		1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H8390	016	0	1	01	01	H8390_016_0	7	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	3		1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H8424	001	0	1	20	08	H8424_001_0	1																																																																																																																																																							
H8424	002	0	1	20	08	H8424_002_0	1																																																																																																																																																							
H8432	007	0	1	01	01	H8432_007_0	9	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8432	009	0	1	01	01	H8432_009_0	6	1	1110	4	2	2	3		4	2	2	3		3					4	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	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H8432	010	0	1	01	01	H8432_010_0	6	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H8432	011	0	1	01	01	H8432_011_0	6	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H8432	016	0	1	01	01	H8432_016_0	7	1	1111	2	1				2	1				2	1				2	1				1		750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8432	028	0	1	01	01	H8432_028_0	6	1	1111	2	1				2	1				2	1				2	1				1		1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8432	034	0	1	01	01	H8432_034_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8432	036	0	1	01	01	H8432_036_0	3	2		3					3					3					3																																														2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H8432	037	1	1	01	01	H8432_037_1	4	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8432	037	2	1	01	01	H8432_037_2	4	1	1111	4	1				4	1				4	1				4	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8432	038	1	1	01	01	H8432_038_1	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8432	038	2	1	01	01	H8432_038_2	8	1	1111	4	1				4	1				4	1				4	1				1		2750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8432	039	1	1	01	01	H8432_039_1	7	1	1110	2	2	2	3		2	2	2	3							2	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	2																																											2					1	01000000	20	20															2		2																		1	2
H8432	039	2	1	01	01	H8432_039_2	6	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8432	040	0	1	01	01	H8432_040_0	5	2		3					3					3					3																																														2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H8432	801	0	1	01	01	H8432_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8432	802	0	1	01	01	H8432_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8432	803	0	2	01	01	H8432_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8432	804	0	1	01	01	H8432_804_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8432	805	0	1	01	01	H8432_805_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8432	806	0	2	01	01	H8432_806_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8432	807	0	2	01	01	H8432_807_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8432	809	0	1	01	01	H8432_809_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8432	811	0	2	01	01	H8432_811_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8432	813	0	1	01	01	H8432_813_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8432	815	0	2	01	01	H8432_815_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8432	816	0	2	01	01	H8432_816_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8452	001	0	1	48	05	H8452_001_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		2					2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		2																		1	2
H8457	001	0	1	01	01	H8457_001_0	5	1	1111	2	1				2	1				2	1				2	1				1		2850.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H8458	003	0	1	04	01	H8458_003_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															1	2
H8492	001	0	1	01	01	H8492_001_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8547	001	0	1	01	01	H8547_001_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H8552	020	0	1	04	01	H8552_020_0	7	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	35.00	35.00															1	2
H8552	028	0	1	04	01	H8552_028_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8552	029	0	1	04	01	H8552_029_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8553	001	0	1	04	01	H8553_001_0	19	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	16B Comprehensive Dental - EXTRACTIONS once per tooth.	2	2	1	6	16B Comprehensive Dental - PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8553	002	0	1	04	01	H8553_002_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	2000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8554	001	0	1	01	01	H8554_001_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H8554	003	0	1	01	01	H8554_003_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	4000.00	3		2					1	11111111	20	20	0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2
H8554	004	0	1	01	01	H8554_004_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1		2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H8578	001	0	1	01	01	H8578_001_0	9	1	1111	2	1				2	1				2	1				2	1				1		975.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	100.00															1	2
H8578	003	0	1	01	01	H8578_003_0	7	1	1111	2	1				2	1				2	1				2	1				1		750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	100.00															1	2
H8578	004	0	1	01	01	H8578_004_0	9	1	1111	2	1				2	1				2	1				2	1				1		775.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	35.00	250.00															1	2
H8578	009	0	1	01	01	H8578_009_0	7	1	1111	2	1				2	1				2	1				2	1				1		450.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	400.00															1	2
H8578	012	0	1	01	01	H8578_012_0	9	1	1111	2	1				2	1				2	1				2	1				1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	400.00															1	2
H8578	018	0	1	01	01	H8578_018_0	10	1	1111	2	1				2	1				2	1				2	1				1		1225.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	400.00															1	2
H8578	801	0	1	02	01	H8578_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8578	802	0	1	02	01	H8578_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8578	803	0	1	02	01	H8578_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8597	001	0	1	01	01	H8597_001_0	9	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8597	002	0	1	01	01	H8597_002_0	8	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8597	003	0	1	01	01	H8597_003_0	8	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8604	010	0	1	04	01	H8604_010_0	14	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	1 set of bitewing x-rays every year. 1 full mouth radiographic image (x-ray) every three years	2					2				2		2												2		2		2												2	2	2												3					3					3					3					3											2					2																		2		1	01000000	45.00	45.00															1	2
H8604	011	0	1	04	01	H8604_011_0	14	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	1 set of bitewing x-rays every year. 1 full mouth radiographic image (x-ray) every three years	2					2				2		2												2		2		2												2	2	2												3					3					3					3					3											2					2																		2		1	01000000	45.00	45.00															1	2
H8604	013	0	1	04	01	H8604_013_0	14	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	1 set of bitewing x-rays every year. 1 full mouth radiographic image (x-ray) every three years	2					2				2		2												2		2		2												2	2	2												3					3					3					3					3											2					2																		2		1	01000000	45.00	45.00															1	2
H8604	014	1	1	04	01	H8604_014_1	17	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	1 set of bitewing x-rays every year. 1 full mouth radiographic image (x-ray) every three years	2					2				2		2												2		2		2												2	2	1	1011111						2	2	2	6	Oral evaluations 2 every yr. 1 set of bitewing x-rays every yr. 1 full mouth radiographic image (x-ray) every three yrs. Bitewing x-rays covered up to 4 every yr. depending on number of images.	4	2	1	6	0% coinsurance for fillings - 1 per tooth every three years at Liberty Dental provider.  50% co-insurance for fillings- 1 per tooth every three years at non-Liberty Dental provider.	4	1				4	2	1	6	Scaling and root planning 1 site every 3 yrs. Periodontal maintenance 2 every yr. Full mouth debridement 1 every 3 yrs.	4	1				4	2	1	6	Dentures one set every 60 months, rebase dentures one per arch every year, reline one per arch every year. Anesthesia and sedations - unlimited.	1	2	2	1500.00	3		2					1	10001111							0	50	0	50	0	50	0	50	0	50	2		1	01000000	40.00	40.00															1	2
H8604	014	2	1	04	01	H8604_014_2	16	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	1 set of bitewing x-rays every year. 1 full mouth radiographic image (x-ray) every three years	2					2				2		2												2		2		2												2	2	1	1011111						2	2	2	6	Oral evaluations 2 every yr. 1 set of bitewing x-rays every yr. 1 full mouth radiographic image (x-ray) every three yrs. Bitewing x-rays covered up to 4 every yr. depending on number of images.	4	2	1	6	Restorative Services: Fillings- 0% - 50% coinsurance for Fillings-1 per tooth every 3 years, 0% - 50% coinsurance for Crowns -1 per tooth every 5 years	4	1				4	2	1	6	Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs.	4	1				4	2	1	6	Dentures one set every 60 months, rebase dentures one per arch every year, reline one per arch every year. Anesthesia and sedations - unlimited.	1	2	2	1500.00	3		2					1	10001111							0	50	0	50	0	50	0	50	0	50	2		1	01000000	40.00	40.00															1	2
H8604	801	0	1	04	01	H8604_801_0	2	2																																																															2																																											2					2																		2		2																		1	2
H8614	001	0	1	20	08	H8614_001_0	1																																																																																																																																																							
H8614	002	0	1	20	08	H8614_002_0	1																																																																																																																																																							
H8634	003	0	1	04	01	H8634_003_0	7	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H8634	004	0	1	04	01	H8634_004_0	7	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1	2	2	1000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H8634	008	0	1	04	01	H8634_008_0	7	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H8634	009	0	1	04	01	H8634_009_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	4000.00	3		2					1	11111111	20	20	0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2
H8634	010	0	1	04	01	H8634_010_0	6	2		3					3										3																																														2		3										3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															2	2
H8634	012	0	1	04	01	H8634_012_0	7	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H8634	014	0	1	04	01	H8634_014_0	7	2		3					3										3																																														2		3										3					3					3					3					3											2					1	01000000	0	0															2		2																		2	2
H8634	015	0	1	04	01	H8634_015_0	6	2		3					3										3																																														2		3										3					3					3					3					3											2					1	01000000	0	0															2		2																		2	2
H8634	016	0	1	04	01	H8634_016_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1	2	2	2000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H8634	017	0	1	04	01	H8634_017_0	7	2		3					3										3																																														2		3										3					3					3					3					3											2					2																		2		1	01000000	35.00	35.00															2	2
H8634	018	0	1	04	01	H8634_018_0	5	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1	2	2	1000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H8634	019	0	1	04	01	H8634_019_0	5	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H8634	020	0	1	04	01	H8634_020_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1	2	2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H8634	021	0	1	04	01	H8634_021_0	7	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1	2	2	5000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H8634	801	0	1	04	01	H8634_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8634	803	0	1	04	01	H8634_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8634	805	0	1	04	01	H8634_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8634	807	0	1	04	01	H8634_807_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8634	809	0	1	04	01	H8634_809_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8634	811	0	1	04	01	H8634_811_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8634	813	0	1	04	01	H8634_813_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8634	815	0	1	04	01	H8634_815_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8634	817	0	1	04	01	H8634_817_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8634	819	0	1	04	01	H8634_819_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8634	820	0	1	04	01	H8634_820_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8634	821	0	1	04	01	H8634_821_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8634	822	0	1	04	01	H8634_822_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8634	823	0	1	04	01	H8634_823_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8634	824	0	1	04	01	H8634_824_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8649	003	0	1	02	01	H8649_003_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8649	008	0	1	02	01	H8649_008_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8649	010	0	1	01	01	H8649_010_0	7	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8649	801	0	1	01	01	H8649_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8649	803	0	1	01	01	H8649_803_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H8655	004	0	1	20	08	H8655_004_0	1																																																																																																																																																							
H8655	005	0	1	20	08	H8655_005_0	1																																																																																																																																																							
H8711	004	0	1	04	01	H8711_004_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1	2	2	1000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	40.00	40.00															1	2
H8764	001	0	1	01	01	H8764_001_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		2					2				2		2												2		2		2												2	2	2												3					3					3					3					3											2					2																		2		1	01000000	25.00	25.00															2	2
H8764	002	0	1	02	01	H8764_002_0	7	2		3					3										3																																														2												3					3					3					3					3											2					2																		2		1	01000000	20.00	20.00															2	2
H8764	003	0	1	01	01	H8764_003_0	7	2		3					3										3																																														2												3					3					3					3					3											2					2																		2		1	01000000	45.00	45.00															2	2
H8764	004	0	1	01	01	H8764_004_0	7	2		3					3										3																																														2												3					3					3					3					3											2					2																		2		1	01000000	45.00	45.00															2	2
H8764	801	0	1	02	01	H8764_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8768	003	0	1	04	01	H8768_003_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	005	0	1	04	01	H8768_005_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	007	0	1	04	01	H8768_007_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	008	0	1	04	01	H8768_008_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	009	0	1	04	01	H8768_009_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	010	0	1	04	01	H8768_010_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	011	0	1	04	01	H8768_011_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	013	0	1	04	01	H8768_013_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	014	0	1	04	01	H8768_014_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	016	0	1	04	01	H8768_016_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H8768	017	1	1	04	01	H8768_017_1	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	017	2	1	04	01	H8768_017_2	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H8768	018	0	1	04	01	H8768_018_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	019	0	1	04	01	H8768_019_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	020	0	1	04	01	H8768_020_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	021	0	1	04	01	H8768_021_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	022	0	1	04	01	H8768_022_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H8768	023	0	1	04	01	H8768_023_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	024	0	1	04	01	H8768_024_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	025	0	1	04	01	H8768_025_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	026	0	1	04	01	H8768_026_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	027	0	1	04	01	H8768_027_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	028	0	1	04	01	H8768_028_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	030	0	1	04	01	H8768_030_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	031	0	1	04	01	H8768_031_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	032	0	1	04	01	H8768_032_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H8768	034	0	1	04	01	H8768_034_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	035	0	1	04	01	H8768_035_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	037	1	1	04	01	H8768_037_1	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	037	2	1	04	01	H8768_037_2	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	038	1	1	04	01	H8768_038_1	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	038	2	1	04	01	H8768_038_2	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	039	0	1	04	01	H8768_039_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	040	0	1	04	01	H8768_040_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	042	0	1	04	01	H8768_042_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	043	0	1	04	01	H8768_043_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H8768	044	0	1	04	01	H8768_044_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	045	0	1	04	01	H8768_045_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	046	0	1	04	01	H8768_046_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	047	0	1	04	01	H8768_047_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	048	0	1	04	01	H8768_048_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	049	0	1	04	01	H8768_049_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H8768	050	0	1	04	01	H8768_050_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
H8768	051	0	1	04	01	H8768_051_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
H8769	001	0	1	20	08	H8769_001_0	1																																																																																																																																																							
H8769	002	0	1	20	08	H8769_002_0	1																																																																																																																																																							
H8777	001	0	1	20	08	H8777_001_0	1																																																																																																																																																							
H8777	002	0	1	20	08	H8777_002_0	1																																																																																																																																																							
H8783	001	0	1	04	01	H8783_001_0	10	1	1111	4	2	1	3		4	2	1	3		2	1				4	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	0000010	3					3					3					3					4	2	1	3		3					3					1		1				2					2																		2		2																		2	2
H8783	002	0	1	04	01	H8783_002_0	9	1	1111	4	2	1	3		4	2	1	3		2	1				4	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	0000010	3					3					3					3					4	2	1	3		3					3					1		1				2					2																		2		2																		2	2
H8783	003	0	1	04	01	H8783_003_0	10	1	1111	2	1				2	1				2	1				2	1				1	2	900.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H8786	001	0	1	48	05	H8786_001_0	7	1	1110	2	2	1	4		2	2	1	4							2	2	1	3		2					2				2		2												2		2		2												1	2	1	0111111	2	1				2	1				2	1				2	1				2	1				2	1									1		2	400.00	5		2					2																		2		2																		1	1
H8794	001	0	1	01	01	H8794_001_0	11	1	1110	2	1				2	2	2	4							2	1				2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H8794	002	0	1	01	01	H8794_002_0	11	1	1110	2	1				2	2	2	4							2	1				2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H8794	004	0	1	01	01	H8794_004_0	8	1	1110	2	1				2	2	2	4							2	1				2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H8794	005	0	1	01	01	H8794_005_0	11	1	1110	2	1				2	2	2	4							2	1				2					2				2		2												2		1		1	1110	0.00	0.00									1	1	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	1
H8797	001	0	1	01	01	H8797_001_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		1				2					1	01000000	20	20															2		2																		1	2
H8797	003	0	1	02	01	H8797_003_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		1				2					1	01000000	20	20															2		2																		1	2
H8797	004	0	1	02	01	H8797_004_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		1				2					1	01000000	20	20															2		2																		1	2
H8800	001	0	1	20	08	H8800_001_0	1																																																																																																																																																							
H8800	002	0	1	20	08	H8800_002_0	1																																																																																																																																																							
H8845	001	0	1	01	01	H8845_001_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	550.00	3		2					1	01000000	20	20															2		2																		2	2
H8845	002	0	1	01	01	H8845_002_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	750.00	3		2					2																		2		1	01000000	20.00	20.00															2	2
H8849	001	0	1	01	01	H8849_001_0	7	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8849	002	0	1	01	01	H8849_002_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8849	003	0	1	01	01	H8849_003_0	7	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8849	005	0	1	01	01	H8849_005_0	7	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8849	006	0	1	01	01	H8849_006_0	6	1	1111	4	1				4	1				4	1				4	1				1		1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8849	009	0	1	01	01	H8849_009_0	6	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8849	010	1	1	01	01	H8849_010_1	6	1	1111	2	1				2	1				2	1				2	1				1		5500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8849	010	2	1	01	01	H8849_010_2	6	1	1111	2	1				2	1				2	1				2	1				1		5500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8849	010	4	1	01	01	H8849_010_4	6	1	1111	2	1				2	1				2	1				2	1				1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8849	010	5	1	01	01	H8849_010_5	6	1	1111	2	1				2	1				2	1				2	1				1		5000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8849	011	1	1	01	01	H8849_011_1	7	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8849	011	2	1	01	01	H8849_011_2	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8849	011	3	1	01	01	H8849_011_3	6	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8849	011	4	1	01	01	H8849_011_4	6	1	1111	2	1				2	1				2	1				2	1				1		2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8849	011	5	1	01	01	H8849_011_5	6	1	1111	2	1				2	1				2	1				2	1				1		2250.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8849	013	0	1	01	01	H8849_013_0	7	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8854	002	0	1	01	01	H8854_002_0	6	1	1111	2	2	1	6	Oral Exams - Every 6 monthsComprehensive oral exam- once every 36 months	2	2	1	4		2	2	1	6	Fluoride Treatment - Every 6 monthsPalliative Treatment- 3 every 12 months	2	2	1	6	Bitewing- once every 12 monthsPanoramic- once every 36 monthsVertical bitewing- once every 36 monthsintraoral imaging- once every 36 months	2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Restorative services (1 restorations per tooth once every 24 months)	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)Crowns (once per tooth per 60 months)	2	2	1	6	Periodontics 1 per quadrant of scaling every 36 monthsPeriodontal maintenance 1 every 3 monthsDenture repairs 1 every 12 monthsRelines/Rebase 1 every 36 monthsDenture Adjustments 2 every 12 months	2	2	1	6	Simple Extractions (one extraction per tooth)	2	2	1	6	Prosthodontics (dental plates: either upper, lower, or partial, or any combination thereof), once every 60 months	1		2	3000.00	3		2					1	01000000	20	20															2		2																		2	2
H8889	001	0	1	04	01	H8889_001_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	25.00															2	2
H8889	002	0	1	04	01	H8889_002_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	25.00															2	2
H8889	003	0	1	04	01	H8889_003_0	6	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	10.00															2	2
H8889	004	0	1	04	01	H8889_004_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	35.00															2	2
H8889	005	0	1	04	01	H8889_005_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	750.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	35.00															2	2
H8889	008	0	1	04	01	H8889_008_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	50.00															2	2
H8889	009	0	1	04	01	H8889_009_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	30.00															2	2
H8889	010	0	1	04	01	H8889_010_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	35.00															2	2
H8889	011	0	1	04	01	H8889_011_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	10.00															2	2
H8889	012	0	1	04	01	H8889_012_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	800.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	25.00															2	2
H8889	013	0	1	04	01	H8889_013_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H8889	014	0	1	04	01	H8889_014_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	40.00															2	2
H8889	015	0	1	04	01	H8889_015_0	5	1	1111	2	1				2	1				2	1				2	1				1	2	700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	0.00	35.00															2	2
H8889	801	0	1	04	01	H8889_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8894	001	0	1	01	01	H8894_001_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8902	001	0	1	01	01	H8902_001_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	11111111	15.00	15.00	0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H8902	002	0	1	01	01	H8902_002_0	6	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	11111111	15.00	15.00	0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H8902	003	0	1	01	01	H8902_003_0	6	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	11111111	15.00	15.00	0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H8902	004	0	1	01	01	H8902_004_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010						2	2	2	3												2	1														2						2					2																		2		1	01000000	40.00	40.00															1	2
H8902	005	0	1	01	01	H8902_005_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H8902	006	0	1	01	01	H8902_006_0	6	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H8902	007	0	1	01	01	H8902_007_0	7	1	1110	4	2	2	3		4	2	2	3							4	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				2						2					2																		2		1	10111111			0.00	125.00	0.00	5.00	8.00	395.00	5.00	395.00	0.00	380.00	0.00	140.00	13.00	395.00	1	2
H8902	008	0	1	01	01	H8902_008_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010						2	2	2	3												2	1														2						2					2																		2		2																		1	2
H8902	009	0	1	01	01	H8902_009_0	9	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	0010010						2	2	2	3												2	1														2						2					1	01000000	20	20															2		2																		1	2
H8908	001	0	1	02	01	H8908_001_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative services-amalgam and/or composite filling up to unlimited per year, bridge and crown recementation up to 1 every 5 years, crown and other restorative services 1 per tooth per lifetime	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Services include bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year.	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8908	002	0	1	01	01	H8908_002_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	40.00	40.00			0.00	0.00	25.00	25.00									1	2
H8908	004	0	1	02	01	H8908_004_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Restorative svc include amalgam and/or composite filling/unlimited per year, bridge/crown recementation up to 1/5 yrs, crown/core buildup and prefabricated post and core up to 1/tooth/lifetime.	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	6	6	Prosthodontics, Oral/Maxillofacial Surgery, Other Services bridges-crown up to 2/5 yrs, bridges-pontic up to 1/5 yrs, occlusal adjustment up to 1/3 yrs, oral surgery up to 2 per yr.	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8908	005	0	1	01	01	H8908_005_0	5	1	1111	2	1				2	1				2	1				2	1				1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H8908	801	0	1	01	01	H8908_801_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H8908	802	0	1	01	01	H8908_802_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H8908	804	0	1	01	01	H8908_804_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H8908	805	0	1	01	01	H8908_805_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H8928	001	0	1	01	01	H8928_001_0	7	1	1000																2	2	1	6	See Notes below	2					2				2		2												2		2		2												2	2	1	1001110											2	2	1	6	See Notes below	2	2	1	6	See Notes below	2	2	1	6	See Notes below						2	2	1	6	See Notes below	2						2					1	01000000	20	20															2		2																		1	2
H8947	001	1	1	04	01	H8947_001_1	7	1	1111	2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2	2	2	6	2 procedure codes per calendar year	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	2	2	2	3		2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1		1				2					1	11101111	50	50	50	50			50	50	50	50	50	50	50	50	50	50	2		2																		2	2
H8947	001	2	1	04	01	H8947_001_2	6	1	1111	2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2	2	2	6	2 procedure codes per calendar year	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	1	2	3500.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	2	2	2	3		2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1		1				2					1	11101111	50	50	50	50			50	50	50	50	50	50	50	50	50	50	2		2																		2	2
H8947	002	1	1	04	01	H8947_002_1	7	1	1111	2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2	2	2	6	2 procedure codes per calendar year	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	1	2	3500.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	2	2	2	3		2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1		1				2					1	11101111	50	50	50	50			50	50	50	50	50	50	50	50	50	50	2		2																		2	2
H8947	002	2	1	04	01	H8947_002_2	6	1	1111	2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2	2	2	6	2 procedure codes per calendar year	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	1	2	4000.00	3		2				2		2												2		2		2												2	2	1	1101111	2	1									2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	2	2	2	3		2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1		1				2					1	11101111	50	50	50	50			50	50	50	50	50	50	50	50	50	50	2		2																		2	2
H8967	001	0	1	01	01	H8967_001_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Limit once every 5 years	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every two years.	1		2	2000.00	3		2					1	01000000	20	20															2		2																		2	2
H8967	002	0	1	01	01	H8967_002_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	Limit once every 5 years	2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every two years.	1		2	2000.00	3		2					1	01000000	20	20															2		2																		2	2
H8982	001	0	1	20	08	H8982_001_0	1	2																																																																																																																																																						
H8982	003	0	1	20	08	H8982_003_0	1	2																																																																																																																																																						
H8992	001	0	1	20	08	H8992_001_0	1	2																																																																																																																																																						
H8992	002	0	1	20	08	H8992_002_0	1	2																																																																																																																																																						
H8998	001	0	1	04	01	H8998_001_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Benefit is either two series of bitewing per year, or one full mouth every 36 consecutive months. Benefit is combined in and out-of-network for all covered services (includes all preventive services).	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	40.00	40.00			0.00	0.00											2	2
H8998	801	0	1	04	01	H8998_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H8998	802	0	1	04	01	H8998_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9001	030	15	1	01	01	H9001_030_15	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	See notes below.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2						2					2																		2		1	11011111	40.00	40.00			20.00	40.00	31.00	856.00	34.00	990.00	80.00	953.00	37.00	506.00	0.00	865.00	1	2
H9001	030	16	1	01	01	H9001_030_16	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	See notes below.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2						2					2																		2		1	11011111	40.00	40.00			20.00	40.00	31.00	856.00	34.00	990.00	80.00	953.00	37.00	506.00	0.00	865.00	1	2
H9001	030	18	1	01	01	H9001_030_18	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	See notes below.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2						2					2																		2		1	11011111	40.00	40.00			20.00	40.00	31.00	856.00	34.00	990.00	80.00	953.00	37.00	506.00	0.00	865.00	1	2
H9001	031	15	1	01	01	H9001_031_15	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	See notes below.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2						2					2																		2		1	11011111	20.00	20.00			20.00	40.00	31.00	856.00	34.00	990.00	80.00	953.00	37.00	506.00	0.00	865.00	1	2
H9001	031	16	1	01	01	H9001_031_16	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	See notes below.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2						2					2																		2		1	11011111	20.00	20.00			20.00	40.00	31.00	856.00	34.00	990.00	80.00	953.00	37.00	506.00	0.00	865.00	1	2
H9001	031	18	1	01	01	H9001_031_18	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	See notes below.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2						2					2																		2		1	11011111	20.00	20.00			20.00	40.00	31.00	856.00	34.00	990.00	80.00	953.00	37.00	506.00	0.00	865.00	1	2
H9001	035	0	1	01	01	H9001_035_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	See notes below.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2						2					2																		2		1	11011111	20.00	20.00			20.00	40.00	31.00	856.00	34.00	990.00	80.00	953.00	37.00	506.00	0.00	865.00	1	2
H9001	036	0	1	01	01	H9001_036_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	See notes below.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2						2					2																		2		1	11011111	40.00	40.00			20.00	40.00	31.00	856.00	34.00	990.00	80.00	953.00	37.00	506.00	0.00	865.00	1	2
H9001	038	0	1	01	01	H9001_038_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	See notes below.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2						2					2																		2		1	11011111	40.00	40.00			20.00	40.00	31.00	856.00	34.00	990.00	80.00	953.00	37.00	506.00	0.00	865.00	1	2
H9001	039	0	1	01	01	H9001_039_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	See notes below.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2	2	1	6	See notes below.	2						2					2																		2		1	11011111	40.00	40.00			20.00	40.00	31.00	856.00	34.00	990.00	80.00	953.00	37.00	506.00	0.00	865.00	1	2
H9001	040	0	1	01	01	H9001_040_0	6	2																																																															2																																											2					2																		2		1	01000000	50.00	50.00															2	2
H9001	803	0	1	01	01	H9001_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9001	804	0	1	01	01	H9001_804_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9001	805	0	1	01	01	H9001_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9001	806	0	1	01	01	H9001_806_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9001	807	0	1	01	01	H9001_807_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9001	808	0	1	01	01	H9001_808_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9003	001	0	1	02	01	H9003_001_0	10	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	20.00	20.00															1	1
H9003	006	0	1	02	01	H9003_006_0	10	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	35.00	35.00															1	1
H9003	008	0	1	02	01	H9003_008_0	11	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	30.00	30.00															1	1
H9003	009	0	1	02	01	H9003_009_0	10	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	35.00	35.00															1	1
H9003	801	0	1	01	01	H9003_801_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H9003	802	0	1	01	01	H9003_802_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H9003	805	0	1	01	01	H9003_805_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H9042	002	1	1	04	01	H9042_002_1	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H9042	002	2	1	04	01	H9042_002_2	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H9042	003	1	1	04	01	H9042_003_1	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H9042	003	2	1	04	01	H9042_003_2	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	3		1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H9047	013	0	2	01	01	H9047_013_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		4	2	2	6	X-rays are covered as follows: 1 bitewing series or 1 bitewing series plus 1 periapical per calendar year.	2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	20.00	20.00															1	2
H9047	033	0	1	01	01	H9047_033_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		4	2	2	6	X-rays are covered as follows: 1 bitewing series or 1 bitewing series plus 1 periapical per calendar year.	2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	20.00	20.00															1	2
H9047	035	0	1	02	01	H9047_035_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		4	2	2	6	X-rays are covered as follows: 1 bitewing series or 1 bitewing series plus 1 periapical per calendar year.	2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	30.00	30.00															1	2
H9047	037	0	1	01	01	H9047_037_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		4	2	2	6	X-rays are covered as follows: 1 bitewing series or 1 bitewing series plus 1 periapical per calendar year.	2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	40.00	40.00															1	2
H9047	043	0	1	01	01	H9047_043_0	8	1	1111	2	1				2	1				2	1				2	1				1		1700.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H9047	054	0	1	01	01	H9047_054_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		4	2	2	6	X-rays are covered as follows: 1 bitewing series or 1 bitewing series plus 1 periapical per calendar year.	2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		2	350.00	3		2					2																		2		1	01000000	40.00	40.00															1	2
H9047	059	0	1	02	01	H9047_059_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		4	2	2	6	X-rays are covered as follows: 1 bitewing series or 1 bitewing series plus 1 periapical per calendar year.	2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	35.00	35.00															1	2
H9047	062	0	1	02	01	H9047_062_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		4	2	2	6	X-rays are covered as follows: 1 bitewing series or 1 bitewing series plus 1 periapical per calendar year.	2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		2	1000.00	3		2					2																		2		1	01000000	35.00	35.00															1	2
H9047	063	0	1	01	01	H9047_063_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		4	2	2	6	X-rays are covered as follows: 1 bitewing series or 1 bitewing series plus 1 periapical per calendar year.	2					2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		2	400.00	3		2					2																		2		1	01000000	45.00	45.00															1	2
H9047	064	0	1	01	01	H9047_064_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		4	2	2	6	X-rays are covered as follows: 1 bitewing series or 1 bitewing series plus 1 periapical per calendar year.	2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	20.00	20.00															1	2
H9047	065	0	1	02	01	H9047_065_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		4	2	2	6	X-rays are covered as follows: 1 bitewing series or 1 bitewing series plus 1 periapical per calendar year.	2					2				2		2												2		2		2												2	2	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	30.00	30.00															1	2
H9047	066	0	1	01	01	H9047_066_0	5	1	1111	2	1				2	1				2	1				2	1				1		3100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H9047	804	0	1	01	01	H9047_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9047	805	0	1	02	01	H9047_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9047	808	0	1	01	01	H9047_808_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9047	809	0	1	02	01	H9047_809_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9052	001	0	1	20	08	H9052_001_0	1																																																																																																																																																							
H9052	002	0	1	20	08	H9052_002_0	1																																																																																																																																																							
H9065	001	0	1	01	01	H9065_001_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9065	002	0	1	02	01	H9065_002_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9065	003	0	1	02	01	H9065_003_0	9	1	1111	2	1				2	1				2	1				2	1				1		1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9065	004	0	1	02	01	H9065_004_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9065	006	0	1	01	01	H9065_006_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9065	007	0	1	01	01	H9065_007_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9065	008	0	1	01	01	H9065_008_0	8	1	1111	2	1				2	1				2	1				2	1				1		1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9066	001	0	1	01	01	H9066_001_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H9066	002	0	1	01	01	H9066_002_0	4	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		4500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H9066	003	0	1	01	01	H9066_003_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1		2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H9068	001	0	1	20	08	H9068_001_0	1																																																																																																																																																							
H9068	002	0	1	20	08	H9068_002_0	1																																																																																																																																																							
H9096	001	0	1	02	01	H9096_001_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	once per 36 month period	2	2	1	6	Diagnostic x-ray: Once per calendar yearPeriodontal maintenance: Twice per year	2	1				2	1				2	2	1	6	Surgical periodontal services: Once per 36 monthsRoot planing and scaling: once per quadrant every 24 months.	2	1				2	2	1	6	Services are limited to once in a five-year period per tooth.	1		1				2					2																		2		1	11111111	45.00	45.00	45.00	45.00	0.00	45.00	95.00	95.00	595.00	595.00	45.00	595.00	95.00	95.00	595.00	595.00	2	2
H9096	002	0	1	02	01	H9096_002_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	once per 36 month period	2	2	1	6	Diagnostic x-ray: Once per calendar yearPeriodontal maintenance: Twice per year	2	1				2	1				2	2	1	6	Surgical periodontal services: Once per 36 monthsRoot planing and scaling: once per quadrant every 24 months.	2	1				2	2	1	6	Services are limited to once in a five-year period per tooth	1		1				2					2																		2		1	11111111	30.00	30.00	45.00	45.00	0.00	45.00	95.00	95.00	595.00	595.00	45.00	595.00	95.00	95.00	595.00	595.00	2	2
H9096	004	0	1	01	01	H9096_004_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	once per 36 month period	2	2	1	6	Diagnostic x-ray: Once per calendar yearPeriodontal maintenance: Twice per year	2	1				2	1				2	2	1	6	Surgical periodontal services: Once per 36 monthsRoot planing and scaling: once per quadrant every 24 months.	2	1				2	2	1	6	Services are limited to once in a five-year period per tooth.	1		1				2					2																		2		1	11111111	45.00	45.00	45.00	45.00	0.00	45.00	95.00	95.00	595.00	595.00	45.00	595.00	95.00	95.00	595.00	595.00	2	2
H9096	005	0	1	01	01	H9096_005_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	once per 36 month period	2	2	1	6	Diagnostic x-ray: Once per calendar yearPeriodontal maintenance: Twice per year	2	1				2	1				2	2	1	6	Surgical periodontal services: Once per 36 monthsRoot planing and scaling: once per quadrant every 24 months.	2	1				2	2	1	6	Services are limited to once in a five-year period per tooth.	1		1				2					2																		2		1	11111111	10.00	10.00	45.00	45.00	0.00	45.00	95.00	95.00	595.00	595.00	45.00	595.00	95.00	95.00	595.00	595.00	2	2
H9096	010	0	1	02	01	H9096_010_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	once per 36 month period	2	2	1	6	Diagnostic x-ray: Once per calendar yearPeriodontal maintenance: Twice per year	2	1				2	1				2	2	1	6	Surgical periodontal services: Once per 36 monthsRoot planing and scaling: once per quadrant every 24 months.	2	1				2	2	1	6	Services are limited to once in a five-year period per tooth.	1		1				2					2																		2		1	11111111	40.00	40.00	45.00	45.00	0.00	45.00	95.00	95.00	595.00	595.00	45.00	595.00	95.00	95.00	595.00	595.00	2	2
H9096	801	0	1	01	01	H9096_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9096	802	0	1	01	01	H9096_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9096	803	0	1	01	01	H9096_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9096	804	0	1	02	01	H9096_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9096	805	0	1	02	01	H9096_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9096	806	0	1	02	01	H9096_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9104	006	0	1	01	01	H9104_006_0	7	2		3					3										3																																														2		3					3					3					3					3					3					3											2					2																		2		1	01000000	10.00	10.00															1	2
H9147	001	0	1	02	01	H9147_001_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	3		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	2	1	6	Restorative: Fillings - 1 per tooth every 3 yearsRestorative Crowns - 1 per tooth every 5 years	2	1				2	2	1	6	Periodontal Root Planning and Scaling is covered 1 per quadrant every 2 years.	2	1				2	2	1	6	Prosthodontics (Dentures) - 1 set every 5 years	2						2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9153	001	0	1	01	01	H9153_001_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9179	001	0	1	01	01	H9179_001_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	30.00	30.00			0.00	0.00											2	2
H9179	002	0	1	01	01	H9179_002_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011001						2	1				2	1														2	1									1		1				2					1	00001001							50	50					50	50			2		1	01010000	40.00	40.00			0.00	0.00											2	2
H9179	003	0	1	01	01	H9179_003_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	30.00	30.00			0.00	0.00											2	2
H9179	801	0	1	01	01	H9179_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9179	802	0	1	01	01	H9179_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9185	001	0	1	20	08	H9185_001_0	1																																																																																																																																																							
H9185	002	0	1	20	08	H9185_002_0	1																																																																																																																																																							
H9191	001	0	1	01	01	H9191_001_0	5	1	1111	2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		1		3500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H9191	004	0	1	01	01	H9191_004_0	5	1	1111	2	2	1	3		2	2	1	3		2	2	1	3		2	2	1	3		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H9207	002	0	1	02	01	H9207_002_0	10	1	1110	2	2	3	3		2	2	3	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					2																		2		1	01000000	40.00	40.00															1	2
H9207	004	0	1	01	01	H9207_004_0	13	1	1110	2	2	3	3		2	2	3	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	5000.00	3		2					1	01000000	20	20															2		2																		1	2
H9207	012	0	1	02	01	H9207_012_0	11	1	1110	2	2	3	3		2	2	3	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					2																		2		1	01000000	45.00	45.00															1	2
H9207	013	0	1	02	01	H9207_013_0	10	1	1110	2	2	3	3		2	2	3	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					2																		2		1	01000000	45.00	45.00															1	2
H9207	014	0	1	02	01	H9207_014_0	11	1	1110	2	2	3	3		2	2	3	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					2																		2		1	01000000	40.00	40.00															1	2
H9207	015	0	1	02	01	H9207_015_0	12	1	1110	2	2	3	3		2	2	3	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					2																		2		1	01000000	40.00	40.00															1	2
H9207	016	0	1	01	01	H9207_016_0	12	1	1110	2	2	3	3		2	2	3	3							2	2	1	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	10000.00	3		2					1	01000000	20	20															2		2																		1	2
H9219	001	0	1	04	01	H9219_001_0	9	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9219	002	0	1	04	01	H9219_002_0	8	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
H9231	001	0	1	04	01	H9231_001_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	3500.00	3		2					2																		2		1	01000000	25.00	25.00															1	2
H9231	002	0	1	04	01	H9231_002_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						2						2					2																		2		1	01000000	50.00	50.00															1	2
H9231	005	0	1	04	01	H9231_005_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H9231	006	0	1	04	01	H9231_006_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H9231	007	0	1	04	01	H9231_007_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	3500.00	3		2					2																		2		1	01000000	30.00	30.00															1	2
H9231	010	0	1	04	01	H9231_010_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	3500.00	3		2					2																		2		1	01000000	30.00	30.00															1	2
H9239	001	0	1	48	05	H9239_001_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	4		2	2	1	3		2					2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		2																		1	2
H9252	001	0	1	20	08	H9252_001_0	1																																																																																																																																																							
H9252	002	0	1	20	08	H9252_002_0	1																																																																																																																																																							
H9258	001	0	1	01	01	H9258_001_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9266	001	0	1	20	08	H9266_001_0	1																																																																																																																																																							
H9266	003	0	1	20	08	H9266_003_0	1																																																																																																																																																							
H9276	805	0	1	01	01	H9276_805_0	12	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H9306	001	0	1	01	01	H9306_001_0	6	1	1111	2	2	1	6	Oral Exam Coverage: Oral Exams - Every 6 monthsComprehensive oral exam- once every 36 monthsLimited oral evaluations-3 per 12 months	2	2	1	4		2	2	1	4		2	2	1	6	coverage specifics in note	1		3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	coverage specifics in notes	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	2	2	1	6	coverage specifics in notes	2	2	1	6	Simple and surgical Extractions coveredCoronectemy once per tooth per lifetime	2	2	1	6	coverage specifics in notes	1		1				2					1	10001111							20	20	20	20	20	20	20	20	20	20	2		1	01000000	40.00	40.00															1	2
H9306	002	0	1	01	01	H9306_002_0	6	1	1111	2	2	1	6	coverage specifics in notes	2	2	1	4		2	2	1	4		2	2	1	6	coverage specifics in notes	1		5000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	1		1				2					1	10001111							20	20	20	20	20	20	20	20	20	20	2		1	01000000	40.00	40.00															1	2
H9306	003	0	1	01	01	H9306_003_0	5	1	1111	2	2	1	6	coverage specifics in notes	2	2	1	4		2	2	1	4		2	2	1	6	coverage specifics in notes	1		1500.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	1		1				2					1	10001111							20	20	20	20	20	20	20	20	20	20	2		1	01000000	40.00	40.00															1	2
H9306	004	0	1	01	01	H9306_004_0	5	1	1111	2	2	1	6	coverage specifics in notes	2	2	1	4		2	2	1	4		2	2	1	6	coverage specifics in notes	1		3500.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	1		1				2					1	01000000	20	20															2		2																		1	2
H9306	005	0	1	01	01	H9306_005_0	6	1	1111	2	2	1	6	coverage specifics in notes	2	2	1	4		2	2	1	4		2	2	1	6	coverage specifics in notes	1		3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	coverage specifics in notes	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	1		1				2					1	10001111							20	20	20	20	20	20	20	20	20	20	2		1	01000000	40.00	40.00															1	2
H9306	007	0	1	01	01	H9306_007_0	5	1	1111	2	2	1	6	coverage specifics in notes	2	2	1	4		2	2	1	4		2	2	1	6	coverage specifics in notes	1		3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	2	2	1	6	coverage specifics in notes	1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H9323	001	0	1	20	08	H9323_001_0	1																																																																																																																																																							
H9323	002	0	1	20	08	H9323_002_0	1																																																																																																																																																							
H9335	001	0	1	01	01	H9335_001_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9335	003	0	1	01	01	H9335_003_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	5000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9335	005	0	1	01	01	H9335_005_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	40.00	40.00															1	2
H9335	006	0	1	01	01	H9335_006_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9357	001	0	1	04	01	H9357_001_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	40.00	40.00															1	2
H9364	001	0	1	01	01	H9364_001_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9364	002	0	1	01	01	H9364_002_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9364	003	0	1	01	01	H9364_003_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9364	004	0	1	01	01	H9364_004_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	45.00	45.00	0.00	0.00	0.00	0.00											1	2
H9387	001	0	1	04	01	H9387_001_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	1000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	25.00	25.00															1	2
H9387	002	0	1	04	01	H9387_002_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9387	004	0	1	04	01	H9387_004_0	18	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9403	001	0	1	01	01	H9403_001_0	10	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					1	01000000	20	20															2		2																		2	2
H9403	003	0	1	01	01	H9403_003_0	8	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					2																		2		1	01000000	30.00	30.00															2	2
H9403	004	0	1	01	01	H9403_004_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	1500.00	3		2					2																		2		1	01000000	45.00	45.00															2	2
H9412	803	0	1	04	01	H9412_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9414	001	0	1	04	01	H9414_001_0	10	1	1111	2	2	2	3		2	2	4	6	Routine dental cleanings, Prophylaxis, is covered up to 2 times per plan year, and may be covered up to 4 per plan year with a documented history of chronic conditions.	2	2	2	3		2	2	1	6	An FMX and Pano xray 1 every 3 plan years. Bitewings 1 per calendar year; Other xrays covered when required for medically necessary treatments and/or diagnosis.	1	2	2300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	Comprehensive exams covered one procedure every 3 plan years.	2	2	1	6	Fillings and recementing a fallen crown are unlimited per plan year. Crowns and fillings/pins when preparing a crown, as well as bridges: limited to 1 per tooth every 60 months.	2	2	1	6	Root canals are covered for 1 initial root canal procedure and 1 retreatment procedure per tooth per member lifetime.	2	2	1	6	Scaling and root planning 1 per quad every 24 months. Cleaning buildup 1 every 3 plan yrs. Gum disease med placement 1 per site during SRP. Perio maintenance cleanings:  up to 4 per plan yr.	2	2	1	6	1 per tooth per lifetime of the member. Reshaping of the bone that surrounds the teeth or space covered 1 per quad per plan year, max of 4 on unique quads per plan year. Abscess drainage unlimited.	2	2	1	6	Complete or partial dentures 1 every 60 months. Immediate complete /partial dentures once per lifetime. Adjustments 2 per plan yr. Repairs 1 of each type per denture per plan yr. 4 Implants per yr.	1		1				2					1	01000000	20	20															2		2																		1	2
H9414	002	0	1	04	01	H9414_002_0	11	1	1111	2	2	2	3		2	2	4	6	Routine dental cleanings, Prophylaxis, is covered up to 2 times per plan year, and may be covered up to 4 per plan year with a documented history of chronic conditions.	2	2	2	3		2	2	1	6	An FMX and Pano xray 1 every 3 plan years. Bitewings 1 per calendar year; Other xrays covered when required for medically necessary treatments and/or diagnosis	1	2	2300.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	Diagnostic Services: Comprehensive exams covered one procedure every 3 plan years.	2	2	1	6	Fillings and recementing a fallen crown are unlimited per plan year. Crowns and fillings/pins when preparing a crown, as well as bridges: limited to 1 per tooth every 60 months.	2	2	1	6	Root canals are covered for 1 initial root canal procedure and 1 retreatment procedure per tooth per member lifetime.	2	2	1	6	Scaling and root planning 1 per quad every 24 months. Cleaning buildup 1 every 3 plan yrs. Gum disease med placement 1 per site during SRP. Perio maintenance cleanings:  up to 4 per plan yr.	2	2	1	6	1 per tooth per lifetime of the member. Reshaping of the bone that surrounds the teeth or space covered 1 per quad per plan year, max of 4 on unique quads per plan year. Abscess drainage unlimited.	2	2	1	6	Complete or partial dentures 1 every 60 months. Immediate complete /partial dentures once per lifetime. Adjustments 2 per plan yr. Repaimplants per arch per year, for a total of 4 implants per year.	1		1				2					2																		2		2																		1	2
H9428	001	0	1	04	01	H9428_001_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth.	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime.	1	2	2	1500.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	25.00	25.00															1	2
H9428	002	0	1	04	01	H9428_002_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	40.00	40.00	0.00	0.00	0.00	0.00											1	2
H9431	001	0	1	04	01	H9431_001_0	8	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2500.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	35.00	35.00			0.00	0.00											1	2
H9431	002	0	1	04	01	H9431_002_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9431	004	0	1	04	01	H9431_004_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	775.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9431	005	0	1	04	01	H9431_005_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9431	006	0	1	04	01	H9431_006_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9431	013	0	1	04	01	H9431_013_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	650.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9431	014	0	1	04	01	H9431_014_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9431	015	0	1	04	01	H9431_015_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9431	016	0	1	04	01	H9431_016_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9431	017	0	1	04	01	H9431_017_0	4	1	1110	2	2	4	3		2	2	2	3							2	2	1	3		2					2				2		2												2		1	1010	2						0.00	0.00			0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	2	6	Varies by procedure, see below.	2	2	4	6	Varies by procedure, see below.	2	2	1	6	Plan will cover 1 extraction per tooth per lifetime.	2	2	6	6	Varies by procedure, see below.	1	2	2	2000.00	3		2					1	10101111			20	50			20	50	20	20	20	50	20	50	50	50	2		1	01010000	40.00	40.00			0.00	0.00											1	2
H9431	018	0	1	04	01	H9431_018_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9431	019	0	1	04	01	H9431_019_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1750.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9431	801	0	1	04	01	H9431_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9431	802	0	1	04	01	H9431_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9438	001	0	1	20	08	H9438_001_0	1																																																																																																																																																							
H9438	002	0	1	20	08	H9438_002_0	1																																																																																																																																																							
H9460	001	0	1	01	01	H9460_001_0	8	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	40.00	40.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H9468	001	0	1	20	08	H9468_001_0	1	2																																																																																																																																																						
H9468	002	0	1	20	08	H9468_002_0	1	2																																																																																																																																																						
H9469	001	0	1	04	01	H9469_001_0	4	1	1111	2	1				2	1				2	1				2	1				1	2	2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9469	002	0	1	04	01	H9469_002_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9469	003	0	1	04	01	H9469_003_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9469	004	0	1	04	01	H9469_004_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9469	005	0	1	04	01	H9469_005_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9469	006	0	1	04	01	H9469_006_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9469	007	0	1	04	01	H9469_007_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9469	008	0	1	04	01	H9469_008_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9469	009	0	1	04	01	H9469_009_0	4	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9485	001	0	1	04	01	H9485_001_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	3		2	2	1	3		2	2	2	3		2	1				2	2	1	3		1	2	2	1500.00	3		2					2																		2		1	01000000	45.00	45.00															2	2
H9485	002	0	1	04	01	H9485_002_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	2	3		2					2				2		2												2		2		2												2	2	1	1001111											2	2	1	3		2	2	1	3		2	2	2	3		2	1				2	2	1	3		1	2	2	2500.00	3		2					2																		2		1	01000000	20.00	20.00															2	2
H9485	801	0	1	04	01	H9485_801_0	7	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9489	001	0	1	01	01	H9489_001_0	9	1	1111	2	2	3	3		2	2	3	3		2	2	1	3		2	2	1	3		2					2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	1150.00	3		2					1	10011111					0	0	0	0	0	0	0	0	0	0	0	0	2		1	01000000	40.00	40.00															2	2
H9489	801	0	1	01	01	H9489_801_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9489	802	0	1	02	01	H9489_802_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9489	803	0	1	01	01	H9489_803_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9489	804	0	1	02	01	H9489_804_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9489	805	0	1	01	01	H9489_805_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9489	806	0	1	02	01	H9489_806_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9489	807	0	1	01	01	H9489_807_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9489	808	0	1	02	01	H9489_808_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9525	003	0	1	01	01	H9525_003_0	5	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9525	004	0	1	01	01	H9525_004_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					1	10101111			50	50			50	50	70	70	70	70	50	50	70	70	2		1	01010000	0.00	0.00			0.00	0.00											1	2
H9525	006	0	1	01	01	H9525_006_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					1	10101111			50	50			50	50	70	70	70	70	50	50	70	70	2		1	01010000	0.00	0.00			0.00	0.00											1	2
H9525	007	0	1	01	01	H9525_007_0	5	1	1111	2	1				2	1				2	1				2	1				1		3500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9525	011	0	1	01	01	H9525_011_0	6	1	1111	4	1				4	1				4	1				4	1				1		1200.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9525	012	0	1	01	01	H9525_012_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9525	013	1	1	01	01	H9525_013_1	7	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9525	013	2	1	01	01	H9525_013_2	7	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9525	013	3	1	01	01	H9525_013_3	7	1	1111	4	1				4	1				4	1				4	1				1		2600.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9525	013	4	1	01	01	H9525_013_4	7	1	1111	4	1				4	1				4	1				4	1				1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9525	015	0	1	01	01	H9525_015_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					1	10101111			50	50			50	50	70	70	70	70	50	50	70	70	2		1	01010000	0.00	0.00			0.00	0.00											1	2
H9525	016	0	1	01	01	H9525_016_0	5	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9525	017	0	1	01	01	H9525_017_0	6	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9525	801	0	1	01	01	H9525_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9525	802	0	1	01	01	H9525_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9525	803	0	2	01	01	H9525_803_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9525	804	0	1	01	01	H9525_804_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9525	805	0	1	01	01	H9525_805_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9525	806	0	2	01	01	H9525_806_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9525	807	0	2	01	01	H9525_807_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9525	809	0	1	01	01	H9525_809_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9525	811	0	2	01	01	H9525_811_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9525	813	0	1	01	01	H9525_813_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9525	815	0	2	01	01	H9525_815_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9525	816	0	2	01	01	H9525_816_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9564	001	0	1	20	08	H9564_001_0	1																																																																																																																																																							
H9564	002	0	1	20	08	H9564_002_0	1																																																																																																																																																							
H9572	001	1	1	04	01	H9572_001_1	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	35.00															2	2
H9572	001	2	1	04	01	H9572_001_2	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	35.00															2	2
H9572	001	3	1	04	01	H9572_001_3	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	35.00															2	2
H9572	001	4	1	04	01	H9572_001_4	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	35.00															2	2
H9572	001	6	1	04	01	H9572_001_6	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	35.00															2	2
H9572	002	1	1	04	01	H9572_002_1	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	40.00															2	2
H9572	002	2	1	04	01	H9572_002_2	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	40.00															2	2
H9572	002	3	1	04	01	H9572_002_3	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	40.00															2	2
H9572	002	4	1	04	01	H9572_002_4	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	40.00															2	2
H9572	002	6	1	04	01	H9572_002_6	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	40.00															2	2
H9572	003	1	1	04	01	H9572_003_1	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		2																		2	2
H9572	003	2	1	04	01	H9572_003_2	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		2																		2	2
H9572	003	3	1	04	01	H9572_003_3	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		2																		2	2
H9572	003	4	1	04	01	H9572_003_4	5	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		2																		2	2
H9572	003	6	1	04	01	H9572_003_6	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals once per lifetime per tooth	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		2																		2	2
H9572	004	1	1	04	01	H9572_004_1	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	45.00															2	2
H9572	004	2	1	04	01	H9572_004_2	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	45.00															2	2
H9572	004	3	1	04	01	H9572_004_3	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	45.00															2	2
H9572	004	4	1	04	01	H9572_004_4	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	45.00															2	2
H9572	004	6	1	04	01	H9572_004_6	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	45.00															2	2
H9572	006	1	1	04	01	H9572_006_1	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	50.00															2	2
H9572	006	2	1	04	01	H9572_006_2	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	50.00															2	2
H9572	006	3	1	04	01	H9572_006_3	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	50.00															2	2
H9572	006	4	1	04	01	H9572_006_4	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	50.00															2	2
H9572	006	6	1	04	01	H9572_006_6	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	50.00															2	2
H9572	007	1	1	04	01	H9572_007_1	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	45.00															2	2
H9572	007	2	1	04	01	H9572_007_2	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	45.00															2	2
H9572	007	3	1	04	01	H9572_007_3	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	45.00															2	2
H9572	007	4	1	04	01	H9572_007_4	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	45.00															2	2
H9572	007	6	1	04	01	H9572_007_6	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical	1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	2	1	6	X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapicalExams - 2 per calendar year	4	2	1	6	Crowns - once per permanent tooth per 84 monthsCrown Repairs - 3 per permanent tooth per calendar yearFillings - once per tooth/surface per 48 months	2	2	1	6	Root canals - once per tooth per lifetime	4	2	1	6	Deep Cleaning - once per quadrant per 24 months	2	2	1	6	Extractions - once per tooth per lifetime	4	2	2	6	Oral Surgery - 2 per tooth per lifetimeBrush Biopsy - 2 per calendar year	1		1				2					2																		2		1	01000000	0.00	45.00															2	2
H9572	801	0	1	04	01	H9572_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9572	802	0	1	04	01	H9572_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9572	803	0	1	04	01	H9572_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9572	804	0	1	04	01	H9572_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9572	805	0	1	04	01	H9572_805_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9572	806	0	1	04	01	H9572_806_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9576	001	0	1	48	05	H9576_001_0	8	1	1111	2	2	1	3		2	2	2	3		2	2	1	3		2	2	9999	6	1 Bitewing X-ray annually, Single X-Rays as needed, 1 Full-Mouth X-Ray every 5 years	1		1000.00	6	Benefit covers  2 cleanings, 1 Exam, 1 Bitewing X-Ray,  1 Adult Fluoride Treatment annually, 1 Full-Mouth X-Ray every 5 years, Amalgam Fillings, and Denture Repairs, Single X-Rays as needed	2				2		2												2		2		2												2	2	1	1000000																															2	1				2						2					2																		2		2																		1	2
H9585	001	0	1	01	01	H9585_001_0	13	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9589	003	0	1	04	01	H9589_003_0	9	1	1111	2	2	1	4		2	2	1	4		2	2	1	3		2	2	2	6	Full mouth xrays-every 36 months. Bitewings- every 12 months per provider or location. Panoramic - every 36 months.	2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	2000.00	3		2					2																		2		1	01000000	50.00	50.00															2	2
H9590	001	0	1	01	01	H9590_001_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9592	001	0	1	20	08	H9592_001_0	1																																																																																																																																																							
H9592	002	0	1	20	08	H9592_002_0	1																																																																																																																																																							
H9614	001	0	1	04	01	H9614_001_0	12	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	0001010	3					3					4	1				3					4	1				3					3					1	2	2	500.00	3		2					2																		2		1	00001010							20.00	20.00			20.00	20.00					2	2
H9614	801	0	1	04	01	H9614_801_0	2	2																																																															2																																											2					2																		2		2																		1	2
H9614	802	0	1	04	01	H9614_802_0	2	2																																																															2																																											2					2																		2		2																		1	2
H9614	803	0	1	04	01	H9614_803_0	2	2																																																															2																																											2					2																		2		2																		1	2
H9614	804	0	1	04	01	H9614_804_0	2	2																																																															2																																											2					2																		2		2																		1	2
H9615	007	0	1	04	01	H9615_007_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	12 to 36 months depending on type of service	1	2	2000.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	2	1	6	24 to 60 months depending on type of service	2	2	1	6	1 per tooth in a lifetime	2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	2	1				2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H9615	008	0	1	04	01	H9615_008_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	12 to 36 months depending on type of service	1	2	1500.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	2	1	6	24 to 60 months depending on type of service	2	2	1	6	1 per tooth in a lifetime	2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	2	1				2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H9615	010	0	1	04	01	H9615_010_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	12 to 36 months depending on type of service	1	2	1500.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	2	1	6	24 to 60 months depending on type of service	2	2	1	6	1 per tooth in a lifetime	2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	2	1				2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H9615	012	0	1	04	01	H9615_012_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	12 to 36 months depending on type of service	1	2	2000.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	2	1	6	24 to 60 months depending on type of service	2	2	1	6	1 per tooth in a lifetime	2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	2	1				2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	1		1				2					2																		2		1	01000000	45.00	45.00															1	2
H9615	014	0	1	04	01	H9615_014_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	12 to 36 months depending on type of service	1	2	1500.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	2	1	6	24 to 60 months depending on type of service	2	2	1	6	1 per tooth in a lifetime	2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	2	1				2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H9615	015	0	1	04	01	H9615_015_0	14	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	1250.00	3		2					2																		2		1	01000000	40.00	40.00															1	2
H9615	016	0	1	04	01	H9615_016_0	13	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	1500.00	3		2					2																		2		1	01000000	35.00	35.00															1	2
H9615	017	0	1	04	01	H9615_017_0	12	1	1110	2	2	2	3		2	2	2	3							2	2	2	3		2					2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1	2	2	2000.00	3		2					2																		2		1	01000000	30.00	30.00															1	2
H9615	018	0	1	04	01	H9615_018_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	12 to 36 months depending on type of service	1	2	1750.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	2	1	6	24 to 60 months depending on type of service	2	2	1	6	1 per tooth in a lifetime	2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	2	1				2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H9615	019	0	1	04	01	H9615_019_0	11	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	2	6	12 to 36 months depending on type of service	1	2	2000.00	3		2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	2	1	6	24 to 60 months depending on type of service	2	2	1	6	1 per tooth in a lifetime	2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	2	1				2	2	1	6	12 to 60 months depending on type of service. Some services 1 per tooth in a lifetime	1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H9615	802	0	1	04	01	H9615_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9615	807	0	1	04	01	H9615_807_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9615	810	0	1	04	01	H9615_810_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9615	811	0	1	04	01	H9615_811_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
H9616	001	0	1	20	08	H9616_001_0	1																																																																																																																																																							
H9616	002	0	1	20	08	H9616_002_0	1																																																																																																																																																							
H9630	002	0	1	01	01	H9630_002_0	16	1	1111	2	2	2	3		2	2	4	3		2	2	1	3		2	2	1	6	DENTAL X-RAYS PERIODICITY – Bitewing X-rays are limited to four films per calendar year. Full mouth x-rays, including bitewing x-rays or a panorex, are payable once in a 5 year period.	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	1	1111111	2	1				2	2	1	6	16B Comprehensive Dental – DIAGNOSTIC PERIODICITY –  every 12 months per test.	2	2	1	6	16B Comprehensive Dental – RESTORATIVE PERIODICITY – every 12 to 84 months.	2	2	1	6	16B Comprehensive Dental – ENDODONTICS PERIODICITY – once per lifetime per tooth.	2	2	1	6	16B Comprehensive Dental – PERIODONTICS PERIODICITY – every 12 to 36 months or per lifetime. Periodontal prophylaxes, including prophylaxes (cleanings), are payable four times per calendar year.	2	1				2	2	1	6	PROSTHODONTICS PERIODICITY – every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY PERIODICITY – every 12 to 60 months or per lifetime. OTHER SERVICES PERIODICITY – every 6 to 60 months.	1		1				2					1	10101111			0	20			20	20	20	20	20	50	20	50	50	50	1	25.00	1	01010000	30.00	30.00			0.00	0.00											1	2
H9630	005	0	1	01	01	H9630_005_0	5	1	1111	2	2	2	3		2	2	4	3		2	2	1	3		2	2	1	6	DENTAL X-RAYS PERIODICITY – Bitewing X-rays are limited to four films per calendar year. Full mouth x-rays, including bitewing x-rays or a panorex, are payable once in a 5 year period.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	16B Comprehensive Dental – DIAGNOSTIC PERIODICITY –  every 12 months per test.	2	2	1	6	16B Comprehensive Dental – RESTORATIVE PERIODICITY – every 12 to 84 months.	2	2	1	6	16B Comprehensive Dental – ENDODONTICS PERIODICITY – once per lifetime per tooth.	2	2	1	6	16B Comprehensive Dental – PERIODONTICS PERIODICITY – every 12 to 36 months or per lifetime. Periodontal prophylaxes, including prophylaxes (cleanings), are payable four times per calendar year.	2	1				2	2	1	6	PROSTHODONTICS PERIODICITY – every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY PERIODICITY – every 12 to 60 months or per lifetime. OTHER SERVICES PERIODICITY – every 6 to 60 months.	1		1				2					1	10101111			0	20			20	20	20	20	20	50	20	50	50	50	1	25.00	1	01010000	35.00	35.00			0.00	0.00											1	2
H9630	008	0	1	01	01	H9630_008_0	16	1	1111	2	2	2	3		2	2	4	3		2	2	1	3		2	2	1	6	16A Preventive Dental - DENTAL X-RAYS PERIODICITY - Bitewing X-rays are limited to four films per calendar year.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2																																											2					2																		2		1	01000000	50.00	50.00															1	2
H9630	010	0	1	01	01	H9630_010_0	17	1	1111	2	2	2	3		2	2	4	3		2	2	1	3		2	2	1	6	DENTAL X-RAYS PERIODICITY – Bitewing X-rays are limited to four films per calendar year. Full mouth x-rays, including bitewing x-rays or a panorex, are payable once in a 5 year period.	1		3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	16B Comprehensive Dental – DIAGNOSTIC PERIODICITY –  every 12 months per test.	2	2	1	6	16B Comprehensive Dental – RESTORATIVE PERIODICITY – every 12 to 84 months.	2	2	1	6	16B Comprehensive Dental – ENDODONTICS PERIODICITY – once per lifetime per tooth.	2	2	1	6	16B Comprehensive Dental – PERIODONTICS PERIODICITY – every 12 to 36 months or per lifetime. Periodontal prophylaxes, including prophylaxes (cleanings), are payable four times per calendar year.	2	1				2	2	1	6	PROSTHODONTICS PERIODICITY – every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY PERIODICITY – every 12 to 60 months or per lifetime. OTHER SERVICES PERIODICITY – every 6 to 60 months.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9630	011	0	1	01	01	H9630_011_0	17	1	1111	2	2	2	3		2	2	4	3		2	2	1	3		2	2	1	6	DENTAL X-RAYS PERIODICITY – Bitewing X-rays are limited to four films per calendar year. Full mouth x-rays, including bitewing x-rays or a panorex, are payable once in a 5 year period.	1		4000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	16B Comprehensive Dental – DIAGNOSTIC PERIODICITY –  every 12 months per test.	2	2	1	6	16B Comprehensive Dental – RESTORATIVE PERIODICITY – every 12 to 84 months.	2	2	1	6	16B Comprehensive Dental – ENDODONTICS PERIODICITY – once per lifetime per tooth.	2	2	1	6	16B Comprehensive Dental – PERIODONTICS PERIODICITY – every 12 to 36 months or per lifetime. Periodontal prophylaxes, including prophylaxes (cleanings), are payable four times per calendar year.	2	1				2	2	1	6	PROSTHODONTICS PERIODICITY – every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY PERIODICITY – every 12 to 60 months or per lifetime. OTHER SERVICES PERIODICITY – every 6 to 60 months.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9630	013	0	1	01	01	H9630_013_0	16	1	1111	2	2	2	3		2	2	4	3		2	2	1	3		2	2	1	6	DENTAL X-RAYS PERIODICITY – Bitewing X-rays are limited to four films per calendar year. Full mouth x-rays, including bitewing x-rays or a panorex, are payable once in a 5 year period.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	16B Comprehensive Dental – DIAGNOSTIC PERIODICITY –  every 12 months per test.	2	2	1	6	16B Comprehensive Dental – RESTORATIVE PERIODICITY – every 12 to 84 months.	2	2	1	6	16B Comprehensive Dental – ENDODONTICS PERIODICITY – once per lifetime per tooth.	2	2	1	6	16B Comprehensive Dental – PERIODONTICS PERIODICITY – every 12 to 36 months or per lifetime. Periodontal prophylaxes, including prophylaxes (cleanings), are payable four times per calendar year.	2	1				2	2	1	6	PROSTHODONTICS PERIODICITY – every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY PERIODICITY – every 12 to 60 months or per lifetime. OTHER SERVICES PERIODICITY – every 6 to 60 months.	1		1				2					1	10101111			0	20			20	20	20	20	20	50	20	50	50	50	1	25.00	1	01010000	30.00	30.00			0.00	0.00											1	2
H9630	014	0	1	01	01	H9630_014_0	17	1	1111	2	2	2	3		2	2	4	3		2	2	1	3		2	2	1	6	DENTAL X-RAYS PERIODICITY – Bitewing X-rays are limited to four films per calendar year. Full mouth x-rays, including bitewing x-rays or a panorex, are payable once in a 5 year period.	1		2500.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	16B Comprehensive Dental – DIAGNOSTIC PERIODICITY –  every 12 months per test.	2	2	1	6	16B Comprehensive Dental – RESTORATIVE PERIODICITY – every 12 to 84 months.	2	2	1	6	16B Comprehensive Dental – ENDODONTICS PERIODICITY – once per lifetime per tooth.	2	2	1	6	16B Comprehensive Dental – PERIODONTICS PERIODICITY – every 12 to 36 months or per lifetime. Periodontal prophylaxes, including prophylaxes (cleanings), are payable four times per calendar year.	2	1				2	2	1	6	PROSTHODONTICS PERIODICITY – every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY PERIODICITY – every 12 to 60 months or per lifetime. OTHER SERVICES PERIODICITY – every 6 to 60 months.	1		1				2					1	10101111			0	20			20	20	20	20	20	50	20	50	50	50	1	25.00	1	01010000	35.00	35.00			0.00	0.00											1	2
H9649	001	0	1	20	08	H9649_001_0	1																																																																																																																																																							
H9649	002	0	1	20	08	H9649_002_0	1																																																																																																																																																							
H9656	001	0	1	01	01	H9656_001_0	4	1	1101	2	2	2	3							2	2	2	3		2	2	2	6	For x-rays, coverage is 1 bite wings every year: 1 full mouth x-ray every three years.	1		3500.00	3		2				2		2												2		2		2												2	2	1	1101100	2	2	1	6	Up to one incision or drainage per tooth per lifetime.						2	2	1	2		2	2	1	6	Root canals not to exceed one per tooth per lifetime.											2	2	7	6	One set of dentures every three years.Up to four denture repairs and adjustments per year.Up to two crowns/crown repair every calendar year, once every five years per tooth.	1		1				2					1	01000000	38	38															2		2																		1	2
H9656	002	0	1	01	01	H9656_002_0	4	1	1101	2	2	2	3							2	2	2	3		2	2	2	6	For x-rays, coverage is 1 bite wings every year: 1 full mouth x-ray every three years.	1		3500.00	3		2				2		2												2		2		2												2	2	1	1101100	2	2	1	6	Up to one incision or drainage per tooth per lifetime.						2	2	1	2		2	2	1	6	Root canals not to exceed one per tooth per lifetime.											2	2	7	6	One set of dentures every three years.Up to four denture repairs and adjustments per year.Up to two crowns/crown repair every calendar year, once every five years per tooth.	1		1				2					1	01000000	38	38															2		2																		1	2
H9662	801	0	1	01	01	H9662_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H9662	802	0	1	01	01	H9662_802_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H9678	001	0	1	04	01	H9678_001_0	12	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	Dental X-rays: 1 set per year	1	2	1500.00	3		2				2		2												2		2		2												1	2	1	1111111	2	2	1	6	Limits vary by procedure.	2	2	1	6	Limits vary by procedure.	2	2	1	6	Restorative Services: Limits vary by procedure, ranging from once every 24 months to once every 60 months per tooth.	2	2	1	6	Endodontics are limited to one surgery per tooth per lifetime.	2	2	1	6	Limits vary by procedure. Periodontic scaling and root planing is covered once every 24 months, per area.	2	2	1	6	Extractions are limited to one surgery per tooth per lifetime.	2	2	1	6	Prosthodontic limits vary by procedure. Dentures are limited to one set every 5 years. Crowns are limited to once every 5 years for each tooth.	1		1				2					2																		2		2																		1	2
H9686	001	0	1	01	01	H9686_001_0	12	1	1111	2	1				2	1				2	1				2	1				1		1000.00	4		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H9686	004	0	1	01	01	H9686_004_0	13	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		2	750.00	4		2					2																		2		2																		2	2
H9686	005	0	1	01	01	H9686_005_0	13	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H9686	801	0	1	01	01	H9686_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H9686	802	0	1	01	01	H9686_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H9686	803	0	1	01	01	H9686_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H9686	804	0	1	01	01	H9686_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H9690	001	0	1	01	01	H9690_001_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9699	007	0	1	01	01	H9699_007_0	3	1	1111	2	2	2	3		2	2	2	3		2	1				2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	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	1	1001011											2	2	1	3							2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	2	1				2	2	2	6	Periodicities for covered services range from every year to every five years depending on the service.	1		1				2					1	10001011							20	20			20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H9706	001	0	1	01	01	H9706_001_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		2	2000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H9706	002	0	1	01	01	H9706_002_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		2	4000.00	3		2					1	11111111	20	20	0	0	0	0	0	0	0	0	0	0	0	0	0	0	2		2																		2	2
H9706	005	0	1	01	01	H9706_005_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		2	1000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H9706	007	0	1	01	01	H9706_007_0	5	1	1110	2	2	2	3		2	2	2	3							2	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	1	1101111	2	1									2	1				2	1				2	1				2	1				2	1				1		2	5000.00	3		2					1	10101111			0	0			0	0	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															2	2
H9706	008	0	1	01	01	H9706_008_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1		2	1000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H9706	009	0	1	01	01	H9706_009_0	6	1	1110	2	2	2	3		2	2	2	3							2	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	1	0101001	2	1									2	1				3					3					2	1				3					1		2	2000.00	3		2					1	00101001			0	50			0	0					50	50			2		1	01000000	35.00	35.00															2	2
H9706	801	0	1	01	01	H9706_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9706	802	0	1	01	01	H9706_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9706	803	0	1	01	01	H9706_803_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9712	001	0	1	48	05	H9712_001_0	13	1	1111	2	2	1	4		2	2	1	4		2	2	6	6	Per lifetime.	2	2	1	6	Every 12months: Bitewing Radiographs Every 3yrs per arch (under age 21): Occlusal Radiograph Every 5yrs (over age 5): Panoramic Radiograph, Full mouth/Complete series everyday, with medical necessity	2					2				2		2												2		2		2												2	2	1	1011011						2	1				2	1									2	2	1	3		2	2	999	6	Everyday, based on medical necessity.	2	2	1	6	Prosthodontics(removable)-Once per 5yrs per arch when prognosis of complete/partial denture is at least 5yrs: Complete/partial dentures. Every day per medical need: Other Oral/Maxillofacial Surgery.	2						2					2																		2		2																		2	2
H9725	003	0	1	01	01	H9725_003_0	8	1	1111	2	1				2	1				2	1				2	1				1		2500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		1	2
H9725	005	0	1	01	01	H9725_005_0	5	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H9725	006	0	1	01	01	H9725_006_0	7	1	1111	2	1				2	1				2	1				2	1				1		2400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	15.00	15.00															1	2
H9725	008	0	1	01	01	H9725_008_0	7	1	1111	2	1				2	1				2	1				2	1				1		2100.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	10.00	10.00															1	2
H9725	009	1	1	01	01	H9725_009_1	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H9725	009	2	1	01	01	H9725_009_2	7	1	1111	2	1				2	1				2	1				2	1				1		2600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	20.00	20.00															1	2
H9725	009	3	1	01	01	H9725_009_3	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H9725	009	4	1	01	01	H9725_009_4	7	1	1111	2	1				2	1				2	1				2	1				1		1600.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H9725	010	0	1	01	01	H9725_010_0	7	1	1111	2	1				2	1				2	1				2	1				1		1200.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H9725	011	0	1	01	01	H9725_011_0	7	1	1111	2	1				2	1				2	1				2	1				1		1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	25.00	25.00															1	2
H9725	012	0	1	01	01	H9725_012_0	7	1	1111	2	1				2	1				2	1				2	1				1		500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	50.00	50.00															1	2
H9725	013	0	1	01	01	H9725_013_0	8	1	1111	2	1				2	1				2	1				2	1				1		4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H9725	014	0	1	01	01	H9725_014_0	7	1	1111	2	2	4	3		2	2	2	3		2	2	2	3		2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	1		20000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11101110	25.00	25.00	0.00	285.00			0.00	550.00	0.00	675.00	0.00	595.00			0.00	615.00	1	2
H9725	801	0	1	01	01	H9725_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H9730	003	0	1	01	01	H9730_003_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9730	004	0	1	01	01	H9730_004_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth.	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9730	005	0	1	02	01	H9730_005_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1		2	1000.00	3		2					1	10111111			40	40	40	40	40	40	40	40	40	40	40	40	40	40	2		1	01000000	35.00	35.00															1	2
H9730	007	0	1	01	01	H9730_007_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	45.00	45.00	0.00	0.00	0.00	0.00											1	2
H9730	009	0	1	01	01	H9730_009_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9730	010	0	1	01	01	H9730_010_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	1500.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9730	011	0	1	01	01	H9730_011_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9761	001	0	1	04	01	H9761_001_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1	2	2	1000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9761	002	0	1	04	01	H9761_002_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months	2	2	1	3																											2						2					2																		2		1	01110000	45.00	45.00	0.00	0.00	0.00	0.00											1	2
H9761	004	0	1	04	01	H9761_004_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1	2	2	3000.00	3		2					2																		2		1	11111111	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9763	003	1	1	01	01	H9763_003_1	9	1	1110	2	2	2	3		2	2	2	3							2	2	1	1		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	1		2	2	1	1		2	2	1	3		2	2	1	6	End Therapy limited to 1 per lifetime.  Other Services available.	2	2	1	3		2	1				2	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.  Other Oral/Maxillofacial Surgery, Other Services - No limit on prosthodontics (Dentures) adjustments.	1		1				2					2																		2		1	11101111	0.00	0.00	50.00	50.00			11.00	295.00	15.00	270.00	30.00	53.00	15.00	56.00	20.00	217.75	2	2
H9763	003	2	1	01	01	H9763_003_2	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	1		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	1		2	2	1	1		2	2	1	3		2	2	1	6	End Therapy limited to 1 per lifetime.  Other Services available.	2	2	1	3		2	1				2	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.  Other Oral/Maxillofacial Surgery, Other Services - No limit on prosthodontics (Dentures) adjustments.	1		1				2					2																		2		1	11101111	0.00	0.00	50.00	50.00			11.00	295.00	15.00	270.00	30.00	53.00	15.00	56.00	20.00	217.75	2	2
H9763	004	1	1	02	01	H9763_004_1	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	1		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	1		2	2	1	1		2	2	1	3		2	2	1	6	End Therapy limited to 1 per lifetime.  Other Services available.	2	2	1	3		2	1				2	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.  Other Oral/Maxillofacial Surgery, Other Services - No limit on prosthodontics (Dentures) adjustments.	1		1				2					2																		2		1	11101111	0.00	0.00	50.00	50.00			11.00	295.00	15.00	270.00	30.00	53.00	15.00	56.00	20.00	217.75	2	2
H9763	004	2	1	02	01	H9763_004_2	9	1	1110	2	2	2	3		2	2	2	3							2	2	1	1		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	1		2	2	1	1		2	2	1	3		2	2	1	6	End Therapy limited to 1 per lifetime.  Other Services available.	2	2	1	3		2	1				2	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.  Other Oral/Maxillofacial Surgery, Other Services - No limit on prosthodontics (Dentures) adjustments.	1		1				2					2																		2		1	11101111	0.00	0.00	50.00	50.00			11.00	295.00	15.00	270.00	30.00	53.00	15.00	56.00	20.00	217.75	2	2
H9763	005	0	1	01	01	H9763_005_0	8	1	1110	2	2	2	3		2	2	2	3							2	2	1	1		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	1		2	2	1	1		2	2	1	3		2	2	1	6	End Therapy limited to 1 per lifetime.  Other Services available.	2	2	1	3		2	1				2	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.  Other Oral/Maxillofacial Surgery, Other Services - No limit on prosthodontics (Dentures) adjustments.	1		1				2					2																		2		1	11101111	0.00	0.00	50.00	50.00			11.00	295.00	15.00	270.00	30.00	53.00	15.00	56.00	20.00	217.75	2	2
H9763	006	0	1	02	01	H9763_006_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	1		1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	1		2	2	1	1		2	2	1	3		2	2	1	6	End Therapy limited to 1 per lifetime.  Other Services available.	2	2	1	3		2	1				2	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.  Other Oral/Maxillofacial Surgery, Other Services - No limit on prosthodontics (Dentures) adjustments.	1		1				2					2																		2		1	11101111	0.00	0.00	50.00	50.00			11.00	295.00	15.00	270.00	30.00	53.00	15.00	56.00	20.00	217.75	2	2
H9808	004	0	1	04	01	H9808_004_0	10	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	see notes	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	4	2		2	2	4	3		2	2	1	6	see notes	1		1				2					1	10001101							20	20	20	20			20	20	20	20	2		2																		2	2
H9808	005	0	1	04	01	H9808_005_0	10	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	see notes	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	4	3		2	2	1	6	see notes	2	2	4	2		2	2	4	3		2	2	1	6	see notes	1		1				2					1	10001101							0	20	20	20			20	20	20	20	2		2																		2	2
H9808	009	0	1	04	01	H9808_009_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H9808	807	0	1	04	01	H9808_807_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	see notes	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	4	2		2	2	4	3		2	2	1	6	see notes	1		1				2					1	10001101							20	20	20	20			20	20	20	20	2		2																		2	2
H9808	808	0	1	04	01	H9808_808_0	5	1	1110	2	2	2	3		2	2	2	3							2	2	1	6	see notes	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	4	3		2	2	1	3		2	2	4	2		2	2	4	3		2	2	1	6	see notes	1		1				2					1	10001101							20	20	20	20			20	20	20	20	2		2																		2	2
H9811	801	0	1	01	01	H9811_801_0	13	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H9826	002	1	1	01	01	H9826_002_1	9	1	1110	2	2	1	4		2	2	1	4							2	2	1	3		1		4500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H9826	002	2	1	01	01	H9826_002_2	9	1	1110	2	2	1	4		2	2	1	4							2	2	1	3		1		4500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H9826	002	3	1	01	01	H9826_002_3	9	1	1110	2	2	1	4		2	2	1	4							2	2	1	3		1		4500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H9827	001	0	1	01	01	H9827_001_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	30.00	30.00			0.00	0.00											2	2
H9827	002	0	1	01	01	H9827_002_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	25.00	25.00			0.00	0.00											2	2
H9827	003	0	1	01	01	H9827_003_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011111						4	1				4	1				4	1				4	1				4	1				3					1		1				2					1	00001111							50	50	70	70	70	70	50	50			2		1	01010000	25.00	25.00			0.00	0.00											2	2
H9827	004	0	1	01	01	H9827_004_0	9	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-ray benefit is for either two series of bitewing x-rays per year, or one full mouth x-ray every 36 consecutive months.	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	1	0011001						2	1				2	1														2	1									1		1				2					1	00001001							50	50					50	50			2		1	01010000	45.00	45.00			0.00	0.00											2	2
H9827	801	0	1	01	01	H9827_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9827	802	0	1	01	01	H9827_802_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9830	001	0	1	20	08	H9830_001_0	1																																																																																																																																																							
H9830	002	0	1	20	08	H9830_002_0	1																																																																																																																																																							
H9834	001	0	1	01	01	H9834_001_0	4	1	1111	4	1				4	1				4	1				4	1				1		1550.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	30.00	30.00															2	2
H9834	003	0	1	01	01	H9834_003_0	4	1	1111	4	1				4	1				4	1				4	1				1		1250.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H9834	004	0	1	01	01	H9834_004_0	3	1	1111	4	1				4	1				4	1				4	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	40.00	40.00															2	2
H9834	005	0	1	01	01	H9834_005_0	3	1	1111	4	1				4	1				4	1				4	1				1		1200.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	30.00	30.00															2	2
H9834	006	0	1	01	01	H9834_006_0	4	1	1111	4	1				4	1				4	1				4	1				1		850.00	3		2				2		2												2		2		2												2	2	1	1111111	4	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	01000000	50.00	50.00															2	2
H9842	001	0	1	20	08	H9842_001_0	1																																																																																																																																																							
H9842	002	0	1	20	08	H9842_002_0	1																																																																																																																																																							
H9861	001	0	1	02	01	H9861_001_0	11	1	1111	2	2	2	6	Periodic oral exams are payable twice per calendar year. Comprehensive oral exams are payable once per 3 year period.	2	2	2	3		2	2	2	3		2	2	1	6	An FMX  and Pano xray 1 every 3 plan years. Bitewings 1 per calendar year; Other xrays covered when required for medically necessary treatments and/or diagnosis	1		2000.00	3		2				2		2												2		2		2												2	2	1	1001111											2	2	1	6	Fillings and crown repair are covered. Composite resin (white) restorations are covered services on posterior teeth. Crowns and onlays are covered 1 per 5 year period.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Root planing and scaling is payable once per quadrant every 24 months. Full mouth debridement is covered once per lifetime. Surgical periodontal services are payable once per 36 month period.	2	2	1	6	Extractions (simple or surgical) are payable once per tooth per lifetime.	2	2	1	6	Full/ partial dentures 1x in a 5-yr period. Denture relines and repairs 1x per 36 mo. Bridges 1x in 5 yrs. Bridge repairs 1x per 36 mo. Implants 1x per tooth in 5 yrs. Occlusal guards 1x per lifetime.	1		1				2					2																		2		2																		1	2
H9861	003	0	1	01	01	H9861_003_0	11	1	1111	2	2	2	6	Periodic oral exams are payable twice per calendar year. Comprehensive oral exams are payable once per 3 year period.	2	2	2	3		2	2	1	1		2	2	1	6	An FMX  and Pano xray 1 every 3 plan years. Bitewings 1 per calendar year; Other xrays covered when required for medically necessary treatments and/or diagnosis	1		3500.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	2	1	6	Minor restorative services are covered. Composite resin (white) restorations are covered on posterior teeth. Crowns and onlays are covered 1 per 5 year period.	2	2	1	6	Endodontic procedures are covered once per tooth per lifetime.	2	2	1	6	Surgical perio payable once per 36 month period. Perio: 2 per calendar year. Scaling and root planing: once per quadrant per 24 month; full mouth debridement once per lifetime.	2	2	1	6	Extractions (simple or surgical) are payable once per tooth per lifetime.	2	2	1	6	Full/ partial dentures 1x in a 5-yr period. Denture relines and repairs 1x per 36 mo. Bridges 1x in 5 yrs. Bridge repairs 1x per 36 mo. Implants 1x per tooth in 5 yrs. Occlusal guards 1x per lifetime.	1		1				2					2																		2		2																		1	2
H9869	001	0	1	48	05	H9869_001_0	5	1	1110	2	2	1	4		2	2	1	4							2	2	1	4		2					2				2		2												2		2		2												1	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				2						2					2																		2		2																		1	2
H9876	001	0	1	04	01	H9876_001_0	9	1	1111	2	2	2	3		2	2	4	6	Routine dental cleanings, Prophylaxis, is covered up to 2 times per plan year, and may be covered up to 4 per plan year with a documented history of chronic conditions.	2	2	2	3		2	2	1	6	An FMX  and Pano xray 1 every 3 plan years. Bitewings 1 per calendar year; Other xrays covered when required for medically necessary treatments and/or diagnosis	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	Diagnostic Services: Comprehensive exams covered one procedure every 3 plan years.	2	2	1	6	Fillings and recementing a fallen crown are unlimited per plan year. Crowns and fillings/pins when preparing a crown, as well as bridges: limited to 1 per tooth every 60 months.	2	2	1	6	Root canals are covered for 1 initial root canal procedure and 1 retreatment procedure per tooth per member lifetime.	2	2	1	6	Scaling and root planning 1 per quad every 24 months. Cleaning buildup 1 every 3 plan yrs. Gum disease med placement 1 per site during SRP. Perio maintenance cleanings:  up to 4 per plan yr.	2	2	1	6	1 per tooth per lifetime of the member. Reshaping of the bone that surrounds the teeth or space covered 1 per quad per plan year, max of 4 on unique quads per plan year. Abscess drainage unlimited.	2	2	1	6	Complete or partial dentures 1 every 60 months. Immediate complete /partial dentures once per lifetime. Adjustments 2 per plan yr. Repairs 1 of each type per denture per plan yr. 4 Implants per yr.	1		1				2					2																		2		2																		1	2
H9876	002	0	1	04	01	H9876_002_0	9	1	1111	2	2	2	3		2	2	4	6	Routine dental cleanings, Prophylaxis, is covered up to 2 times per plan year, and may be covered up to 4 per plan year with a documented history of chronic conditions.	2	2	2	3		2	2	1	6	An FMX  and Pano xray 1 every 3 plan years. Bitewings 1 per calendar year; Other xrays covered when required for medically necessary treatments and/or diagnosis	1	2	3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	2	1	6	Comprehensive exams covered one procedure every 3 plan years.	2	2	1	6	Fillings and recementing a fallen crown are unlimited per plan year. Crowns and fillings/pins when preparing a crown, as well as bridges: limited to 1 per tooth every 60 months.	2	2	1	6	Root canals are covered for 1 initial root canal procedure and 1 retreatment procedure per tooth per member lifetime.	2	2	1	6	Scaling and root planning 1 per quad every 24 months. Cleaning buildup 1 every 3 plan yrs. Gum disease med placement 1 per site during SRP. Perio maintenance cleanings:  up to 4 per plan yr.	2	2	1	6	1 per tooth per lifetime of the member. Reshaping of the bone that surrounds the teeth or space covered 1 per quad per plan year, max of 4 on unique quads per plan year. Abscess drainage unlimited.	2	2	1	6	Complete or partial dentures 1 every 60 months. Immediate complete /partial dentures once per lifetime. Adjustments 2 per plan yr. Repairs 1 of each type per denture per plan yr. 4 Implants per yr.	1		1				2					2																		2		2																		1	2
H9884	001	0	1	04	01	H9884_001_0	11	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H9884	003	0	1	04	01	H9884_003_0	10	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H9884	004	0	1	04	01	H9884_004_0	10	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H9884	005	0	1	04	01	H9884_005_0	10	1	1111	2	1				2	1				2	1				2	1				1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H9884	006	0	1	04	01	H9884_006_0	10	1	1111	2	1				2	1				2	1				2	1				1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H9884	007	0	1	04	01	H9884_007_0	10	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H9884	008	0	1	04	01	H9884_008_0	10	1	1111	2	1				2	1				2	1				2	1				1	2	1250.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H9884	011	0	1	04	01	H9884_011_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	3000.00	3		2					2																		2		1	01000000	30.00	30.00															1	2
H9884	012	0	1	04	01	H9884_012_0	10	1	1111	2	1				2	1				2	1				2	1				1	2	2000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	30.00	30.00															1	2
H9884	013	0	1	04	01	H9884_013_0	10	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	1	2	1000.00	3		2				2		2												2		2		2												2	2	1	0011011						2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.						2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.						1		1				2					2																		2		1	01000000	40.00	40.00															1	2
H9888	001	0	1	04	01	H9888_001_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	6000.00	3		2					2																		2		1	01000000	20.00	20.00															1	2
H9888	002	0	1	04	01	H9888_002_0	11	1	1111	2	2	2	6	Plan covers up to two oral exams per year.	2	2	2	6	Plan covers up to two basic cleanings per year.	2	2	2	6	Plan covers up to two fluoride treatments per year.	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2	2	2	6	Plan covers diagnostic services such as patient assessments two times per year.	2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2	2	1	6	Plan covers periodontal services, such as deep cleaning once every three years.	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2	2	1	6	Plan covers services such as dentures (once every five years), crowns (once per tooth every five years).	1	2	2	5000.00	3		2					2																		2		1	01000000	20.00	20.00															1	2
H9900	001	0	1	01	01	H9900_001_0	16	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	0110000	2	2	1	6	Every date of service to 24 months.	2	2	1	3																											2						2					2																		2		1	01110000	50.00	50.00	0.00	0.00	0.00	0.00											1	2
H9900	002	0	1	01	01	H9900_002_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9900	003	0	1	01	01	H9900_003_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	4000.00	3		2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9900	004	0	1	01	01	H9900_004_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															1	2
H9900	005	0	1	01	01	H9900_005_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	35.00	35.00															1	2
H9900	006	0	1	01	01	H9900_006_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9900	007	0	1	01	01	H9900_007_0	6	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 60 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth OR once per tooth per lifetime.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	3000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9900	008	0	1	01	01	H9900_008_0	4	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9900	009	0	1	01	01	H9900_009_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	Every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	Every date of service to 24 months.	2	2	1	3		2	2	1	6	Every 12 to 84 months per tooth	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	PROSTHODONTICS every 12 to 84 months. OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime. OTHER SERVICES every 6 to 60 months	1		2	2000.00	3		2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
H9904	001	0	1	04	01	H9904_001_0	6	1	1111	2	2	2	6	Comprehensive oral exam is covered once every 36 months.	2	2	2	3		2	2	2	3		2	2	1	6	One vertical bitewing imaging and one panoramic imaging covered once every 36 mos. Intraoral occlucal imaging is covered twice every 24 mos. Intraoral-complete series is covered once every 36 mos.	2					2				2		2												2		2		2												2	2	1	1011111						2	2	1	3		2	2	1	2		2	2	1	6	See notes below	2	2	1	1		2	2	1	6	Extractions are covered once per tooth per lifetime.	2	2	1	6	Complete and partial dentures are covered once per 60 months. Adjustments to removable prostheses are covered twice per 12 months. Repairs to dentures are covered once per arch or tooth per 12 months.	1	2	2	2000.00	3		2					1	10011111					20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	45.00	45.00															2	2
H9907	001	0	1	04	01	H9907_001_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	1500.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	01000000	45.00	45.00															2	2
H9907	801	0	1	04	01	H9907_801_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9907	802	0	1	04	01	H9907_802_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9907	803	0	1	04	01	H9907_803_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9907	804	0	1	04	01	H9907_804_0	1	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9909	001	0	1	01	01	H9909_001_0	6	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9917	001	0	1	01	01	H9917_001_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	1		2400.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		1				2					1	01000000	20	20															2		2																		1	2
H9917	002	0	1	01	01	H9917_002_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		1				2					1	01000000	20	20															2		2																		1	2
H9917	003	0	1	01	01	H9917_003_0	8	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	2					2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		2	2000.00	3		2					1	01000000	20	20															2		2																		1	2
H9917	004	0	1	01	01	H9917_004_0	10	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	One bitewing radiograph is covered annually. One panoramic radiograph or one complete series is covered every 3 years. Intraoral occlusal radiographs are covered twice a year.	1		3000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	2	1	6	Palliative treatment of dental pain; 2 every calendar yearOcclusal guard, analysis, and adjustments are covered once every three (3) years.Teledentistry covered two (2) every calendar years.	2	1				2	2	1	6	Fillings are covered; no duplicate surface tooth for 2 years. Fixed prosthodontic services are a covered benefit once per tooth every 5 years. Continued in notes below.	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2	2	1	6	Scaling and root planing once per quadrant every two (2) years. Periodontal maintenance is a covered benefit two (2) per year.Continued in notes below.	2	2	1	6	Simple and Surgical extractions are a covered benefit once per tooth per lifetime.  The extraction of an impacted tooth is a covered benefit.Continued in notes below.	2	2	1	6	Prosthodontic services include complete and partial dentures once per arch every five (5) years.Denture adjustments and repairs are a covered benefit once per arch every year.Continued in notes.	1		1				2					1	01000000	20	20															2		2																		1	2
H9940	001	0	1	01	01	H9940_001_0	11	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9942	001	0	1	04	01	H9942_001_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		2	2
H9943	001	0	1	02	01	H9943_001_0	13	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1		2000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H9943	002	0	1	02	01	H9943_002_0	13	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1		2000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H9943	003	0	1	01	01	H9943_003_0	14	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1		2000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H9943	004	0	1	01	01	H9943_004_0	15	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		1		2000.00	3		2				2		2												2		2		2												2	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H9943	005	0	1	02	01	H9943_005_0	13	1	1111	2	2	1	4		2	2	1	4		2	2	1	4		2	2	1	1		2					2				2		2												2		2		2												2	1	2		3					3					3					3					3					3					3											2					2																		2		2																		2	2
H9943	801	0	1	01	01	H9943_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H9943	802	0	1	01	01	H9943_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H9943	803	0	1	01	01	H9943_803_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H9943	804	0	1	01	01	H9943_804_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
H9946	001	0	1	04	01	H9946_001_0	7	1	1110	2	2	2	3		2	2	2	3							2	2	1	3		1	2	4000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		2	2
H9952	001	0	1	01	01	H9952_001_0	6	1	1100	2	2	1	3												2	2	1	6	The plan covers one full mouth x-ray per five years.	2					2				2		2												2		2		2												2	2	1	0000100																2	2	1	6	Plan covers endodontic services of: molar root canal one per tooth per lifetime, root canal retreatment 1 per tooth per lifetime only covered if billed 24 months after original root canal.																2						2					1	01000000	20	20															2		2																		2	2
H9955	001	0	1	01	01	H9955_001_0	5	1	1111	2	1				2	1				2	1				2	1				1		1000.00	3		2				2		2												2		2		2												2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		2																		2	2
H9955	002	0	1	01	01	H9955_002_0	7	1	1111	2	2	2	3		2	2	2	3		2	2	2	3		2	2	1	6	X-Rays: Periapicals up to 6 per year, Bitewings up to 4 per year, Panoramic up to one every 5 years.	2					2				2		2												2		2		2												2	2	2																																											2					2																		2		2																		2	2
H9955	003	0	1	01	01	H9955_003_0	6	2																																																															2																																											2					2																		2		2																		2	2
H9955	004	0	1	01	01	H9955_004_0	5	2																																																															2																																											2					2																		2		1	01000000	50.00	50.00															2	2
H9976	002	0	1	04	01	H9976_002_0	17	1	1111	2	2	2	3		2	2	2	3		2	2	1	3		2	2	1	6	every 12 to 36 months	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2	1	1111111	2	2	1	6	every date of service to 24 months.	2	2	1	3		2	2	1	6	16B Comprehensive Dental - RESTORATIVE SERVICES every 12 to 84 months.	2	2	1	6	ENDODONTICS once per tooth.	2	2	1	6	PERIODONTICS every 6 to 36 months.	2	2	1	6	EXTRACTIONS once per tooth.	2	2	1	6	OTHER ORAL/MAXILLOFACIAL SURGERY every 12 to 60 months or per lifetime	1	2	2	1500.00	3		2					1	10111111			20	20	20	20	20	20	20	20	20	20	20	20	20	20	2		1	01000000	40.00	40.00															1	2
H9986	001	0	1	01	01	H9986_001_0	6	1	1110	2	2	1	4		2	2	1	4							2	2	1	3		1		3500.00	3		2				2		2												2		2		2												1	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H9986	002	0	1	01	01	H9986_002_0	6	1	1110	2	2	1	4		2	2	1	4							2	2	1	3		1		3500.00	3		2				2		2												2		2		2												1	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H9986	003	0	1	01	01	H9986_003_0	6	1	1110	2	2	1	4		2	2	1	4							2	2	1	3		1		3500.00	3		2				2		2												2		2		2												1	2	1	1011111						2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					1	01000000	20	20															2		2																		1	2
H9998	001	0	1	20	08	H9998_001_0	1																																																																																																																																																							
H9998	002	0	1	20	08	H9998_002_0	1																																																																																																																																																							
R0110	001	0	1	31	11	R0110_001_0	6	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R0110	003	0	1	31	11	R0110_003_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R0110	801	0	1	31	11	R0110_801_0	5	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R0110	802	0	1	31	11	R0110_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R0759	001	0	1	31	11	R0759_001_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
R0759	002	0	1	31	11	R0759_002_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2																																											2					1	01000000	20	20															2		2																		1	2
R0759	003	0	1	31	11	R0759_003_0	4	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R0865	001	0	1	31	11	R0865_001_0	8	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Fillings unlimited per year, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime, crown recementation 1 every 5 years	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	10	6	Denture adj, rebase, reline, repair, and tissue conditioning 1/year, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R0865	003	0	1	31	11	R0865_003_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	40.00	40.00			0.00	0.00	25.00	25.00									1	2
R0865	801	0	1	31	11	R0865_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R0865	802	0	1	31	11	R0865_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R0923	001	0	1	31	11	R0923_001_0	12	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	3000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												1	2	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	amalgam/composite filling $25 unlimited/year, bridge/crown recementation $25 1/ 5 years, crown and other restorative services - core buildup and prefabr post and core 50% up to 1/ tooth per lifetime	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	14	6	denture adj,rebase,reline,repair, tissue cond 1/yr, bridges-crown 2/5 yrs, bridges-pontic, complete+prtl dentures 1/5 yrs, occlusal adj 1/3 yrs, oral surgery 2/yr, restoration implant 1/tooth/lifetime	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	35.00	35.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
R0923	002	0	1	31	11	R0923_002_0	18	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
R0923	801	0	1	31	11	R0923_801_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R0923	802	0	1	31	11	R0923_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R1390	001	0	1	31	11	R1390_001_0	5	1	1111	4	2	3	6	Oral Exams services include emergency diagnostic exam up to 1 per year, periodic oral exam up to 2 per year.	4	2	6	6	Prophylaxis (cleaning) services include periodontal maintenance up to 4 per year, prophylaxis (cleaning) up to 2 per year.	4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
R1390	002	0	1	31	11	R1390_002_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
R1390	003	0	1	31	11	R1390_003_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R1390	801	0	1	31	11	R1390_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R1390	802	0	1	31	11	R1390_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R1532	001	0	1	31	11	R1532_001_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R1532	002	0	1	31	11	R1532_002_0	7	1	1111	2	1				2	1				2	1				2	1				1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R1532	801	0	1	31	11	R1532_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R1532	802	0	1	31	11	R1532_802_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R2604	001	0	1	31	11	R2604_001_0	5	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
R2604	002	0	1	31	11	R2604_002_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R2604	003	0	1	31	11	R2604_003_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
R2604	005	0	1	31	11	R2604_005_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
R3175	003	0	1	31	11	R3175_003_0	4	2																																																															2																																											2					1	01000000	20	20															2		2																		1	2
R3332	001	0	1	31	11	R3332_001_0	9	2																																																															2																																											2					2																		2		1	01000000	50.00	50.00															1	2
R3392	001	0	1	31	11	R3392_001_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	2	3		4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R3392	002	0	1	31	11	R3392_002_0	9	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000	3					4	2	1	1		4	2	2	3		3					3					3					3					1		1				2					2																		2		1	01011000	50.00	50.00			0.00	0.00	25.00	25.00									1	2
R3392	004	0	1	31	11	R3392_004_0	9	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R3392	801	0	1	31	11	R3392_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R3392	802	0	1	31	11	R3392_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R3444	008	0	1	31	11	R3444_008_0	6	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	1	2	3000.00	3		2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	1111111	2	1				2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	2	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	01000000	20	20															2		1	10111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R3444	009	0	1	31	11	R3444_009_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	6	Periodicity varies for different types of dental x-rays. Contact plan for details.	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	1	1111111	4	1				4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	4	2	1	6	Periodicity varies for specific services within each coverage category. Contact plan for services covered within each category and periodicity, limitations and exclusions that apply to each service.	1		1				2					1	11000000	20	20													0	50	2		1	00111111			0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00			1	2
R3444	012	0	1	31	11	R3444_012_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
R3887	001	0	1	31	11	R3887_001_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Fillings up to unlimited per year, recementation of crown up to 1 every 5 years, recementation of bridges up to 1 every 5 years, crown and other restorative service up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Prosthodontics, Other Oral/Maxillofacial Surgery-Bridges-crown up to 2 every 5 years, bridges-ponic  up to 1 every 5 years, oral surgery up to 2 per year, occlusal adjustments up to 1 every 3 years.	1		1				2					2																		2		1	11111111	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R3887	002	0	1	31	11	R3887_002_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative services include fillings up to unlimited per year, recementation of bridge and crown up to 1 every 5 years, crown and other restorative services up to 1 per tooth per lifetime.	4	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges-crown 2/5 yrs, bridges-pontic up to 1/5 yrs, oral surgery up to 2 per year, occlusal adjustments up to 1 every 3 years.	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R3887	801	0	1	31	11	R3887_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R3887	802	0	1	31	11	R3887_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R4182	001	0	1	31	11	R4182_001_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	2	2	2	3		2	2	1	1		2	2	4	6	Fillings unlimited per year, bridge and crown recementation 1 every 5 years, crown and other restorative services - core buildup and prefabricated post and core 1 per tooth per lifetime	2	2	2	6	Endodontics include root canal, and root canal retreatment up to 1 per tooth per lifetime.	2	2	2	1		2	1				2	2	13	6	Denture adj., rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj. 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R4182	003	0	1	31	11	R4182_003_0	8	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010						2	2	1	1		2	1									2	2	2	1												1		1				2					2																		2		1	01011010	45.00	45.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
R4182	004	0	1	31	11	R4182_004_0	8	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010						2	2	1	1		2	1									2	2	2	1												1		1				2					2																		2		1	01011010	45.00	45.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
R4182	801	0	1	31	11	R4182_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R4182	802	0	1	31	11	R4182_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R4487	001	0	1	31	11	R4487_001_0	12	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
R4845	001	0	1	31	11	R4845_001_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	35.00	35.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
R4845	002	0	1	31	11	R4845_002_0	5	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
R4845	801	0	1	31	11	R4845_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R4845	802	0	1	31	11	R4845_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R5329	001	0	1	31	11	R5329_001_0	5	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
R5342	001	0	1	31	11	R5342_001_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
R5342	002	0	1	31	11	R5342_002_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
R5342	005	0	1	31	11	R5342_005_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
R5342	006	0	1	31	11	R5342_006_0	5	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
R5361	001	0	1	31	11	R5361_001_0	7	1	1111	4	2	3	6	Oral Exams services include emergency diagnostic exam up to 1 per year, periodic oral exam up to 2 per year.	4	2	6	6	Prophylaxis (cleaning) services include periodontal maintenance up to 4 per year, prophylaxis (cleaning) up to 2 per year.	4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	3	6	Fillings up to unlimited per year, crown and other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime, crown recementation up to 1 every 5 years	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	6	Periodontics services include scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years, scaling for moderate inflammation up to 1 every 3 years.	4	1				4	2	10	6	Denture adjustments, rebase, reline, repair, and tissue conditioning 1 per year, complete dentures and partial dentures 1 every 5 years, occlusal adjustment 1 every 3 years, oral surgery 2 per year	1		1				2					2																		2		1	11111111	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R5361	002	0	1	31	11	R5361_002_0	5	1	1111	4	2	3	6	Oral Exams services include emergency diagnostic exam up to 1 per year, periodic oral exam up to 2 per year.	4	2	6	6	Prophylaxis (cleaning) services include periodontal maintenance up to 4 per year, prophylaxis (cleaning) up to 2 per year.	4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					1	01000000	20	20															2		1	00010000					0.00	0.00											1	2
R5361	801	0	1	31	11	R5361_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R5361	802	0	1	31	11	R5361_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R5495	001	0	1	31	11	R5495_001_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative services include fillings up to unlimited per year, bridge and crown recementation up to 1/5 years, crown and other restorative services up to 1 per tooth per lifetime.	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	13	6	Denture adj, rebase, reline, repair, and tissue conditioning 1/year, bridges-crown 2/5 years, bridges-pontic, complete and partial dentures 1/5 years, occlusal adj., 1/3 years, oral surgery 2/year	1		1				2					2																		2		1	11111111	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R5495	002	0	1	31	11	R5495_002_0	7	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	1111111	4	2	2	3		4	2	1	1		4	2	4	6	Restorative services include fillings up to unlimited per year, bridge recementation and crown recementation up to 1 every 5 years, crown and other restorative services up to 1 per tooth per lifetime	4	2	2	6	Endodontics services include root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	1				4	2	6	6	Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services include bridges-crown up to 2/5 yrs, bridges-pontic up to 1/5 yrs, occlusal adjustment up to 1/3 yrs, oral surgery up to 2 per yr.	1		1				2					2																		2		1	11111111	50.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R5495	801	0	1	31	11	R5495_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R5495	802	0	1	31	11	R5495_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R5826	005	0	1	31	11	R5826_005_0	7	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011000						2	2	1	1		2	2	2	3																						1		1				2					2																		2		1	01011000	45.00	45.00			0.00	0.00	25.00	25.00									1	2
R5826	018	0	1	31	11	R5826_018_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, and panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111011	2	2	2	3		2	2	1	1		2	2	4	6	Restorative services include fillings $25 up to 2 per year, recementation of crown $25 up to 1 every 5 years, crown 50% up to 1 per tooth per lifetime.						2	2	2	1		2	2	2	3		2	2	8	6	Denture adjustments, rebase, reline, repair, and tissue conditioning up to 1 per year, complete dentures and partial dentures up to 1 every 5 years, occlusal adjustment up to 1 every 3 years.	1		1				2					1	10011000					0	0	50	50							50	50	2		1	01101011	30.00	30.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
R5826	074	0	1	31	11	R5826_074_0	6	1	1111	2	2	3	3		2	2	6	3		2	2	2	3		2	2	3	6	Bitewing and intraoral x-rays each 1 set per year, panoramic film or diagnostic x-rays 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000						2	2	1	1																											2						2					2																		2		1	01010000	50.00	50.00			0.00	0.00											1	2
R5826	805	0	1	31	11	R5826_805_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R5826	819	0	1	31	11	R5826_819_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R5941	013	0	1	31	11	R5941_013_0	7	1	1111	4	1				4	1				4	1				4	1				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	1	1111111	2	1				4	1				4	1				4	1				4	1				4	1				4	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R5941	014	0	1	31	11	R5941_014_0	8	1	0110	4	2	1	3		4	2	1	3		3					3					2					2				2		2												2		1	0110	2				0.00	0.00	0.00	0.00					2	2	2							3					3					3					3					3					3											2					2																		2		1	01000000	0.00	0.00															1	2
R6694	003	0	1	31	11	R6694_003_0	8	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R6694	005	0	1	31	11	R6694_005_0	7	1	1111	2	1				2	1				2	1				2	1				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	1	1111111	2	1				2	1				2	1				2	1				2	1				2	1				2	1				1		1				2					2																		2		1	11111111	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1	2
R6694	006	0	1	31	11	R6694_006_0	9	1	1110	2	2	4	3		2	2	2	3							2	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	2		3					3					3					3					3					3					3											2					2																		2		1	01000000	50.00	50.00															1	2
R6801	008	0	1	31	11	R6801_008_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2																																											2					2																		2		1	01000000	0.00	0.00															1	2
R6801	009	0	1	31	11	R6801_009_0	5	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
R6801	011	0	1	31	11	R6801_011_0	5	1	1111	2	2	2	3		2	2	3	3		2	2	2	3		2	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2																																											2					1	01000000	20	20															2		2																		1	2
R6801	012	0	1	31	11	R6801_012_0	6	2		3					3					3					3																																														2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
R7220	001	0	1	31	11	R7220_001_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	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	1	0011010	3					4	2	1	1		4	1				3					4	2	2	1		3					3					1		1				2					2																		2		1	01011010	40.00	40.00			0.00	0.00	0.00	0.00			0.00	0.00					1	2
R7220	002	0	1	31	11	R7220_002_0	4	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
R7220	801	0	1	31	11	R7220_801_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R7220	802	0	1	31	11	R7220_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R7315	001	0	1	31	11	R7315_001_0	8	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	1	2	1000.00	3		2				1	1111	2				0	0	0	0	0	0	0	0	2		2		2												2	2	1	1111111	4	2	2	3		4	2	1	1		4	2	6	6	Amalgam and/or composite filling 2/year; bridge recementation and crown recementation 1/5 years; crown and other restorative services - core buildup and prefabricated post and core 1/tooth/lifetime.	4	2	2	6	Root canal and root canal retreatment up to 1 per tooth per lifetime.	4	2	2	1		4	2	2	3		4	2	6	6	Bridges-crown up to 2 every 5 years, bridges-pontic up to 1 every 5 years, occlusal adjustment up to 1 every 3 years, oral surgery up to 2 per year	1		1				2					1	10011100					0	0	50	50	50	50					50	50	2		1	01101011	30.00	30.00	25.00	25.00			25.00	25.00			25.00	25.00	25.00	25.00			1	2
R7315	002	0	1	31	11	R7315_002_0	6	1	1111	4	2	3	3		4	2	6	3		4	2	2	3		4	2	3	6	Dental X-Rays services include bitewing x-rays and intraoral x-rays up to 1 set(s) per year, panoramic film or diagnostic x-rays up to 1 every 5 years.	2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	1	0010000	3					4	2	1	1		3					3					3					3					3					2						2					2																		2		1	01010000	45.00	45.00			0.00	0.00											1	2
R7315	801	0	1	31	11	R7315_801_0	3	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R7315	802	0	1	31	11	R7315_802_0	2	2																																																															2																																											2					1	01000000	20	20															2		2																		1	1
R7444	001	0	1	31	11	R7444_001_0	6	1	1111	4	2	2	3		4	2	3	3		4	2	2	3		4	2	1	1		2					2				2		2												2		1	1111	2				0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2	2	2		3					3					3					3					3					3					3											2					1	01000000	20	20															2		2																		1	2
